How should I treat a 39‑year‑old woman with genital herpes simplex virus infection, including initial outbreak, recurrent episodes, and suppressive therapy?

Treatment of Genital Herpes Simplex in a 39-Year-Old Woman

For a 39-year-old woman with genital herpes, initiate valacyclovir 1 g orally twice daily for 7–10 days for a first episode, valacyclovir 500 mg orally twice daily for 3–5 days for recurrent outbreaks, and offer daily suppressive therapy with valacyclovir 500 mg to 1 g once daily if she experiences ≥6 recurrences per year. 1

First Clinical Episode Management

For an initial outbreak, prescribe valacyclovir 1 g orally twice daily for 7–10 days, starting within 48 hours of symptom onset for maximum benefit. 1 Alternative first-line regimens include acyclovir 400 mg orally three times daily for 7–10 days or famciclovir 250 mg orally three times daily for 7–10 days. 1

• Extend treatment beyond 10 days if lesions have not completely healed. 1
• For severe disease requiring hospitalization (disseminated infection, inability to tolerate oral medication, or CNS involvement), administer acyclovir 5–10 mg/kg IV every 8 hours for 5–7 days or until clinical resolution. 1
• Never use topical acyclovir as monotherapy—it is substantially less effective than oral therapy and does not reduce systemic viral shedding from the cervix or urethra. 2, 1

Recurrent Episode Treatment (Episodic Therapy)

For recurrent outbreaks, prescribe valacyclovir 500 mg orally twice daily for 3 days, initiated at the first sign of prodrome (tingling, itching) or within 24 hours of lesion onset. 1, 3 This short 3-day regimen is FDA-approved and highly convenient. 3

Alternative episodic regimens include:

• Acyclovir 800 mg orally twice daily for 5 days 1
• Acyclovir 400 mg orally three times daily for 5 days 1
• Famciclovir 125 mg orally twice daily for 5 days 1

Provide the patient with a prescription to self-initiate treatment at home at the first prodromal symptom—delaying beyond 24 hours significantly reduces efficacy. 1

Daily Suppressive Therapy

Recommend daily suppressive therapy if the patient experiences ≥6 recurrences per year, which reduces recurrence frequency by ≥75%. 1

Suppressive regimen options:

• Valacyclovir 500 mg orally once daily (for patients with <10 recurrences/year) 1, 3
• Valacyclovir 1 g orally once daily (for patients with ≥10 recurrences/year or for transmission reduction to uninfected partners) 1, 3
• Acyclovir 400 mg orally twice daily (safety documented for up to 6 years) 1
• Famciclovir 250 mg orally twice daily (safety documented for 1 year) 1

After 1 year of continuous suppressive therapy, discontinue temporarily to reassess recurrence frequency, as the natural rate often declines over time. 1

Critical Patient Counseling Points

Counsel the patient that genital herpes is a chronic, incurable infection with potential for lifelong recurrences, and that antiviral therapy controls symptoms but does not eradicate the virus. 1

• Asymptomatic viral shedding occurs even without visible lesions and can transmit infection to partners—this risk persists even on suppressive therapy, though it is reduced. 1
• Abstain from all sexual activity when lesions or prodromal symptoms are present. 1
• Inform all sexual partners about the herpes diagnosis. 1
• Use condoms consistently with new or uninfected partners, though condoms do not eliminate transmission risk completely. 1
• HSV-2 causes more frequent asymptomatic shedding than HSV-1, particularly in the first 12 months after infection. 1

Special Considerations for Women of Childbearing Age

If the patient is pregnant or planning pregnancy, inform her that she must notify her obstetrician about the herpes diagnosis. 1

• Neonatal transmission risk is 25–44% with a primary episode at delivery versus ≈1% with recurrent infection. 1
• Daily suppressive antiviral therapy from 36 weeks gestation until delivery is recommended to reduce term recurrences and cesarean delivery rates. 1
• Cesarean delivery is indicated if prodrome or visible lesions are present at labor onset, or if a first episode occurred <6 weeks before delivery. 1

Common Pitfalls to Avoid

• Do not prescribe valacyclovir 500 mg once daily for patients with ≥10 recurrences per year—it is less effective; use 1 g once daily instead. 1
• Do not delay episodic treatment—efficacy drops sharply if not started during prodrome or within 24 hours of lesion onset. 1
• Suspect acyclovir resistance if lesions fail to improve within 7–10 days of appropriate therapy; confirm with viral culture and switch to IV foscarnet 40 mg/kg every 8 hours. 1 Resistance is rare in immunocompetent patients but more common in HIV-infected individuals. 1
• Assess renal function before initiating and during antiviral therapy; adjust dosing for creatinine clearance to avoid toxicity. 1

Algorithm for Treatment Selection

1. First episode → Valacyclovir 1 g twice daily × 7–10 days 1
2. Recurrent episode → Valacyclovir 500 mg twice daily × 3 days (patient-initiated at prodrome) 1, 3
3. Frequent recurrences (≥6/year) → Daily suppressive therapy with valacyclovir 500 mg to 1 g once daily 1
4. Severe disease or immunocompromised → Acyclovir 5–10 mg/kg IV every 8 hours 1
5. Pregnancy → Suppressive therapy from 36 weeks until delivery 1

2, 1, 3, 4