Primary infection. Management of the first clinical episode of genital herpes includes systemic antiviral medication (acyclovir, famciclovir, or valacyclovir) and counseling. Recommended regimens are listed in Table 1. Topical antiviral therapy, which provides only minimal benefit, is not recommended.
|Table 1 – Recommended oral treatment regimens for genital herpes|
||Recurrences||Daily suppressive therapy|
|Acyclovir||400 mg tid for 7 - 10 d||400 mg tid for 5 d||400 mg bid|
200 mg 5 times daily for 7 - 10 d
200 mg 5 times daily for 5 d
800 mg bid for 5 d
|Famciclovir||250 mg tid for 7 - 10 d||125 mg bid for 5 d||250 mg bid|
|Valacyclovir||1 g bid for 7 - 10 d||500 mg bid for 3 - 5 d||500 mg/d*|
|*This regimen may be less effective than other valacyclovir or acyclovir regimens in patients with 10 or more recurrences per year.
Adapted from Centers for Disease Control and Prevention. MMWR. 2002.1
Counseling is an important aspect of management, not only at the initial visit but also at follow-up visits, after the acute illness subsides. When talking to patients about genital herpes, be sure to:
• Discuss the benefits of episodic and suppressive antiviral therapy with patients who are having a first episode of genital herpes.
• Emphasize the potential for recurrence, asymptomatic viral shedding, and sexual transmission when you describe the natural history of the disease.
• Advise patients to abstain from sexual activity when lesions or prodromal symptoms are present. Encourage them to tell their partners that they have genital herpes.
• Advocate the use of latex condoms during all sexual exposures with new or uninfected partners.
• Counsel patients that sexual transmission of HSV can occur during asymptomatic periods. Asymptomatic viral shedding occurs more frequently in patients who have HSV-2 infection and in those who have had genital herpes for less than 12 months.
• Explain the risk of neonatal transmission to all patients, including men. Tell women who are of childbearing age to inform all their health care providers of the HSV infection if they become pregnant.
• Advise the sex partners of patients with genital herpes that they might be infected even if they have no symptoms. Offer type-specific serologic testing to the partner.
• Provide the same counseling to patients with asymptomatic HSV-2 infection detected by serologic testing that those who have symptomatic infection receive. Antiviral therapy is not recommended for persons who have no clinical manifestations of infection.
1. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR. 2002;51(RR-6):1-80.
2. Fife KH, Barbarash RA, Rudolph T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection: results of an international, double-blind randomized clinical trial. Sex Transm Dis. 1997;24:481-486.
3. Reitano M, Tyring S, Lang W, et al. Valaciclovir for the suppression of recurrent genital herpes simplex virus infection: a large-scale dose range-finding study. J Infect Dis. 1998;178:603-610.
4. Chosidow O, Drouault Y, Leconte-Veyriac F, et al. Famciclovir vs aciclovir in immunocompetent patients with recurrent genital herpes infections: a parallel-group, randomized, double-blind clinical trial. Br J Dermatol. 2001;144:818-824.
5. Diaz-Mitoma F, Sibbald RG, Shafran SD, et al. Oral famciclovir for the suppression of recurrent genital herpes: a randomized controlled trial. JAMA. 1998;280:887-892.
6. Loveless M, Harris W, Sacks S. Treatment of the first episode of genital herpes with famciclovir. In: Programs and abstracts of the 35th Interscience Conference on Antimicrobial Agents and Chemotherapy; 1995; San Francisco.