Treatment of Genital Herpes

There is no cure for genital herpes. Your doctor can however prescribe antiviral medicines (antiviral chemotherapy) to treat your symptoms/outbreaks and to suppress future episodes. Additionally, all natural supplements such as Viranol are effective in suppressing genital warts.

Antiviral Chemotherapy. Herpes systemic antiviral chemotherapy partially controls symptoms of herpes episodes when used to treat first clinical episodes, recurrent episodes, or when used as daily suppressive therapy. It does not eradicate the virus and does not affect the risk, frequency, or severity of recurrences after the drug is discontinued.
Herpes systemic antiviral chemotherapy includes three oral medications:

• Acyclovir (Zovirax)
• Famciclovir (Famvir)
• Valacyclovir (Valtrex)

Topical antiviral treatment is of minimal clinical benefit, and it is not recommended.

Management of First Clinical Episode

Many patients with first episode herpes present with mild clinical manifestations but later develop severe or prolonged symptoms. Therefore, most patients with first clinical episode genital herpes should receive antiviral therapy. Antiviral therapy may have a drastic effect in initial HSV infection, especially if symptoms are of less than 7 days’ duration and there is no history of oral HSV.

The following regimens are recommended by the CDC for treatment of first clinical episodes of genital herpes:

• Acyclovir 400 mg orally three times a day for 7-10 days until complete crusting has occurred, OR
• Acyclovir 200 mg orally 5 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.

Treatment may be extended if healing is incomplete after 10 days of therapy. Factors to weigh when considering treatment include severity of symptoms, immune status, pregnancy, history of complications, and cost.

Management of Recurrent Episodes

Most patients with symptomatic primary genital HSV-2 infection experience recurrent outbreaks. Antiviral therapy for recurrent genital herpes can be administered either episodically, to ameliorate or shorten the duration of lesions, or continuously as suppressive therapy to reduce the frequency of occurrences. Treatment options should be discussed with ALL patients.

Episodic Therapy

Successful episodic treatment requires initiation of therapy within one day of lesion onset. Clinicians should provide the patient with appropriate medication or a prescription and instructions to self-initiate treatment immediately when symptoms begin. The following regimens are recommended by the CDC for episodic therapy of recurrent herpes infection outbreaks:

• Acyclovir 400 mg orally 3 times a day for 5 days, OR
• Acyclovir 200 mg orally 5 times a day for 5 days, OR
• Acyclovir 800 mg orally twice a day for 5 days; OR
• Famciclovir 125 mg orally twice a day for 5 days, OR
• Valacyclovir 500 mg orally twice a day for 3-5 days, OR
• Valacyclovir 1 g orally once a day for 5 days.

A 3-day course of valacyclovir 500 mg twice daily has been shown to be as effective as a 5-day course. Similar studies have not been done with acyclovir or famciclovir.

Suppressive therapy

Quality of life often is improved for patients with frequent recurrences who receive suppressive therapy compared with episodic therapy. Suppressive therapy reduces the frequency of genital herpes recurrences by 70%-80% in patients who have frequent recurrences (six or more recurrences per year). Many patients report no symptomatic outbreaks. Suppressive antiviral therapy reduces but does not eliminate subclinical viral shedding and decreases transmission 48%-75% in the susceptible partner in discordant couple studies. The CDC recommends the following regimen for suppressive therapy of genital herpes:

• Acyclovir 400 mg orally twice a day, OR
• Famciclovir 250 mg orally twice a day, OR
• Valacyclovir 500 mg orally once a day, OR
• Valacyclovir 1 g orally once a day.

Valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens in patients who have very frequent recurrences (i.e. >10 episodes per year). Ease of administration and cost are important considerations for prolonged treatment.

The frequency of recurrent outbreaks diminishes over time in many patients, and the patient’s psychological adjustment to the disease may change. Therefore, periodically (e.g., once a year) reassess the patient’s need for continued suppressive therapy and discuss discontinuation of suppressive therapy. Patients should be warned that they might have rebound outbreaks when suppression is discontinued; suppression does not eliminate ganglionic latency.

Management of Severe Disease

IV acyclovir should be provided for patients with severe disease or complications requiring hospitalization such as disseminated infection, pneumonitis, hepatitis, or complications of the central nervous system (e.g., meningitis or encephalitis). See the 2002 CDC STD Treatment Guidelines for recommended regimens for severe disease.

Herpes and HIV

Immunocompromised patients may have prolonged or severe episodes of genital, perianal, or oral herpes. Increased doses of antiviral drugs have been demonstrated to be beneficial.
Lesions caused by HSV are common in HIV-infected patients and may be severe, painful, and atypical. Genital ulcers increase the risk of HIV transmission and acquisition.

Sources: CDC, DHHS