Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Herpes genitalis
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Herpes genitalis (genital herpes) is a recurrent vesicular eruption of the skin and mucosa arising in the region between the navel, thighs, and buttocks. It is a common sexually transmitted disease, usually preceded by prodromal symptoms including itching, burning, and tingling, and caused predominantly by herpes simplex virus type 2 (HSV-2) and less frequently by HSV-1. First-episode genital herpes due to HSV-1 has become increasingly common in certain populations – namely, heterosexual women and men who have sex with men. Primary infection may have associated systemic, influenza-like signs and symptoms, including fever, headache, malaise, and myalgias, which occur 2–20 days following exposure. Lesions of the initial infection typically last 2–3 weeks, during which time they progress from grouped papules on an erythematous base, to vesicles, to ulcers with eventual crusting. Recurrences generally lack systemic symptoms and are less severe than the primary outbreak. Recurrent lesions, which typically last 5–10 days, occur in the same area but are fewer in number and heal quickly. Genital herpes infection due to HSV-1 results in fewer symptomatic recurrences than infection by HSV-2. Residual hypopigmentation, hyperpigmentation, and scarring may occur with healing.
Management Strategy
Because no cure exists for herpes genitalis, treatment is focused on reducing the number of recurrences through suppressive therapy and on promoting rapid healing when a recurrence is present. In addition, treatment aims to reduce infectivity by reducing viral shedding and to reduce complications, such as urinary retention and aseptic meningitis. In the past, topical and oral acyclovir were used as first-line treatments for recurrences. Due to its low bioavailability, it requires frequent dosing. The standard dosing of oral acyclovir for a recurrence is 200 mg five times daily for 5 days. Alternative regimens have also been shown to be effective, including 400 mg three times daily for 5 days, 800 mg three times daily for 2 days, and 800 mg twice daily for 5 days. The frequent dosing of acyclovir led to the development of valacyclovir and famciclovir (the prodrugs of acyclovir and penciclovir, respectively) as alternative therapies with improved bioavailability. The use of topical acyclovir should be discouraged because it has lower efficacy in comparison to oral acyclovir. Valacyclovir has been shown to be effective when dosed 500 mg twice daily for 3 days or 1000 mg once daily for 5 days. A dosing regimen of oral valacyclovir, given 2000 mg twice daily for 1 day, has been studied and shown to be more convenient; however, further comparative studies are needed. Famciclovir is effective when prescribed as 1000 mg twice daily for 1 day. It may also be taken as 125 mg twice daily for 5 days. Acyclovir, valacyclovir, and famciclovir may all be used for suppressive therapy.
Immunocompromised individuals have more frequent recurrences and can develop more severe lesions, thus requiring longer treatment periods with higher doses than those used in the immunocompetent. Severe cases may require intravenous therapy. Suppressive dosage regimens have been used in this population. Long-term therapy may lead to the selection of resistant strains of the virus. In acyclovir-resistant cases, intravenous therapy with foscarnet may be required.
Addressing psychosocial issues is another important aspect of genital herpes management. The recurrent nature of genital HSV infection can have a negative emotional and psychological impact on patients. Counseling serves to help patients cope with the infection and to prevent sexual and perinatal transmission.
Specific Investigations
Type-specific laboratory testing should be performed to distinguish HSV-2 infections from HSV-1 infections, as this has implications for disease course and patient counseling. Patients with confirmed genital herpes should be offered testing for HIV and other sexually transmitted diseases. Severe or refractory cases may be due to underlying immunosuppression, which should be further investigated.
Clinical evaluation and cost analysis of a Trioplex real-time PCR assay for the detection and differentiation of herpes simplex virus 1 and 2 in cutaneous and mucocutaneous lesions
Navidad J, Pfotenhauer B, Leigh N, et al. J Med Microbiol. 2019; 68: 748-54.
Performance of ELISA and Western blot to detect antibodies against HSV-2 using dried blood spots
García-Cisneros S, Sánchez-Alemán MÁ, Conde-Glez CJ, et al. J Infect Public Health 2019; 12: 224–8.
Precision of the Kalon herpes simplex virus type 2 IgG ELISA: an international interlaboratory assessment
Patel EU, Manucci J, Kahle EM, et al. BMC Infect Dis 2015; 15: 398.
Performance of the Focus HerpeSelect-2 EIA for the detection of herpes simplex virus type 2 antibodies in seven African countries
Mujugira A, Morrow RA, Celum C, et al. Sex Transm Infect 2011; 87: 238–41.
Effect of sexually transmitted disease (STD) coinfections on performance of three commercially available immunosorbent assays used for detection of herpes simplex virus type 2-specific antibody in men attending Baltimore, Maryland, STD clinics
Summerton J, Riedesel M, Laeyendecker O, et al. Clin Vaccine Immunol 2007; 14: 1545–9.
Using the evidence base on genital herpes: optimizing the use of diagnostic tests and information provision
Primary Genital Infection
Antiviral treatment should be initiated promptly, ideally within 72 hours of the appearance of lesions, and should be continued for 7–10 days. Treatment duration may be extended if adequate healing has not occurred. The following regimens may be used: acyclovir 400 mg three times daily or 200 mg five times daily; valacyclovir 1000 mg twice daily; or famciclovir 250 mg three times daily. Because acyclovir, valacyclovir, and famciclovir demonstrate similar efficacy, the initial drug choice may be based on factors such as provider preference, cost, and availability. Valacyclovir may be preferable due to the convenience of twice-daily dosing.
Genital herpes
Gnann JW Jr, Whitley RJ. N Engl J Med 2016; 375: 666–74.
Neonatal herpes simplex virus infections
Pinninti SG, Kimberlin DW. Semin Perinatol 2018; 42(3): 168–75.
Acute Reactivation Episodes
Standard-dose and high-dose daily antiviral therapy for short episodes of genital HSV-2 reactivation: three randomised, open-label, crossover trials
Johnston C, Saracino M, Kuntz S, et al. Lancet 2012; 379: 641–7. Erratum in: Lancet 2012; 379: 616.
Three open-label crossover studies compared no medication with acyclovir 400 mg twice daily (standard dose), valacyclovir 500 mg daily (standard dose) with acyclovir 800 mg three times daily (high dose), and standard-dose valacyclovir with valacyclovir 1 g three times daily (high dose). High-dose acyclovir was associated with less viral shedding than standard-dose valacyclovir, but there was no significant difference in time to lesion healing between the groups. High-dose valacyclovir had less viral shedding and shorter lesion healing time compared with its standard dose. Viral shedding persisted even in high-dose regimens.
Single-day therapy for recurrent genital herpes
Tyring S, Berger T, Yen-Moore A, et al. Am J Clin Dermatol 2006; 7: 209–11.
A multicenter, randomized, double-blind, placebo-controlled clinical trial found that famciclovir 1000 mg twice daily for 1 day, taken within 6 hours of prodrome onset, resulted in a significant reduction in lesion healing time and reduced the time of all symptom resolution compared with placebo. A greater proportion of subjects who took famciclovir did not progress to a full genital herpes outbreak compared with those taking placebo (23.3% vs. 12.7%, respectively).
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here
