Herpes simplex genitalis antiviral treatment of first episode genital herpes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Principles of Management of Genital Herpes

• Antiviral chemotherapy offers clinical benefits to the majority of symptomatic patients and is the mainstay of management.

• Systemic antiviral drugs can partially control the signs and symptoms of herpes episodes when used to treat first clinical episodes and recurrent episodes or when used as daily suppressive therapy. However, these drugs neither eradicate latent virus nor affect the risk, frequency, or severity of recurrences after the drug is discontinued.

• Topical therapy with antiviral drugs offers minimal clinical benefit, and its use is discouraged.

First Clinical Episode of Genital Herpes

• Many patients with first-episode herpes have mild clinical manifestations but later develop severe or prolonged symptoms. Therefore, patients with initial genital herpes should receive antiviral therapy.

• General advice:

• Saline bathing
• Analgesia
• Topical anaesthetic agents such as 5% lidocaine ointment may be useful to apply especially prior to micturition but should be used with caution because of the risk of potential sensitization.

• Anti-viral therapy:

• Oral antiviral drugs are indicated within 5 days of the start of the episode and while new lesions are still forming.
• Antiviral therapy does not alter the natural history of the disease.
• Topical agents are less effective than oral agents. Combined oral and topical treatment is of no benefit.
• Intravenous therapy is indicated only when the patient cannot swallow or tolerate oral medication because of vomiting.
• There is no evidence for benefit from courses longer than five days. However, it may be prudent to review the patient after 5 days and continue therapy if new lesions are still appearing at this time.

CDC Recommended Regimens:

• Acyclovir 400 mg orally three times a day for 7-10 days OR
• Acyclovir 200 mg orally five times a day for 7-10 days OR
• Famciclovir 250 mg orally three times a day for 7-10 days OR
• Valacyclovir 1 g orally twice a day for 7-10 days

Management of Complications

• Hospitalisation may be required for urinary retention, meningism, and severe constitutional symptoms.

• If catheterisation is required, suprapubic catheterisation is preferred to prevent theoretical risk of ascending infection, to reduce the pain associated with the procedure, to allow normal micturition to be restored without multiple removals and re-catheterisations