Genital herpes guide: Treatment and follow-up
Treatment and follow-up guidance for the genital herpes.
Note: This guide provides minimal information about neonatal herpes. For more information, refer to the Canadian Paediatric Society Position Statement about the prevention and management of neonatal herpes simplex virus infections.
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Management and treatment
The management of people with genital herpes includes psychological support and counselling to help them understand and cope with chronic infection. See Genital Herpes Counselling Tool.
Treatment indicationsFootnote 1Footnote 2
Treatment can accelerate healing, prevent complications, reduce psychological burden, improve quality of life and reduce the risk of transmissionFootnote 3.
Indications for treatment include:
- First episode of genital herpes, before crusting occurs;
- Recurrent episodes (during prodromal) symptoms;
- Highly symptomatic episodes;
- Disseminated and severe disease;
- Infection in pregnancy;
- Neonates exposed to herpes simplex virus;
- Being born vaginally to the birthing parent who had a first episode of herpes infection within the 6 weeks preceding deliveryFootnote 4.
Treatment
The following treatment options are recommended in the absence of contraindication. Consult product monographs for contraindications, safety data and side effects.
Medications used to treat genital herpes include oral acyclovir, valacyclovir and famciclovirFootnote 3. These medications have comparable efficacyFootnote 5Footnote 6Footnote 7Footnote 8. Topical acyclovir should not be used because it is not as effective as oral antiviral treatments and does not alleviate systemic signs and symptomsFootnote 9.
Start antiviral medications as soon as possible as they can reduce the duration of viral shedding, time to crusting and healing of lesions, duration of local pain and constitutional symptomsFootnote 7Footnote 9Footnote 10.
First episodes of genital herpes are typically treated with antiviral medications unless all lesions have crusted or healed. Decisions on suppressive and episodic treatment should be individualized. Consider the annual frequency or severity of recurrences, quality of life and the need to prevent transmission to sexual partners and neonates.
Analgesia and laxatives may be required for outbreaks of anal herpes.
Non-pregnant persons
First episode in a non-pregnant adult
- Acyclovir 200 mg PO five times per day for 5-10 days [A-I]Footnote 9
or - Famciclovir 250 mg PO TID for 5 days [A-I]Footnote 10
or - Valacyclovir 1000 mg PO BID for 10 days [A-I]Footnote 7
Provide antiviral treatment to those experiencing a first episode of genital herpes unless all lesions have already healed.
For maximum benefits of oral treatment, these medications should be started within the following timeframes:
- Acyclovir, within 7 days after symptom onset [A-I]Footnote 9
- Famciclovir, within 5 days after symptom onset [A-I]Footnote 10
- Valacyclovir, within 3 days after symptom onset [A-I]Footnote 7
Recurrent episodes in a non-pregnant adult
-
Valacyclovir 500 mg PO BID OR 1 g PO once daily for 3 days [B-I]Footnote 11
or - Famciclovir 125 mg PO BID for 5 days [B-I]Footnote 12
or - Acyclovir 200 mg PO 5 times per day for 5 days [C-I]Footnote 13
Prompt initiation of episodic antiviral therapy at the onset of prodromal symptoms may shorten the severity and duration of lesionsFootnote 12.
Notes:
- A shorter course of acyclovir 800 mg PO TID for 2 days appears as efficacious as acyclovir 200 mg PO 5 times/day for 5 days [B-I]
- Valacyclovir should be initiated within 12 hours after symptom onsetFootnote 11.
- Famciclovir should be initiated within 6 hours after symptom onsetFootnote 12.
Suppressive therapy in a non-pregnant adult
- Acyclovir 200 mg PO 3-5 five times per day or 400 mg PO BID [A-I]Footnote 14Footnote 15Footnote 16Footnote 17Footnote 18Footnote 19Note de bas de page 20
or - Famciclovir 250 mg PO BID [A-I]Footnote 21Footnote 22
or - Valacyclovir 500 mg PO OD [A-I] (for people with ≤ 9 recurrences per year)Footnote 20Footnote 23
or - Valacyclovir 1000 mg PO OD [A-I] (for people with >9 recurrences per year)Footnote 20Footnote 23
Daily suppressive antiviral therapy reduces the length, frequency and severity of recurrences, asymptomatic viral shedding and transmission, but does not eradicate the virusFootnote 24Footnote 25Footnote 26. It can also reduce psychological morbidity in people with multiple recurrencesFootnote 27. As such, it may be indicated for:
- Frequent recurrences (generally every 2 months or 6 times per year)
- People experiencing significant complications from infectionFootnote 28
- Serodifferent or serodiscordant partnersFootnote 29
- People with multiple sexual partnersFootnote 29
The need to continue suppressive therapy should be re-evaluated annuallyFootnote 12Footnote 15Footnote 18Footnote 23Footnote 30. Refer to product monographs for safety information.
