What is the recommended management for a patient with genital herpes, including acute antiviral therapy, pain control, hygiene measures, sexual precautions, and suppressive therapy for frequent recurrences?

Genital Herpes Symptom Management

All patients with symptomatic genital herpes should receive oral antiviral therapy and be offered daily suppressive therapy if they experience ≥6 recurrences per year, which reduces recurrence frequency by ≥75%. 1

Acute Antiviral Therapy

First Clinical Episode

For initial genital herpes outbreaks, start one of the following regimens for 7-10 days:

• Valacyclovir 1 g orally twice daily (preferred for convenience) 2, 3
• Acyclovir 400 mg orally three times daily 2, 3, 4
• Acyclovir 200 mg orally five times daily 3, 4
• Famciclovir 250 mg orally three times daily 3

Extend treatment beyond 10 days if healing is incomplete. 2, 3 For severe disease requiring hospitalization (disseminated infection, encephalitis, pneumonitis, hepatitis, or inability to tolerate oral medication), administer acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution. 1, 3, 4

Recurrent Episodes (Episodic Therapy)

Initiate treatment at the first sign of prodrome or within 24 hours of lesion onset for maximum benefit (viral replication peaks in the first 24 hours). 2, 3 Provide patients with a prescription to self-initiate therapy at the earliest symptoms. 2, 3

Recommended 5-day episodic regimens:

• Valacyclovir 500 mg orally twice daily 1, 2, 3
• Acyclovir 800 mg orally twice daily 3
• Acyclovir 400 mg orally three times daily 2, 3
• Famciclovir 125 mg orally twice daily 2, 3

Critical pitfall: Delaying treatment beyond 72 hours significantly reduces efficacy. 2 Topical acyclovir is substantially less effective than oral therapy and should not be used. 2, 3

Suppressive Therapy for Frequent Recurrences

Offer daily suppressive therapy to all patients with ≥6 recurrences per year, as it reduces recurrence frequency by ≥75% and decreases asymptomatic viral shedding. 1, 2, 3

Recommended suppressive regimens:

• Valacyclovir 500 mg orally once daily (for <10 recurrences/year) 3
• Valacyclovir 1 g orally once daily 3
• Acyclovir 400 mg orally twice daily (safety documented up to 6 years) 1, 2, 3
• Famciclovir 250 mg orally twice daily (safety documented up to 1 year) 3

After 1 year of continuous suppressive therapy, discontinue temporarily to reassess recurrence frequency, as natural decline often occurs over time. 1, 2, 3 Suppressive therapy significantly lowers but does not eliminate asymptomatic viral shedding or transmission risk. 2, 3

Important caveat: Do not use valacyclovir 500 mg once daily in patients with ≥10 recurrences per year; it is less effective than higher-dose regimens. 3

Pain Control and Hygiene Measures

For pain management during acute outbreaks:

• Use oral analgesics (NSAIDs or acetaminophen) for systemic pain control 5
• Keep lesions clean and dry to prevent secondary bacterial infection 5
• Avoid tight-fitting clothing that may irritate lesions 5
• Consider sitz baths for perineal lesions to provide symptomatic relief 5

For severe pain, particularly in primary infections, the median duration of pain is reduced from 10.6 days to 4.2 days with intravenous acyclovir. 6

Sexual Precautions and Transmission Counseling

Patients must abstain from all sexual activity when lesions or prodromal symptoms are present. 1, 3, 4 Even with suppressive therapy, asymptomatic viral shedding can occur, allowing transmission to partners. 3

Essential counseling points:

• Inform all sexual partners about the genital herpes diagnosis 1, 3
• Use condoms during all sexual encounters with new or uninfected partners, though condoms do not completely eliminate transmission risk 1, 3
• Asymptomatic viral shedding occurs more frequently with HSV-2 than HSV-1 and during the first 12 months after infection 3
• Suppressive therapy reduces transmission to uninfected partners in HIV-negative heterosexual couples, though it does not eliminate risk entirely 1

Critical exception: Suppressive therapy is not effective to decrease transmission risk among persons with HIV/HSV-2 coinfection. 1

Special Populations

Pregnancy

Women with a history of genital herpes should receive antiviral prophylaxis from 36 weeks gestation until delivery to reduce term-time recurrences and cesarean delivery rates. 3, 5 Perform cesarean delivery if prodromal symptoms or visible lesions are present at labor onset, or if a first episode occurred <6 weeks before delivery. 3

Immunocompromised Patients

Higher doses are required: acyclovir 400 mg orally 3-5 times daily until clinical resolution. 1, 3 If lesions persist despite acyclovir treatment, suspect viral resistance and obtain viral culture with susceptibility testing. 3 For confirmed resistance, use IV foscarnet 40 mg/kg every 8 hours. 3

HIV-Infected Patients

For suppressive therapy, use valacyclovir 500 mg orally twice daily (not once daily) to achieve adequate viral control. 3 Antiviral resistance is more common in immunocompromised individuals, especially those on long-term suppressive therapy. 3, 4

Renal Function Monitoring

Assess renal function before starting and during antiviral therapy; adjust dosing frequency or total daily dose according to creatinine clearance to avoid toxicity. 3