Herpes

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Genital Herpes simplex virus (HSV) infection may be acquired from either symptomatic or asymptomatic partners, and from either genital or oral sexual contact. About 70% is caused by HSV type 2 but an increasing number of genital infections are due to HSV type 1. Most HSV infections are asymptomatic.

Clinical manifestations depend on site of viral entry and immunity from previous exposure. Manifestations of newly acquired infection may be severe in non-immune persons who have had no previous exposure. Sexually acquired manifestations include genital ulceration, gingiva-stomatitis, urethritis, cervicitis and proctitis.

DIAGNOSIS

Swab for viral HSV Polymerase Chain Reaction (PCR)
HSV serology should not be used in screening and only ordered when there are clear clinical indications.

MANAGEMENT

Due to the possibility of psychosexual morbidity often associated with a genital herpes diagnosis, patients should be given adequate education, information and referrals for counseling as required. Please see the patient fact sheet on this website.

Primary HSV/Initial episode
Treatment with antiviral medications is more effective when started early, but there are still benefits with initiating treatment after the onset of symptoms. There is no 72-hour rule for initiating antiviral treatment for herpes as there is for shingles.
The following options are equally effective:

  • Aciclovir 200 mg, two tablets three times daily for 7-10 days 
  • Valaciclovir 500 mg, one tablet twice daily for 7-10 days

Together with:

  • Lignocaine 2% jelly or LMX4 cream topically if needed. Exercise caution with topical anaesthesia as may cause sensitization with prolonged use. 


Paracetamol/codeine for pain relief

  • Antifungal medication (preferably oral) for thrush if present
  • Antibiotics if secondary bacterial infection is suspected. Topical antivirals and antibiotics are ineffective 
  • Education and counselling for psychosocial effects of reactivation and reoccurrences. 

Recurrent Genital Herpes
Episodic:
Episodic therapy should be self-initiated, commenced within 24 hours of symptom onset, and preferably at the prodromal or erythematous stage before vesicles appear. Patients should be advised to keep their medications readily available.

  • Famciclovir 250 mg, four tablets at once and repeated in 12 hours
  • Famciclovir 250 mg, two tablets at once and then three further doses of one tablet at 12-hourly Intervals
  • Aciclovir 200 mg, four tablets three times daily for 2 days

Suppressive:

  • Aciclovir 200 mg , two tablets twice daily 1,2
  • Famciclovir 250 mg, one tablet twice daily1,2 
  • Valaciclovir 500 mg , one tablet daily*

*In patients who have frequent recurrences (10 or more per year) once daily therapy using 500mg may be insufficient. These patients may require 500 mg tablets taken twice daily or two 500mg tablets once daily.
Education and counselling may be useful for psychosocial effects of recurrences.

Patients with proven genital herpes who have > 6 episodes annually are likely to experience substantial reduction in frequency of episodes on suppressive therapy.
All patients should be given information on advantages and disadvantages of suppressive therapy in the context of their overall clinical care.

Treatment may be interrupted at 6 months to evaluate natural history. A single episode after stopping suppressive therapy is not necessarily an indication for recommencement of suppression.

Disclaimer
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.

Last Updated Jamuary 2017