Treatment of genital herpes simplex virus infection
●Causative agent – Genital herpes simplex is a common sexually transmitted virus infection that is found worldwide. Most of these genital infections are caused by herpes simplex virus-2 (HSV-2), but herpes simplex virus-1 (HSV-1) also produces a clinically similar disease, and the incidence of HSV-1 genital disease is increasing.
●First episode – For almost all patients experiencing a first episode of genital HSV, we recommend antiviral therapy (Grade 1B). Antiviral therapy decreases the duration and severity of disease by days to weeks with minimal adverse drug effects and reduces the development of new lesions. Ideally, treatment should be started within 72 hours of lesion appearance.
•Most patients can be treated with oral therapy. We prefer oral valacyclovir (1000 mg twice daily for 7 to 10 days) rather than oral acyclovir or famciclovir. All three of these agents appear to have similar efficacy, and the margins of safety and tolerability are excellent; however, valacyclovir is dosed less frequently.
•Parenteral therapy should be reserved for patients with severe clinical manifestations/complications (eg, sacral nerve involvement leading to urinary retention, hepatitis, meningitis). The ultimate dose of intravenous acyclovir and the specific duration of therapy should be individually tailored to the specific clinical setting.
●Recurrent infection – The approach to treatment for recurrent genital infection must be determined on a case-by-case basis since patient preference should be strongly factored into this decision.
•Suppressive therapy – In general, we suggest chronic suppressive therapy (eg, daily valacyclovir) for the following groups (Grade 2B):
–Those with severe or frequent (eg, six or more per year) recurrences
–Immunocompetent patients who want to reduce the risk of HSV transmission to an uninfected sexual partner
•Episodic therapy – Patients with less severe or frequent recurrences and those who are not sexually active may reasonably prefer episodic therapy (antiviral therapy for individual outbreaks started at the very first sign of prodromal symptoms) or no therapy at all.
●No role for topical therapy – There is no role for topical antiviral therapy in the treatment of genital herpes since topical therapy is only of marginal benefit, and there does not appear to be any advantage of adding topical therapy to oral agents.
●Considerations for persons with HIV – Patients with HIV may have prolonged or severe episodes of genital herpes and are at greater risk for developing drug-resistant HSV compared with immunocompetent hosts. The treatment of genital herpes in patients with HIV is reviewed in detail elsewhere.
