What is the recommended management of a genital ulcer due to herpes simplex virus in an immunocompetent adult?

Management of Genital Herpes Simplex Virus Ulcers in Immunocompetent Adults

For an immunocompetent adult presenting with a genital HSV ulcer, initiate oral antiviral therapy immediately with valacyclovir 1 gram twice daily, acyclovir 400 mg three times daily, or famciclovir 250 mg three times daily for 7-10 days for first episodes, or 5 days for recurrent episodes. 1, 2

Initial Episode Management

Treatment must be started as soon as possible, ideally within 72 hours of symptom onset, though benefit may still occur if initiated later. 1, 2

First-Line Antiviral Regimens for Initial Episode

Choose one of the following equivalent options 1:

• Valacyclovir 1 gram orally twice daily for 7-10 days (preferred for convenience) 2
• Acyclovir 400 mg orally three times daily for 7-10 days 1
• Famciclovir 250 mg orally three times daily for 7-10 days 1

The FDA label specifies that valacyclovir's efficacy when initiated more than 72 hours after symptom onset has not been established, emphasizing the importance of early treatment 2. However, clinical practice supports treating even beyond this window, as some benefit typically occurs 1.

Adjunctive Symptomatic Management

• Provide oral analgesics (acetaminophen or NSAIDs) for pain control 1
• Recommend sitz baths or topical ice application for local symptom relief 1
• Avoid topical antivirals, as they are substantially less effective than systemic therapy 1

Recurrent Episode Management

For patients experiencing recurrent genital herpes outbreaks, two management strategies exist: episodic therapy and daily suppressive therapy 1.

Episodic Treatment for Recurrences

Initiate treatment at the first sign of prodrome or within 24 hours of lesion onset for maximum benefit. 1, 2

Recommended regimens (choose one) 1:

• Valacyclovir 500 mg orally twice daily for 5 days
• Acyclovir 400 mg orally three times daily for 5 days
• Acyclovir 800 mg orally twice daily for 5 days
• Famciclovir 125 mg orally twice daily for 5 days

Provide patients with a prescription or medication supply to keep at home so they can self-initiate treatment immediately when symptoms begin 1.

Daily Suppressive Therapy Indications

Offer suppressive therapy to patients with frequent recurrences (≥6 episodes per year) or those experiencing significant psychological distress from the diagnosis. 1

Recommended suppressive regimens (choose one) 1:

• Valacyclovir 500 mg orally once daily (most convenient)
• Valacyclovir 1000 mg orally once daily
• Acyclovir 400 mg orally twice daily
• Famciclovir 250 mg orally twice daily

Important caveat: Valacyclovir 500 mg once daily appears less effective in patients with very frequent recurrences (≥10 episodes per year); use higher doses or alternative regimens in this population 1.

Suppressive therapy reduces recurrence frequency by ≥75% and has been documented as safe for continuous use up to 6 years with acyclovir and 1 year with valacyclovir and famciclovir 1. After 1 year of continuous therapy, discuss discontinuation with the patient to reassess recurrence patterns, as frequency often decreases over time 1.

Transmission Risk Reduction

For Patients Concerned About Transmitting to Partners

Daily suppressive valacyclovir 500 mg once daily in the infected partner reduces HSV-2 transmission to susceptible heterosexual partners by approximately 48-50% and reduces symptomatic disease in the partner by 75%. 3, 4

Critical counseling points 1, 3:

• Transmission occurs most commonly during asymptomatic periods when no visible lesions are present 3
• Asymptomatic viral shedding occurs on approximately 10.8% of days without suppressive therapy, reduced to 2.9% of days with daily suppressive therapy 3
• Avoid all sexual contact when prodromal symptoms or visible lesions are present 3
• Consistent condom use provides additional protection but does not eliminate transmission risk 3
• Even with both suppressive therapy and condoms, transmission can still occur 3

HSV-1 vs HSV-2 Counseling Differences

Genital HSV-1 infection has significantly less shedding and fewer recurrences compared to HSV-2, particularly after the first year. 1

• Transmission to sexual partners is less likely with genital HSV-1 due to decreased shedding frequency 1
• Episodic therapy is recommended for HSV-1 recurrences 1
• Suppressive therapy for genital HSV-1 has not been shown to reduce transmission risk to partners 1
• The risk-benefit ratio of daily suppressive therapy for genital HSV-1 is unclear given the lower recurrence rate 1

Severe Disease Requiring Hospitalization

Patients with severe disease, disseminated infection, pneumonitis, hepatitis, or CNS complications (meningitis, encephalitis) require intravenous acyclovir 5-10 mg/kg every 8 hours for 5-7 days or until clinical resolution. 1

Essential Patient Counseling

Natural History and Prognosis

• Most patients with first-episode genital HSV-2 will experience recurrent episodes 1
• Recurrent episodes are generally milder and more localized than the primary infection 5
• Recurrence frequency typically decreases over time 1
• Asymptomatic shedding occurs more frequently in patients with HSV-2 infection and in those who have had genital herpes for less than 12 months 1

Special Populations

All women of childbearing age with genital herpes must inform their obstetric providers about the infection during any pregnancy due to risk of neonatal transmission. 1, 3

For pregnant women with a history of genital herpes, suppressive-dose acyclovir starting at week 36 prevents HSV recurrences requiring cesarean delivery 6.

Partner Management

• Sexual partners should be evaluated and counseled 1
• Symptomatic partners should be evaluated and treated using the same regimens 1
• Approximately 60% of individuals exposed to HSV-2 do not develop symptoms but can still transmit the virus 6

Common Pitfalls to Avoid

• Do not assume episodic treatment reduces transmission risk—only daily suppressive therapy has this effect 3
• Do not rely solely on avoiding sex during visible outbreaks—the majority of transmission occurs during asymptomatic periods 3
• Do not use topical antivirals—they are substantially less effective than systemic therapy 1
• Do not delay treatment waiting for culture confirmation—initiate therapy based on clinical presentation 1
• Acyclovir resistance has not been associated with clinical failure in immunocompetent patients, though it can occur in immunocompromised individuals 1, 7