Recurrent Genital Herpes

Aka: Recurrent Genital Herpes, Secondary Genital Herpes, Chronic Genital Herpes, Herpetic Vulvovaginitis, Herpetic Vulvar Ulcer, Herpetic Penile Lesion, Herpetic Cervicitis

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II. History: Prodrome (occurs in 50% of cases, hours to days before lesions)

  1. Focal genital Paresthesias, dysesthesia, numbness

III. Signs

  1. Lymphadenopathy: slight, mildly tender
  2. Vessicles ulcerate and then crust
    1. Solitary or 3-4
    2. Enlarges over 3-4 days
    3. Peaks at 4-8 days

IV. Diagnosis

  1. See HSV Test

V. Course

  1. Viral shedding during first 3-4 days
  2. Recurrence: 5-8 episodes per year

VI. Management: Episodic in Immunocompetent Patients (Start within 24 hours of first symptoms):

  1. Acyclovir
    1. Acyclovir 400 mg orally three times daily for 5 days OR
    2. Acyclovir 800 mg orally twice daily for 5 days OR
    3. Acyclovir 800 mg orally three times daily for 2 days
      1. Two day regimen as effective as 5 day
      2. Wald (2002) Clin Infect Dis 34:944-8 [PubMed]
  2. Famciclovir
    1. Famciclovir 125 mg orally twice daily for 5 days OR
    2. Famciclovir 250 mg orally twice daily for 2 days (500 mg for first dose) OR
    3. Famciclovir 1000 mg orally twice daily for 1 day
  3. Valacyclovir
    1. Valacyclovir 500 mg orally twice daily for 3 days OR
    2. Valacyclovir 1000 mg orally once daily for 5 days

VII. Management: Episodic in Immunocompromised Patients (e.g. HIV)

  1. Acyclovir
    1. Acyclovir 400 mg orally three times daily for 5-10 days
  2. Famciclovir
    1. Famciclovir 500 mg orally twice daily for 5-10 days
  3. Valacyclovir
    1. Valacyclovir 1000 mg orally twice daily for 5-10 days

VIII. Management: Suppression/Prophylaxis in Immunocompetent Patients

  1. Suppression reduces recurrences by ~50%
  2. Indications for suppression
    1. More than 6 episodes per year
    2. Consider for disabling episodes less often
  3. Acyclovir
    1. Acyclovir 400 mg orally twice daily
    2. Duration
      1. Typically used for 12 months (Appears safe for up to 6 years)
      2. Consider as prophylaxis at stress times
    3. Efficacy
      1. Decreases episodes from 11.4 to 1.8 per year
      2. Kaplowitz (1991) JAMA 265:747-51 [PubMed]
  4. Famciclovir
    1. Famciclovir 250 mg orally twice daily
  5. Valacyclovir
    1. Valacyclovir 500 to 1000 mg orally daily
    2. Efficacy
      1. Reduces HSV-2 transmission to partner by 50%
      2. Corey (2004) N Engl J Med 350:11-20 [PubMed]

IX. Management: Suppression/Prophylaxis in Immunocompromised Patients (e.g. HIV)

  1. Acyclovir 400 to 800 mg orally twice to three times daily OR
  2. Famciclovir 500 mg orally twice daily OR
  3. Valaciclovir 500 mg orally twice daily

X. Course

  1. Recurrence rate: Four episodes per year
  2. Factors predictive of more frequent recurrences
    1. Severe primary outbreak
    2. Male gender
    3. More frequent initially, decrease over time
    4. Exposure to provocative factors
      1. Fever
      2. Trauma
      3. Stressful situations
      4. Heat or cold extreme exposure
      5. Immunocompromised
      6. Menses

XI. References

  1. Beauman (2005) Am Fam Physician 72(8):1527-34 [PubMed]
  2. Cleach (2014) Cochrane Database Syst Rev (8):CD009036 [PubMed]
  3. Gnan (2016) N Engl J Med 375(7):666-74 +PMID:27532832 [PubMed]
  4. Groves (2016) Am Fam Physician 93(11): 928-34 [PubMed]
  5. Kimberlin (2004) N Engl J Med 350(19): 1970-7 [PubMed]
  6. Nadelman (2000) Postgrad Med 107(3):189-95 [PubMed]
  7. Plunkett (2024) Am Fam Physician 110(5): 487-92 [PubMed]

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