Management of Genital Herpes Simplex Virus (HSV) Infections

Diagnosis

Accurate diagnosis should be established using type-specific molecular or virologic tests when genital ulcers are present, and type-specific serologic tests when lesions are not present, as recommended by the Centers for Disease Control and Prevention 1, 2
Persons with genital symptoms consistent with herpes should undergo HSV-2 serologic testing to establish diagnosis, according to the Clinical Infectious Diseases guidelines 3, 4
Screening is not recommended for asymptomatic individuals with low pretest probability of infection or pregnant women, as stated by the Clinical Infectious Diseases guidelines 5

The American College of Obstetricians and Gynecologists recommends treatment with valacyclovir 1 g orally twice daily, acyclovir 400 mg orally three times daily, or famciclovir 250 mg orally three times daily for 7-10 days for first clinical episodes of genital herpes 6, 7
Treatment may be extended if healing is incomplete after 10 days, as suggested by the Clinical Infectious Diseases guidelines 6

The Centers for Disease Control and Prevention recommends episodic therapy with valacyclovir 500 mg orally twice daily, acyclovir 400 mg orally three times daily, or famciclovir 125 mg orally twice daily for 5 days for recurrent episodes of genital herpes 6, 8
Episodic therapy is most effective when started during the prodrome or within 1 day after onset of lesions, according to the Clinical Infectious Diseases guidelines 8

The American College of Obstetricians and Gynecologists recommends daily suppressive therapy with valacyclovir 1 g orally once daily, acyclovir 400 mg orally twice daily, or famciclovir 250 mg orally twice daily for patients with frequent recurrences (≥6 episodes per year) 3, 6
Suppressive therapy reduces recurrence frequency by ≥75% and reduces asymptomatic viral shedding, as stated by the Clinical Infectious Diseases guidelines 6, 8

The Infectious Diseases Society of America suggests that case reports indicate brincidofovir, imiquimod, and topical cidofovir may be useful in treating acyclovir-resistant HSV infections 9
Clinical trials are ongoing for helicase-primase inhibitors for resistant cases, as reported by the Clinical Infectious Diseases guidelines 9

The Centers for Disease Control and Prevention recommends treatment with acyclovir 10 mg/kg IV every 8 hours until resolution of fever and headache, followed by valacyclovir 1 g TID to complete a 14-day course for first episode HSV-2 meningitis 9
For recurrent HSV-2 meningitis, oral therapy may be used for the entire course, as suggested by the Clinical Infectious Diseases guidelines 9

The American College of Obstetricians and Gynecologists advises patients to abstain from sexual activity when lesions or prodromal symptoms are present, and to inform sex partners about having genital herpes and use condoms during all sexual exposures with new or uninfected partners 6, 8
Approximately 20% of persons who are HSV-2 seropositive do not note genital symptoms consistent with genital herpes, as reported by the Clinical Infectious Diseases guidelines 5

Nucleic acid amplification testing (NAAT/PCR) of a genital lesion is the gold‑standard diagnostic method, offering >90 % sensitivity and specificity and should be performed to confirm that HSV is the cause of the current ulcer. 10
If PCR is unavailable, viral culture may be used, but it has lower sensitivity, especially for lesions that are already healing. 10
Direct immunofluorescence and Tzanck smear are not recommended for diagnosing genital HSV because they lack adequate sensitivity and specificity. 10
Clinicians should not assume a genital ulcer is due to HSV without virologic confirmation; other ulcerative etiologies must be excluded, particularly in high‑risk populations. 10

A positive HSV‑2 IgG result confirms chronic HSV‑2 infection but does not prove that the present ulcer is caused by HSV‑2; it only indicates prior exposure. [11][10]
HSV‑2 IgG antibodies persist indefinitely after infection and cannot differentiate between active (replicating) and latent infection. 11
Serologic testing alone is insufficient to determine the etiology of a presenting genital lesion with certainty; virologic testing is required for definitive diagnosis. 11

Only about 13 % of individuals who are HSV‑2 seropositive have ever received a clinical diagnosis, indicating that the majority of infections remain unrecognized. 12
HSV‑2 infection increases the risk of acquiring HIV approximately three‑fold. 12