Pregnant persons
First episode and recurrences in pregnancy
Acyclovir 200 mg PO QID for 5-10 days [A-I]Footnote 31
A newly acquired (primary) HSV infection during pregnancy should be treated with either oral or intravenous acyclovir, depending on the severity of infectionFootnote 1. Treatment with oral acyclovir is also recommended for non-primary and recurrent episodes during pregnancyFootnote 1Footnote 32.
Caesarean delivery can reduce the risk of vertical transmissionFootnote 33. Caesarean delivery is recommended in the case of newly acquired genital HSV in the third trimesterFootnote 33 and particularly:
- If genital lesions or prodromal symptoms are present at the time of delivery or within 6 weeks prior to deliveryFootnote 1.
- In the event of ruptured membranes, ideally within 4 hours, as it is thought to prevent transmission to the newbornFootnote 34Footnote 35.
Suppressive therapy in pregnancy
- Acyclovir 200 mg PO QID [A-I]Footnote 34Footnote 36
or - Acyclovir 400 mg PO TID [A-I]Footnote 31Footnote 37
or - Valacyclovir 500 mg PO BID [A-I]Footnote 38
These regimens have been shown to be effective in reducing the risk of symptomatic recurrences and asymptomatic viral shedding at the time of delivery and the need for Caesarean sectionFootnote 38Footnote 39Footnote 40.
Suppressive therapy should be initiated at 36 weeks and continued until delivery for anyone with a history of HSV-2 and for those who had a recurrence of genital herpes within the previous year. Caesarean section is not necessary unless genital lesions are present during labourFootnote 31Footnote 34Footnote 36Footnote 37Footnote 38.
Complicated herpes
Individuals with complications such as aseptic meningitis, transverse myelitis or disseminated herpes may require intravenous acyclovir treatment and hospitalization. They should be managed by or in consultation with an infectious disease specialist or an experienced colleague.
Urinary retention may occur and may require specialized care if it is not self-limitedFootnote 31Footnote 34Footnote 36Footnote 37Footnote 38.
Neonatal herpes
Infants exposed to HSV during birth should be followed carefully and managed by or in consultation with a paediatric infectious disease specialist or an experienced colleague. Infants with neonatal herpes require hospitalization and prompt treatment with intravenous acyclovir. Oral antivirals are inadequate to prevent complications. Refer to the Canadian Paediatric Society position statement for information on the prevention and management of neonatal herpes.
Follow up
Encourage people to consult their healthcare provider for recurrent episodes as needed.
The need for continued suppressive therapy should be re-evaluated annuallyFootnote 12Footnote 15Footnote 18Footnote 23Footnote 30. Refer to product monographs for safety information.
Follow-up testing is not indicated, except:
- When there are unusual or recurrent signs and symptoms
- To determine in vitro susceptibility when resistance is suspected as a cause of therapeutic failure
Reporting and partner notification
National/provincial/territorial notification
Genital and neonatal herpes infections are reportable in some provinces and territories. Refer to your provincial or territorial reporting guidelines.
Sexual partners
Partner notification is not required as a public health measure for genital herpes, in part because most first episodes are recurrences and because it is difficult to assess whether a sexual partner already has HSV.
People experiencing a first episode of genital herpes should be encouraged to inform their most recent partner(s) and future partners to make them aware of the risk of infection, so that partners may consult their healthcare provider as needed for diagnosis and treatment. People with recurrent disease should also be encouraged to inform current and future sexual partner(s).
References
- Footnote 1
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Patel R, Kennedy OJ, Clarke E, et al. 2017 European guidelines for the management of genital herpes. Int J STD AIDS. 2017;28(14):1366-1379.
- Footnote 2
-
Aoki FY. Contemporary antiviral drug regimens for the prevention and treatment of orolabial and anogenital herpes simplex virus infection in the normal host: Four approved indications and 13 off-label uses. Can J Infect Dis. 2003;14(1):17-27.
- Footnote 3
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Piret J, Boivin G. Resistance of herpes simplex viruses to nucleoside analogues: mechanisms, prevalence, and management. Antimicrob Agents Chemother. 2011;55(2):459-472.
- Footnote 4
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Foley E, Clarke E, Beckett V. Management of genital herpes in pregnancy. BASHH Royal college of Obstetricians & Gynaecologists 2014.
