Herpes simplex genitalis antiviral treatment of first episode genital herpes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Newly acquired genital herpes can cause a prolonged clinical illness with severe genital ulcerations and neurologic involvement. Patients with first-episode herpes who have mild clinical manifestations initially can develop severe or prolonged symptoms. Therefore, all patients with first episodes of genital herpes should receive antiviral therapy.

Principles of Management of Genital Herpes

• Antiviral chemotherapy offers clinical benefits to the majority of symptomatic patients and is the mainstay of management.
• Systemic antiviral drugs can partially control the signs and symptoms of herpes episodes when used to treat first clinical episodes 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 with antiviral drugs offers minimal clinical benefit, and its use is discouraged.

First Clinical Episode of Genital Herpes

• Many patients with first-episode herpes have mild clinical manifestations but later develop severe or prolonged symptoms. Therefore, patients with initial genital herpes should receive antiviral therapy.
• General advice:

• Saline bathing
• Analgesia
• Topical anaesthetic agents such as 5% lidocaine ointment may be useful to apply especially prior to micturition but should be used with caution because of the risk of potential sensitization.

• Anti-viral therapy:

• Oral antiviral drugs are indicated within 5 days of the start of the episode and while new lesions are still forming.
• Antiviral therapy does not alter the natural history of the disease.
• Topical agents are less effective than oral agents. Combined oral and topical treatment is of no benefit.
• Intravenous therapy is indicated only when the patient cannot swallow or tolerate oral medication because of vomiting.
• There is no evidence for benefit from courses longer than five days. However, it may be prudent to review the patient after 5 days and continue therapy if new lesions are still appearing at this time.

Herpes Simplex Initial Episode Preferred Regimen ▸ Acyclovir 400 mg po tid x 7-10 days OR ▸ Famciclovir 250 mg po tid x 7-10 days OR ▸ Valacyclovir 1000 mg bid x 7-10 days Alternative Regimen(severe cases) ▸ Acyclovir 5 mg/kg IV q8h x 5–7 days Alternative Regimen(HSV resistance) ▸ Foscarnet 90 mg/kg IV q12h x 7 days

Established HSV-2 Infection

• Almost all persons with symptomatic first-episode genital HSV-2 infection subsequently experience recurrent episodes of genital lesions; recurrences are less frequent after initial genital HSV-1 infection.
• Intermittent asymptomatic shedding occurs in persons with genital HSV-2 infection, even in those with longstanding or clinically silent infection.
• Antiviral therapy for recurrent genital herpes can be administered either as suppressive therapy to reduce the frequency of recurrences or episodically to ameliorate or shorten the duration of lesions.
• Some persons, including those with mild or infrequent recurrent outbreaks, benefit from antiviral therapy; therefore, options for treatment should be discussed.
• Many persons might prefer suppressive therapy, which has the additional advantage of decreasing the risk for genital HSV-2 transmission to susceptible partners

Management of Complications

• Hospitalisation may be required for urinary retention, meningism, and severe constitutional symptoms.

• If catheterisation is required, suprapubic catheterisation is preferred to prevent theoretical risk of ascending infection, to reduce the pain associated with the procedure, to allow normal micturition to be restored without multiple removals and re-catheterisations