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Management of Primary and Recurrent HSV 2 Vulvar Infections

11/1/2015 - Rajiv B. Gala, MD

Editor: Rebecca P. McAlister, MD

Background 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 in patients with longstanding or clinically silent infections.

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. In most cases, oral antiviral therapy for 7-10 days is sufficient. 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.

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 within 24 hours of lesion onset or during the prodrome that precedes outbreaks.

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 also be counseled on consistent use of barrier protection and the avoidance of sexual activity during recurrences to further minimize transmission.

Further Reading:

Centers for Disease Control and Prevention. Sexually Transmitted Disease Treatment Guidelines, 2015: Diseases Characterized by Genital, Anal, and Perianal Ulcers

Initial Approval: 5/1/2015, Revised: 11/1/2016



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