Treatment for Herpes Simplex 2 (Genital Herpes)

Introduction to Treatment

The Centers for Disease Control and Prevention recommends oral antiviral medications, including valacyclovir, acyclovir, and famciclovir, as the mainstay of treatment for genital herpes simplex 2 (HSV-2) infection, with valacyclovir 500 mg twice daily for 5 days being the preferred first-line therapy for recurrent episodes due to its convenient dosing and effectiveness in reducing symptoms and viral shedding 1, 2

For first clinical episodes of genital herpes, the Centers for Disease Control and Prevention recommends longer treatment courses, including valacyclovir 1 g orally twice daily for 7-10 days, acyclovir 400 mg orally three times daily for 7-10 days, acyclovir 200 mg orally five times daily for 7-10 days, and famciclovir 250 mg orally three times daily for 7-10 days 3, 4
Treatment may be extended if healing is incomplete after 10 days of therapy 3

For recurrent episodes, the American College of Obstetricians and Gynecologists recommends shorter courses, including 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, acyclovir 200 mg orally five times daily for 5 days, and famciclovir 125 mg orally twice daily for 5 days 2, 5
Episodic therapy is most effective when started during the prodromal period or within 1 day after onset of lesions 2, 5
Delayed treatment beyond 72 hours significantly reduces effectiveness 2

The Centers for Disease Control and Prevention recommends daily suppressive therapy for patients with frequent recurrences (≥6 episodes per year), including valacyclovir 1 g orally once daily or 500 mg orally once daily, acyclovir 400 mg orally twice daily, and famciclovir 250 mg orally twice daily 1, 2, 5
Suppressive therapy can reduce recurrence frequency by ≥75% and reduce asymptomatic viral shedding 2, 5
After 1 year of suppressive therapy, consider discontinuation to assess recurrence frequency 5

The Centers for Disease Control and Prevention recommends that HIV-infected patients with genital herpes be monitored closely and may require longer courses of therapy than those recommended for HIV-negative patients 6
Famciclovir 500 mg twice daily has been effective in reducing recurrences and subclinical shedding in HIV-infected patients 7

The American College of Obstetricians and Gynecologists recommends that safety considerations are important for pregnant women, and ciprofloxacin is contraindicated during pregnancy 8

The Infectious Diseases Society of America recommends that topical acyclovir is substantially less effective than systemic therapy and is not recommended 3, 4, 5
Systemic antiviral drugs partially control symptoms but do not eradicate latent virus or affect subsequent recurrences after discontinuation 3, 4
Dosing strategies that are most feasible for patient adherence should be prioritized 1
The same medication dosages and frequencies are recommended for genital HSV-1 infection as for HSV-2 1

The Centers for Disease Control and Prevention recommends that suppressive therapy can reduce the risk of transmission to sexual partners 6, 5
Patients should be counseled to abstain from sexual activity when lesions or prodromal symptoms are present 5
Consistent condom use should be encouraged to reduce HSV-2 transmission 6

If symptoms persist beyond expected healing time, consider incorrect diagnosis, co-infection with another STD, HIV infection, poor medication adherence, or antiviral resistance 6, 8, 4, 1
For acyclovir-resistant HSV, IV foscarnet is the treatment of choice 6

The Centers for Disease Control and Prevention recommends suspecting acyclovir resistance if lesions do not begin to resolve within 7-10 days after initiating therapy, and obtaining viral culture of the lesion and performing susceptibility testing to confirm drug resistance 9
For confirmed acyclovir-resistant HSV, the CDC recommends using IV foscarnet 40 mg/kg every 8 hours as the treatment of choice 9

The CDC states that no laboratory monitoring is needed for patients on episodic or suppressive therapy unless substantial renal impairment exists, and for patients receiving high-dose IV acyclovir, renal function should be monitored at treatment initiation and once or twice weekly during treatment 9
Common side effects of antiviral therapy include nausea and headache, according to the CDC 9

The CDC recommends that patients use condoms consistently during all sexual exposures to reduce transmission risk to sexual partners by approximately 50% 9