Genital Herpes Treatment in Singapore: As genital herpes is caused by the herpes simplex virus, please refer to herpes simplex treatment
Systemic antiviral drugs can partially control the signs and symptoms of herpes episodes when used to treat first clinical 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 is of limited value for genital herpes and is not indicated if systemic therapy is administered.
First episode genital herpes
Acyclovir 400mg orally tid x 7 – 10 days [Ib, A]
Valacyclovir 1g orally bid x 7 – 10 days [Ib, A]
Famciclovir 250mg orally tid x 7 – 10 days [Ib, A]
For optimal benefit, the treatment should be started within 48 to 72 hours of onset of lesions, when new lesions continue to form or when symptoms and signs are severe. Treatment can be extended if healing is incomplete after 10 days of therapy.
Recurrent genital herpes
Most recurrent attacks are mild and can be managed with general measures only. Routine use of specific treatment is not necessary. Management should be decided together with the patient.
Effective episodic treatment of recurrent herpes requires initiation of therapy within 1 day of lesion onset or during the prodrome that precedes some outbreaks. The patient should be provided with a supply of drug or a prescription for the medication with instructions to initiate treatment immediately when symptoms begin.
Acyclovir 400mg orally tid x 5 days [Ib, A]
Acyclovir 800mg orally bid x 5 days [Ib, A]
Acyclovir 800mg tid x 2 days [Ib, A]
Valacyclovir 500mg orally bid x 3 days [Ib, A]
Valacyclovir 1g orally once a day x 5 days [Ib, A]
Famciclovir 125mg orally bid x 5 days [Ib, A]
Famciclovir 1g bid x 1 day [Ib, A]
Suppressive therapy reduces the frequency of genital herpes recurrences and may be considered in patients who have frequent recurrences (i.e. 6 or more recurrences per year).
Suppressive therapy has the additional advantage of decreasing the risk for genital HSV-2 transmission to susceptible partners.
Acyclovir 400mg orally bid [Ib, A]
Valacyclovir 500mg orally od [Ib, A]
Valacyclovir 1000mg orally od (for ≥10 recurrences in 1 year) [Ib, A]
Famciclovir 250mg orally bid [Ib, A]
Physicians should stop treatment after 9 to 12 months to see if the recurrence rate warrants continued prophylaxis.
Treatment of genital herpes in HIV-infected patients
Genital herpes is common in HIV infected individuals. Acyclovir-resistant strains, which usually lack the thymidine kinase enzyme, have been reported in patients with concurrent HIV infection. Acyclovir-resistant strains will also be resistant to valacyclovir and famciclovir. IV foscarnet, topical cidofovir or trifluridine may be used to treat resistant strains.
Acyclovir 400mg orally tid for 7 – 10 days [IV, C]
Valacyclovir 1g orally bid for 7 – 10 days [IV, C]
Famciclovir 500mg orally bid for 7 – 10 days [IV, C]
Acyclovir 400 – 800mg orally bid or tid or qid [IV, C]
Valacyclovir 500mg orally bid [IV, C]
Famciclovir 500mg orally bid [IV, C]
Counselling of infected persons and their sex partners is critical to the management of genital herpes. The goals of counselling are to help patients cope with the infection and prevent sexual and perinatal transmission.
The following should be discussed:
Management of genital herpes in pregnancy
Transmission of genital herpes to neonates is most likely to occur when the mother has an attack of symptomatic herpes at the time of delivery. The risk of transmission to the neonate is highest (30-50%) from a mother with primary genital herpes at the time of delivery; it is much lower (<1%) for mothers with recurrent herpes or asymptomatic viral shedding.
The safety of systemic acyclovir, valacyclovir and famciclovir during pregnancy is not yet established (all US FDA class B). Current findings do not show an increased risk for major birth defects after acyclovir treatment in the first trimester. First episode or severe recurrent genital herpes in pregnancy may be treated with oral acyclovir. In the presence of life- threatening maternal HSV infection, IV acyclovir is indicated.
The use of acyclovir near term may reduce the rate of Caesarean sections amongst women who have frequently recurring or newly acquired genital herpes by decreasing the rate of active lesions. Based on decision analysis, oral acyclovir prophylaxis is more cost effective than Caesarean section for women with recurrent genital herpes. However, routine administration of acyclovir to pregnant women is not recommended.
First episode genital herpes – 1st and 2nd trimester acquisition
Management should be in line with the clinical condition with the use of either oral or intravenous acyclovir [IV, C].
Vaginal delivery is anticipated in women who present with first episode genital herpes in the first and second trimesters as the risk for transmission to the neonate at delivery is low [IV, C].
First episode genital herpes – 3rd trimester acquisition
Caesarean section should be offered to all women presenting with first-episode genital herpes lesions at the time of delivery, or within 6 weeks of the expected date of delivery or onset of labour [IV, C].
Recurrent genital herpes in pregnancy
If there are no genital lesions at the onset of labour, Caesarean section to prevent neonatal herpes is not indicated [IV, C].
For women with a history of recurrent genital herpes, who would opt for caesarean delivery if HSV lesions were detected at the onset of labour, daily suppressive acyclovir given from 36 weeks of gestation until delivery may be given to reduce the likelihood of HSV lesions at term [Ia, A].