Herpes Simplex

Description

Alternative Names

Treatment for Genital Herpes

Choosing the right therapy for HSV depends on the site of the infection and whether the attack is primary or recurrent. To be effective against recurrent HSV infection, treatment of herpes must be initiated in the first week of a primary infection. Later treatment has limited effect in preventing recurrent infection.

Genital herpes is usually caused by HSV-2, but the percentage of genital HSV-1 cases is rising, and new HSV-1 genital cases now equal or exceed those caused by HSV-2. Since there is no difference in treatment, however, differentiating between genital infections caused by HSV-1 or HSV-2 has little practical value. The treatment of infected pregnant women and newborns requires very careful attention.

Treatment for Primary Attacks of Genital Herpes

Oral Agents. Acyclovir is usually administered orally for genital HSV. There is no additional benefit derived from the simultaneous use of both oral and topical types. Oral acyclovir may be prescribed for seven to 10 days during primary infections; benefit occurs within one to three days if the drug is started promptly. When taken early enough, acyclovir reduces the duration of the infection, its pain, and new lesion formation, and also reduces viral shedding.

The newer drugs are also effective. In one study, patients who took 500 mg of the oral form of valacyclovir twice daily for five days experienced faster resolution of pain, a shorter shedding stage, and less severe lesions than those who did not take the drug. Another study reported that a three-day course of valacyclovir might be equally effective.

Topical Agents. Ointments are available for a primary attack but are not as effective as the oral form and have no benefit for recurring infection.

• A penciclovir cream is effective in reducing pain and duration of the infection.
• One study suggested that adding a steroid ointment to an oral anti-viral agent can reduce pain and symptoms. (Some people report that even over-the-counter cortisone ointments can be helpful.)
• Topical 5% lidocaine jelly can be used as a local anesthetic for pain.
• Some oral agents may complement topical treatments. For severe itching in adults or children, diphenhydramine (Benadryl) may be useful, or a physician can prescribe drugs such as hydroxyzine (Atarax or Vistaril).

Treatment for Recurrence of Genital Herpes

Intermittent Treatment for Recurring Outbreaks. Most recurrent infections are mild enough so that treatment is not needed. When it is, acyclovir, famciclovir, or valacyclovir are all useful. The standard recommendation had been to take one of these drugs for five days, although studies now indicate that shorter courses of just two days (for acyclovir) or three days (for valacyclovir) are just as effective.

Preventive Therapy. Some patients may benefit from intermittent, short-term preventive (prophylactic) therapy of acyclovir, valacyclovir, or famciclovir during periods or prior to events when outbreaks are likely.

Suppressive Therapy. Daily long-term preventive therapy, called suppressive therapy, may be appropriate in certain patients to prevent severe long-lasting recurrences, to reduce the risk of transmitting the virus, and to improve quality of life. Acyclovir is the standard agent, but famciclovir and valacyclovir are also effective. In some studies, suppressive therapy using acyclovir has reduced the frequency of recurrence in 80% of patients and prevented recurrence altogether in up to 30%. In one study of famciclovir, after a year, up to 80% of patients had no recurrences. In others trials using valacyclovir, patients preferred suppressive therapy and it was more effective than intermittent treatment.

If an infection occurs during suppressive therapy, healing time is quicker and symptoms are less severe. Suppressive therapy may also reduce the risk for development of drug-resistant viruses compared to intermittent treatments.

Once the disease is under control, some physicians gradually decrease the dose of the drug used in suppressive therapy. In general, people stop taking suppressive therapy after about two years.

Some, however, stay on this therapy for many more years. In one study, patients who started treatment with an average annual recurrence rate of 13% experienced only a 0.6% recurrence rate after 10 years on suppressive study. In another, patients reported a significant reduction in recurrence rates by the seventh year after the first infection.

The treatment is expensive. And, since the frequency of recurrences diminishes over time without suppressive therapy, lifelong use of drugs is not generally recommended. Some experts warn, however, that unless suppressive therapy becomes widespread and prolonged, transmission of the virus will remain a major health problem and the prevalence of HSV-2 infection will not significantly decrease.