Laboratory tests

A. Diagnosis of genital herpes requires the characteristic history and physical appearance of lesions plus the selective use of immunofluorescent assay or viral culture.

B. Immunofluorescent assays rapidly detects HSV in smears. Viral culture requires 48-96 hours and has an accuracy rate of 85-90%. Serologies are not useful since antibodies become permanently positive after infection.

Treatment of HSV Infections

Type of infection

Dosage/regimen

Considerations

Primary infection

Acyclovir (Zovirax) 400 mg

Valacyclovir (Valtrex) 500

mg PO bid x 10 days or Famciclovir (Famvir) 125

mg PO bid x 10 days Acyclovir (Zovirax) 5 mg/kg IV q8h over one hour for 5-7 or until clinical resolution

Preferred route in immuno-competent patients

Only for severe symptoms or complications

Recurrent infection Episodic therapy

Acyclovir (Zovirax) 400 mg

PO tid or 800 mg bid for 5 days or Valacyclovir (Valtrex) 500 mg PO bid for 5 days or Famciclovir (Famvir) 125 mg PO bid for 5 days

Treatment is most effective when initiated at the earliest sign of recurrence; it is of no benefit if initiated more than 48 hours after symptom onset

Suppressive therapy

Acyclovir (Zovirax) 400 mg

PO bid

Indicated for patients with frequent and/or severe recurrences (>6 outbreaks/year)

C. Acyclovir (Zovirax) is the drug of choice for the treatment and suppression of genital herpes. It is usually well tolerated, but nausea, vomiting, rash, or headache occur rarely. Topical acyclovir is not effective. Serious or life-threatening HSV infections require intravenous acyclovir.

D. Other antivirals have more convenient bid dosing, but are more expensive than acyclovir and not more effective.

1. Valacyclovir (Valtrex) 500 mg bid x 5 days.

2. Famciclovir (Famvir) 125 mg bid x 5 days.

E. Oral analgesics and sitz baths are useful. The area should be kept clean and dry with corn starch, baby powder, or a hair dryer. Pyridium may be useful for dysuria.

IV. Patient counseling

A. Patients should be warned about HSV autoinoculation from one body site to another. Infected areas should be patted dry rather than wiped dry. Sunscreen and lip balm are recommended to reduce recurrent disease.

B. Patients should be advised to abstain from sexual activity while lesions are present. Use of latex condoms is encouraged because of asymptomatic viral shedding.

C. The risk of neonatal transmission must be explained to the patient.

D. Recommended testing includes evaluation for gonorrhea, chlamydia, syphilis, genital warts, and human immunodeficiency virus (HIV).

V. Treatment of recurrences

A. Episodic acyclovir therapy. Early initiation of therapy has been shown to produce a reduction in the duration of symptoms. The patient should keep a supply of acyclovir and begin treatment at the earliest prodromal symptom.

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