Treatment of Herpes Simplex Virus (HSV)

First Clinical Episode

The Centers for Disease Control and Prevention recommends treating first-episode genital herpes with oral antiviral therapy for 7-10 days using valacyclovir 1 g twice daily, famciclovir 250 mg three times daily, or acyclovir 400 mg three times daily 1
Acyclovir 400 mg orally three times daily for 7-10 days is the recommended first-line treatment for genital herpes 1
Alternative regimens for genital herpes include acyclovir 200 mg orally five times daily for 7-10 days, valacyclovir 1 g orally twice daily for 7-10 days, and famciclovir 250 mg orally three times daily for 7-10 days 1, 2
For herpes proctitis, treatment with acyclovir 400 mg orally five times daily for 10 days or until clinical resolution is recommended 2
For orolabial herpes, valacyclovir 500 mg twice daily for 5 days initiated at first sign of outbreak is recommended 3

For recurrent genital herpes, the Centers for Disease Control and Prevention recommends using shorter 5-day courses of antiviral therapy initiated during prodrome or within 1 day of lesion onset 4
Valacyclovir 500 mg orally twice daily for 5 days is a preferred treatment for recurrent genital herpes due to its convenience 4
Alternative regimens for recurrent genital herpes include acyclovir 400 mg orally three times daily for 5 days, acyclovir 800 mg orally twice daily for 5 days, and famciclovir 125 mg orally twice daily for 5 days 2, 4

The Centers for Disease Control and Prevention recommends offering daily suppressive therapy to all patients with recurrent HSV-2, which reduces recurrence frequency by ≥75% 6, 4
Indications for suppressive therapy include patients with frequent recurrences (≥6 episodes per year) and those seeking to reduce transmission risk to uninfected partners 2, 4, 6
Regimens for suppressive therapy include valacyclovir 1 g orally once daily, valacyclovir 500 mg orally once daily, acyclovir 400 mg orally twice daily, and famciclovir 250 mg orally twice daily 4

For HIV-infected/immunocompromised patients, treatment with oral valacyclovir, famciclovir, or acyclovir for 5-10 days is recommended for orolabial lesions, and for 5-14 days for genital HSV 7
For acyclovir-resistant HSV, IV foscarnet is the treatment of choice 7

Patients should be counseled to abstain from sexual activity while lesions are present, and to use consistent condom use during all sexual exposures 2, 7
Patients should be informed about the potential for recurrent episodes, asymptomatic viral shedding, and sexual transmission 2, 5, 8

No laboratory monitoring is needed for patients receiving episodic or suppressive therapy unless substantial renal impairment is present 7, 1