- Footnote 5
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Le Cleach L, Trinquart L, Do G, et al. Oral antiviral therapy for prevention of genital herpes outbreaks in immunocompetent and nonpregnant patients. Cochrane Database Syst Rev. 2014;(8):CD009036. Published 2014 Aug 3.
- Footnote 6
-
Le Cleach L, Trinquart L, Do G, et al. Oral antiviral therapy for prevention of genital herpes outbreaks in immunocompetent and nonpregnant patients. Cochrane Database Syst Rev. 2014;(8):CD009036. Published 2014 Aug 3.
- Footnote 7
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Fife KH, Barbarash RA, Rudolph T, Degregorio B, Roth R. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection. Results of an international, multicenter, double-blind, randomized clinical trial. The Valaciclovir International Herpes Simplex Virus Study Group. Sex Transm Dis. 1997;24(8):481-486.
- Footnote 8
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Bodsworth NJ, Crooks RJ, Borelli S, et al. Valaciclovir versus aciclovir in patient initiated treatment of recurrent genital herpes: a randomised, double blind clinical trial. International Valaciclovir HSV Study Group. Genitourin Med. 1997;73(2):110-116.
- Footnote 9
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Mertz GJ, Critchlow CW, Benedetti J, et al. Double-blind placebo-controlled trial of oral acyclovir in first-episode genital herpes simplex virus infection. JAMA. 1984;252(9):1147-1151.
- Footnote 10
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Loveless M, Harris JRW, Sacks SL. Famciclovir in the management of first-episode genital herpes. Infect Dis Clin Pract 1997;6(suppl 1):S12–S16.
- Footnote 11
-
Spruance SL, Tyring SK, DeGregorio B, Miller C, Beutner K. A large-scale, placebo-controlled, dose-ranging trial of peroral valaciclovir for episodic treatment of recurrent herpes genitalis. Valaciclovir HSV Study Group. Arch Intern Med. 1996;156(15):1729-1735.
- Footnote 12
-
Sacks SL, Aoki FY, Diaz-Mitoma F, Sellors J, Shafran SD. Patient-initiated, twice-daily oral famciclovir for early recurrent genital herpes. A randomized, double-blind multicenter trial. Canadian Famciclovir Study Group. JAMA. 1996;276(1):44-49.
- Footnote 13
-
Tyring SK, Douglas JM Jr, Corey L, Spruance SL, Esmann J. A randomized, placebo-controlled comparison of oral valacyclovir and acyclovir in immunocompetent patients with recurrent genital herpes infections. The Valaciclovir International Study Group. Arch Dermatol. 1998;134(2):185-191.
- Footnote 14
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Sacks SL, Fox R, Levendusky P, et al. Chronic suppression for six months compared with intermittent lesional therapy of recurrent genital herpes using oral acyclovir: effects on lesions and nonlesional prodromes. Sex Transm Dis. 1988;15(1):58-62.
- Footnote 15
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Mindel A, Weller IV, Faherty A, et al. Prophylactic oral acyclovir in recurrent genital herpes. Lancet. 1984;2(8394):57-59.
- Footnote 16
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Mertz GJ, Jones CC, Mills J, et al. Long-term acyclovir suppression of frequently recurring genital herpes simplex virus infection. A multicenter double-blind trial. JAMA. 1988;260(2):201-206
- Footnote 17
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Baker DA, Blythe JG, Kaufman R, Hale R, Portnoy J. One-year suppression of frequent recurrences of genital herpes with oral acyclovir. Obstet Gynecol. 1989;73(1):84-87.
- Footnote 18
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Kroon S, Petersen CS, Andersen LP, Rasmussen LP, Vestergaard BF. Oral acyclovir suppressive therapy in severe recurrent genital herpes. A double-blind, placebo-controlled cross-over study. Dan Med Bull. 1989;36(3):298-300.
- Footnote 19
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Mostow SR, Mayfield JL, Marr JJ, Drucker JL. Suppression of recurrent genital herpes by single daily dosages of acyclovir. Am J Med. 1988;85(2A):30-33.
- Footnote 20
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Reitano M, Tyring S, Lang W, et al. Valaciclovir for the suppression of recurrent genital herpes simplex virus infection: a large-scale dose range-finding study. International Valaciclovir HSV Study Group. J Infect Dis. 1998;178(3):603-610.
