Patient Management/Treatment (continued)

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 continuously as suppressive therapy to reduce the frequency of occurrences, or episodically, to ameliorate or shorten the duration of lesions. Treatment options should be discussed with ALL patients.

Suppressive 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). Quality of life often is improved for patients with frequent recurrences who receive suppressive therapy compared with episodic therapy. Many patients report no symptomatic outbreaks. Daily treatment with valacyclovir 500 mg daily decreases the rate of HSV-2 transmission in discordant, heterosexual couples in which the source partner has a history of genital HSV-2 infection. Such couples should be encouraged to consider suppressive antiviral therapy as part of a strategy to prevent transmission, in addition to consistent condom use and avoidance of sexual activity during recurrences. 

CDC-recommended regimens for suppressive therapy for recurrent infection are as follows:

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.

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