Herpes simplex genitalis antiviral treatment of recurrent genital herpes
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yazan Daaboul, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
All patients who develop recurrent genital herpes require antimicrobial therapy using either suppressive therapy (less frequency of recurrence) or episodic therapy (less duration of lesions). The duration of suppressive therapy is often prolonged, and it may continue up to several years. In contrast, the duration of episodic therapy is limited to a few days. Patients with severe disease require IV antmicrobial therapy.
Established HSV-2 Infection
- The majority of patients with symptomatic, first-episode genital HSV-2 infection subsequently experience recurrent episodes of genital lesions.[1]
- All patients who develop recurrent genital herpes require antimicrobial therapy using either suppressive therapy (less frequency of recurrence) or episodic therapy (less duration of lesions).
- Treatment aims to manage present lesions but not cure the disease or prevent future occurrences.[1]
- Patients with severe disease often require IV antmicrobial therapy.
Option 1: Suppressive Therapy for Recurrent Genital Herpes
- The advantage of suppressive therapy is the reduction of frequency of recurrences.[1]
- Suppressive therapy reduces the risk of recurrence by approximately 70% to 80%.
- The duration of therapy is prolonged. The optimal duration of therapy is not well-established:
- Suppressive therapy using acyclovir has been studied for up to 6 years
- Suppressive therapy using either valacyclovir or famciclovir has been studied for up to 1 year
- 1. Recurrent genital herpes therapy[1]
- 1.1 Suppressive therapy
- Preferred regimen: Acyclovir 400 mg PO bid OR Famciclovir 250 mg PO bid OR Valacyclovir 1000 mg PO qd for 7–10 days
- Alternative regimen: Valacyclovir 500 mg PO qd for 7–10 days
- Note (1): Famciclovir is equally effective for episodic treatment of genital herpes but is less effective for suppression of viral shedding
- Note (2): Valacyclovir 500 mg regimen (alternative regimen) may be less effective among patients with ≥ 10 episodes per year
Option 2: Episodic Therapy for Recurrent Genital Herpes
- 1. Recurrent genital herpes therapy[1]
- 1.2 Episodic therapy
- Preferred regimen: Acyclovir 400 mg PO tid for 5 days OR Acyclovir 800 mg PO bid a day for 5 days OR Acyclovir 800 mg PO tid for 2 days OR Famciclovir 125 mg PO bid for 5 days OR Famciclovir 1000 mg PO bid for 1 day OR Famciclovir 500 mg PO once, followed by 250 mg PO bid for 2 days OR Valacyclovir 1000 mg PO qd for 5 days
- Alternative regimen: Valacyclovir 500 mg PO bid for 3 days
- Note: Valacyclovir 500 mg regimen (alternative regimen) may be less effective among patients with ≥ 10 episodes per year
Specific Considerations
Severe Disease
- Severe genital herpes often requires IV antimicrobial therapy.[1]
- 2. Severe genital HSV infection[1]
- Preferred regimen: Acyclovir 5-10 mg/kg IV q8h for 2-7 days or until clinical improvement THEN (Acyclovir 400 mg PO tid for at least 10 days OR Acyclovir 200 mg PO five times a day for at least 10 days OR Famciclovir 250 mg PO tid for at least 10 days OR Valacyclovir 1 g PO bid for at least 10 days)
- Note: Dose-adjustment is often necessary among patients with impaired renal function
HIV-Positive Patients
- Immunocompromised patients can have prolonged or severe episodes of genital, perianal, or oral herpes. Lesions caused by HSV are common among HIV-infected patients and might be severe, painful, and atypical.
- HSV shedding is increased in HIV-infected persons. Whereas antiretroviral therapy reduces the severity and frequency of symptomatic genital herpes, frequent subclinical shedding still occurs.[1]
- Clinical manifestations of genital herpes might worsen during immune reconstitution after initiation of antiretroviral therapy.
- HIV-positive patients are also treated similarly using either suppressive or episodic therapy, but the efficacy of antimicrobial therapy is not very well-established.[1]
- HSV type-specific serologies may be offered to HIV-positive persons during their initial evaluation if the infection status is unknown, and suppressive antiviral therapy can be considered among patients who have HSV-2 infection.[1]