- Footnote 21
-
Mertz GJ, Loveless MO, Levin MJ, Kraus SJ, Fowler SL, Goade D, et al. Oral famciclovir for suppression of recurrent genital herpes simplex virus infection in women: a multicenter, double-blind, placebo-controlled trial. Arch Intern Med 1997;157(3):343-349.
- Footnote 22
-
Diaz-Mitoma F, Sibbald RG, Shafran SD, Boon R, Saltzman RL. Oral famciclovir for the suppression of recurrent genital herpes: a randomized controlled trial. Collaborative Famciclovir Genital Herpes Research Group. JAMA. 1998;280(10):887-892.
- Footnote 23
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Patel R, Bodsworth NJ, Woolley P, et al. Valaciclovir for the suppression of recurrent genital HSV infection: a placebo controlled study of once daily therapy. International Valaciclovir HSV Study Group. Genitourin Med. 1997;73(2):105-109.
- Footnote 24
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Heslop R, Roberts H, Flower D, Jordan V. Interventions for men and women with their first episode of genital herpes. Cochrane Database Syst Rev. 2016;(8):CD010684. Published 2016 Aug 30.
- Footnote 25
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Casper C, Wald A. Condom use and the prevention of genital herpes acquisition. Herpes. 2002;9(1):10-14.
- Footnote 26
-
Corey L, Wald A, Patel R, et al. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med. 2004;350(1):11-20
- Footnote 27
-
Carney O, Ross E, Ikkos G, Mindel A. The effect of suppressive oral acyclovir on the psychological morbidity associated with recurrent genital herpes. Genitourin Med. 1993;69(6):457-459.
- Footnote 28
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Money D, Steben M. No. 207-Genital Herpes: Gynaecological Aspects. J Obstet Gynaecol Can. 2017;39(7):e105-e111.
- Footnote 29
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Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015 [published correction appears in MMWR Recomm Rep. 2015 Aug 28;64(33):924]. MMWR Recomm Rep. 2015;64(RR-03):1-137.
- Footnote 30
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Blom I, Bäck O, Egelrud T, et al. Long-term oral acyclovir treatment prevents recurrent genital herpes. Dermatologica. 1986;173(5):220-223.
- Footnote 31
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Watts DH, Brown ZA, Money D, et al. A double-blind, randomized, placebo-controlled trial of acyclovir in late pregnancy for the reduction of herpes simplex virus shedding and cesarean delivery. Am J Obstet Gynecol. 2003;188(3):836-843.
- Footnote 32
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Prober CG, Sullender WM, Yasukawa LL, Au DS, Yeager AS, Arvin AM. Low risk of herpes simplex virus infections in neonates exposed to the virus at the time of vaginal delivery to mothers with recurrent genital herpes simplex virus infections. N Engl J Med. 1987;316(5):240-244.
- Footnote 33
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Brown ZA, Wald A, Morrow RA, Selke S, Zeh J, Corey L. Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. JAMA 2003;289(2):203-209.
- Footnote 34
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Braig S, Luton D, Sibony O, et al. Acyclovir prophylaxis in late pregnancy prevents recurrent genital herpes and viral shedding. Eur J Obstet Gynecol Reprod Biol. 2001;96(1):55-58.
- Footnote 35
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Amstey MS, Monif GR. Genital herpesvirus infection in pregnancy. Obstet Gynecol. 1974;44(3):394-397.
- Footnote 36
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Stray-Pedersen B. Acyclovir in late pregnancy to prevent neonatal herpes simplex. Lancet. 1990;336(8717):756.
- Footnote 37
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Scott LL, Sanchez PJ, Jackson GL, Zeray F, Wendel GD Jr. Acyclovir suppression to prevent cesarean delivery after first-episode genital herpes. Obstet Gynecol. 1996;87(1):69-73.
- Footnote 38
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Sheffield JS, Hill JB, Hollier LM, et al. Valacyclovir prophylaxis to prevent recurrent herpes at delivery: a randomized clinical trial [published correction appears in Obstet Gynecol. 2006 Sep;108(3 Pt 1):695]. Obstet Gynecol. 2006;108(1):141-147.
- Footnote 39
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Scott LL, Hollier LM, McIntire D, Sanchez PJ, Jackson GL, Wendel GD Jr. Acyclovir suppression to prevent recurrent genital herpes at delivery. Infect Dis Obstet Gynecol. 2002;10(2):71-77.
- Footnote 40
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Sheffield JS, Hollier LM, Hill JB, Stuart GS, Wendel GD. Acyclovir prophylaxis to prevent herpes simplex virus recurrence at delivery: a systematic review. Obstet Gynecol. 2003;102(6):1396-1403.
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