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Management of Primary and Recurrent HSV 2 Vulvar Infections

Genital herpes lesions can be caused by both HSV-1 and HSV-2. Serologic surveys show 26% of patients 12 years and older have antibodies to HSV-2, while nearly 70% of the population has antibodies to HSV-1. Most exposures of HSV1 occur through familial contact with oral herpes lesions, while most HSV2 exposures occur through sexual contact.  Management and prevention of transmission are similar for both viral strains and not affected by the type of HSV detected, however expectations regarding the clinical course are different.      

The initial presentation is similar for HSV-1 and HSV-2, however the rate of recurrent infection is higher for individuals with HSV2. On average, individuals with HSV-1 will have one recurrence in the first year after diagnosis, with subsequent recurrent infection rare. Comparatively, individuals with HSV2 will on average experience four recurrences in the first year after diagnosis, with recurrence rates decreasing slowly thereafter.  Intermittent reactivation of HSV and viral shedding in the genital tract occurs even in the absence of clinical symptoms.      

Treatment for the first clinical episode of genital herpes:

Newly acquired genital herpes can cause a prolonged clinical illness with severe genital ulcerations and neurologic involvement, therefore all patients with a first episode of genital herpes should receive antiviral therapy (acyclovir, valacyclovir or famciclovir). In most cases, oral antiviral therapy for 7-10 days is sufficient. Topical antiviral preparations offer minimal benefit and use is discouraged. Oral and topical analgesics should be provided as needed. Patients should receive counseling regarding the anticipated clinical course of genital herpes including risk of recurrence, the risk of sexual and perinatal transmission, and effective methods to reduce transmission, as discussed later in this publication. Intravenous therapy should be provided for patients who cannot tolerate oral intake, present with severe HSV disease, CNS complications like meningoencephalitis, or complications that would warrant hospitalization such as disseminated infection, hepatitis, or pneumonitis. Hospitalization may also be required for pain control or urinary retention. When IV treatment is recommended it should be continued until clinical improvement can be documented, followed by oral antiviral therapy for a total of 10 days.

Episodic treatment for recurrent genital herpes:

Timely initiation of oral antiviral therapy is the cornerstone to effective episodic treatment of recurrent genital herpes. Patients should have a sufficient supply of medication or active prescription to enable the initiation of therapy during the prodrome that precedes outbreaks or within 24 hours of lesion onset. Therapy duration depends on which antiviral medication is selected and ranges from 1-5 days.

Suppressive treatment for recurrent genital herpes:

Daily suppressive therapy has been found to reduce the frequency of genital herpes recurrences by 70%–80% in patients with frequent recurrences. Many patients report no symptomatic outbreaks while on daily suppression. Daily suppressive therapy is also an important strategy for reducing the rate of HSV-2 transmission among discordant couples.  Antiviral therapy in the source partner has been shown to decrease HSV-2 transmission to susceptible partners by 48%. Partners should be counseled on consistent use of barrier protection and the avoidance of sexual activity during recurrences to further minimize transmission. There is no data to support use of antivirals for pre or post exposure prophylaxis to prevent the acquisition of HSV infection.

Special populations:

Patients with HIV and pregnant women require adjustments in both episodic and suppressive therapy doses, with more frequent dosing and longer duration of therapy. Patients with HIV are also at risk of developing antiviral resistant strains.  Suppressive therapy reduces the risk of resistance as compared to episodic therapy. Pregnant women with recurrent HSV should initiate suppressive therapy at 36 weeks to reduce the risk of active HSV at delivery. 

Further Reading:

Centers for Disease Control and Prevention. Sexually Transmitted Disease Treatment Guidelines, 2021: Diseases Characterized by Genital, Anal, or Perianal Ulcers

U.S. Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. Available at Herpes - STI Treatment Guidelines (cdc.gov)

Initial Approval: May 2015, Revised November 2016, Revised March 2018, Revised: September 2019; Minor revision May 2021; Revised November 2022; Revised September 2024. Revised May 2026.

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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