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Management of Primary and Recurrent HSV 2 Vulvar Infections

Author: Rajiv B. Gala, MD

Editor: Natalie Ann Bowersox, MD

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Serologic surveys show 26% of women 12 years and older have antibodies to HSV-2. While the initial presentation is similar for HSV-1 and HSV-2, most recurrences are caused by HSV-2. On average, women with HSV-1 will have one recurrence in the first year after diagnosis compared to four recurrences in women with HSV-2. Beyond the first year, recurrence rates decrease very slowly for HSV-2, but are rare for HSV-1. HSV infections intermittently reactivate, with or without accompanying symptoms, with resultant shedding of the virus in the genital tract.

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 despite an initial mild clinical presentation. All patients with first episodes 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. 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, and this should be followed with 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 known 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 where the source partner has known genital HSV-2 infection. 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.

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, and 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

Herpes - STI Treatment Guidelines ( - accessed 11/2022

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


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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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