Genital Herpes: Treatment Guidelines

, Withington Hospital and University of Manchester


Medscape General Medicine. 1997;1(2) 

In This Article

Recurrent HSV Management Strategies

Optimal management of recurrent HSV infection should ideally begin with counseling when first-episode HSV infection is diagnosed. At this stage, the patient should be educated regarding the nature of the disease, the chance of viral reactivation, possible trigger factors, and the availability of treatment.

Many patients with occasional recurrences simply require reassurance and guidance regarding avoidance of trigger factors and management of symptoms. Recommendations for saline bathing, preventing transmission to sexual partners, and the use of nonprescription analgesia are sufficient for those with mild, short-lived, and infrequent recurrences.

For those whose recurrences are more frequent or severe and interfere with everyday life or psychosexual functioning, a more active approach is needed. The clinician and patient may choose either episodic antiviral therapy with each recurrence or continuous suppressive antiviral therapy.

The most effective episodic treatment is patient initiation of a 5-day course of antiviral therapy upon onset of prodromal symptoms. Famciclovir 125mg twice daily,[8,9] acyclovir 200mg 5 times daily, or valacyclovir 500mg twice daily can be used. In a recurrent episode, the earlier the treatment is initiated, the more effective it is likely to be in decreasing the severity and duration of the recurrence. In the Canadian Famciclovir Study Group, patients who took famciclovir within 6 hours of onset of either prodromal symptoms or genital lesions experienced more rapid healing of lesions and less viral shedding. Further, those who took famciclovir before viral shedding were more likely not to shed the virus.[9]

Patients with frequent recurrences (generally >8 episodes/year), or who are psychologically disturbed or psychosexually disabled by the condition, should be considered for continuous suppressive therapy. In 1 study of continuous suppressive therapy given for a 16-week period, 78% of patients receiving famciclovir 250mg twice daily remained recurrence-free during the study period; the same result occurred in another similar study in which 69% of patients received valacyclovir 500mg daily.[10,11] Women should be advised that although no teratogenic properties have been ascribed to either of the active therapies (penciclovir or acyclovir), pregnancy should be avoided while taking medication. Usually a 6- to 12-month period is chosen for continuous therapy, during which the patient should be followed at regular intervals. After stopping suppressive treatment, patients should be asked to record the subsequent pattern of recurrences. For many, a single course will enable them to feel in control of their lives once again and enable them to cope better with subsequent recurrences. Others will require longer or multiple courses of treatment. Clinician concerns are unfounded regarding development of resistant strains of herpesvirus with long-term antiviral therapy. Although thymidine kinase-deficient strains have been described, these are rarely clinically significant.

Counseling/patient education. For many sufferers, recurrences of genital herpes are infrequent and merely an inconvenience. Often it is a nonfatal self-limiting condition that will finally remit for most healthy individuals. For others, however, the social and interpersonal difficulties inherent in the disease precipitate psychological reactions that can be so severe as to require clinical attention. What sets this disorder apart from many other infections is the unpredictability of recurrences, the fact that lesions are present on intimate parts of the body, the extent of inaccurate and sensational media reporting, and the moral issues surrounding sexual behavior. A combination of these factors can place an extreme psychological burden on an infected individual. The clinician should be attentive to the patient's psychological as well as physical health and should not hesitate to refer the patient for additional psychotherapy if indicated.

Recurrent genital herpes can have a pervasive negative effect on the emotional life of sufferers; some may become more deeply depressed with each recurrence. There is a tendency for herpes to be regarded as a personal handicap in which a part of the self is lost, which often results in anger directed toward oneself, sexual partner(s), insensitive medical management, and friends and relatives. Few herpes sufferers feel able to talk about the disease to the people from whom they would normally seek support and comfort--family, friends, and spouse/sexual partner. Affected persons find it particularly distressing that the condition cannot be cured, and they may experience a feeling of loss of control over their lives. This can foster helplessness that, in turn, may lead to despair of ever recovering.

According to a survey of members of self-help groups in California, most recurrent herpes sufferers reported a profound effect on their sexual functioning because of the anxiety arising from the condition.[12] There appears to be minimal interference with sexual drive; however, many experience diminished sexual pleasure even in the absence of symptoms because of the anxiety and insecurity associated with fears of transmitting the disease. Patients may experience despair and fear of rejection concerning the formation of new sexual relationships, which may affect their capability for physical warmth, intimacy, and enjoyment of sex. Herpes sufferers may also experience a loss of sexual confidence that adversely affects feelings of sexual desirability.

Ethical issues arise when considering whether, when, and with whom to have sex and the circumstances under which partners should be notified. About 10% consider celibacy as the only reasonable option,[13] and this may be chosen as being preferable to rejection or because it is thought to lessen the chances of a recurrence being triggered. Other responses include limiting sexual contacts to other herpes sufferers, dating people in whom there is little interest to avoid later disappointment, or staying in unfulfilling relationships. If the patient asks whether to reveal the diagnosis of genital herpes to her sexual partner, suggest that she ask whether she would want to know if she were the partner.

Fear of spreading the disease can result in an avoidance of using other people's bathroom facilities and a compulsion to change sheets and towels and to wash one's hands more frequently than necessary.[14]

Recent studies among women with genital herpes have shown that subclinical shedding of HSV is relatively common, and the virus is shed approximately 2% of all asymptomatic days.[15] Shedding was most commonly detected around the time of a clinical recurrence and among women who had frequent recurrences. Nonetheless, asymptomatic viral shedding and the risk of infecting a sexual partner can occur at any time.