Treatment for Recurrent Genital Herpes

Initial Assessment and Diagnosis

Recurrent episodes of genital herpes are common after initial infection, particularly with HSV-2, affecting patients with a history of genital herpes 1, 2
The Centers for Disease Control and Prevention (CDC) recommends that patients with recurrent genital herpes be evaluated for possible concurrent inflammation or infection, such as pelvic pain and discharge 2

The CDC recommends episodic antiviral therapy with valacyclovir 500 mg orally twice daily for 5 days for patients with recurrent genital herpes, such as a 20-year-old female with pelvic pain, discharge, and sores 2
The CDC also recommends acyclovir 400 mg orally three times daily for 5 days, acyclovir 800 mg orally twice daily for 5 days, or acyclovir 200 mg orally five times daily for 5 days as alternative treatment options for patients with recurrent genital herpes 2
Famciclovir 125 mg orally twice daily for 5 days is also a recommended treatment option for patients with recurrent genital herpes 2
Episodic therapy is most effective when started during the prodrome or within 1 day after onset of lesions, according to the CDC 2

The CDC advises patients that genital herpes is a recurrent, incurable viral disease, and antiviral medications can control symptoms but do not eradicate the virus or prevent all recurrences 3
Patients should be counseled to abstain from sexual activity when lesions or prodromal symptoms are present, inform sex partners about having genital herpes, and use condoms during all sexual exposures with new or uninfected partners, as recommended by the CDC 2
The CDC also recommends that patients be aware that asymptomatic viral shedding can occur, potentially leading to transmission 2, 4

The CDC recommends daily suppressive therapy for patients with frequent recurrences (≥6 episodes per year), such as valacyclovir 1 g orally once daily or valacyclovir 500 mg orally once daily 2, 4
Alternative options for daily suppressive therapy include acyclovir 400 mg orally twice daily or famciclovir 250 mg orally twice daily, according to the CDC 2
Suppressive therapy can reduce the frequency of recurrences by ≥75%, reduce asymptomatic viral shedding, and is safe for up to 6 years with acyclovir and 1 year with valacyclovir, as documented by the CDC 2, 4

The CDC recommends that patients with persistent symptoms beyond 5 days of treatment be considered for extended treatment, and evaluated for potential co-infections if discharge and pelvic pain persist 1, 2
After 1 year of suppressive therapy, the CDC recommends considering discontinuation to assess recurrence frequency, and discussing psychological adjustment to having genital herpes 2

The Centers for Disease Control and Prevention, as reported in MMWR Recommendations and Reports, recommends against the use of topical acyclovir due to its substantially lower effectiveness compared to oral therapy 5

The Centers for Disease Control and Prevention recommends against using topical acyclovir due to its substantially lower effectiveness compared to oral therapy 6
The Centers for Disease Control and Prevention advises against using valacyclovir 8 grams per day, as it is associated with hemolytic uremic syndrome/thrombotic thrombocytopenic purpura in immunocompromised patients 7
The Centers for Disease Control and Prevention suggests suspecting acyclovir resistance if lesions do not begin to resolve within 7-10 days of therapy, and recommends using foscarnet 40 mg/kg IV every 8 hours as an alternative for proven or suspected resistance 7
The Centers for Disease Control and Prevention states that routine suppressive therapy is not recommended during pregnancy for recurrent genital herpes, although the safety of systemic acyclovir and valacyclovir in pregnancy has not been definitively established 7

Topical acyclovir is substantially less effective than oral antiviral agents for genital herpes and is not recommended for treatment. (Centers for Disease Control and Prevention MMWR Recommendations and Reports) 8, 9, 10

Valacyclovir does not eradicate latent herpes simplex virus, does not prevent all asymptomatic viral shedding, and therefore does not eliminate the risk of transmission to partners. (Centers for Disease Control and Prevention MMWR Recommendations and Reports) 8, 9, 10