Recurrent Genital Herpes

Aka: Recurrent Genital Herpes, Secondary Genital Herpes, Chronic Genital Herpes

1. See Also
   1. Genital Herpes in Pregnancy
   2. Genital Herpes
   3. Primary Genital Herpes
   4. Genital Ulcer
   5. Sexually Transmitted Disease
2. History: Prodrome (occurs in 50% of cases, hours to days before lesions)
   1. Tingling
   2. Dysesthesia
   3. Numbness
3. Signs
   1. Adenopathy: 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
4. Diagnosis
   1. See HSV Test
5. Course
   1. Viral shedding during first 3-4 days
   2. Recurrence: 5-8 episodes per year
6. Management: Episodic (Start within 24 hours of first symptoms):
   1. Acyclovir
      1. Acyclovir 200 mg orally five times daily for 5 days or
      2. Acyclovir 400 mg orally three times daily for 5 days or
      3. Acyclovir 800 mg orally twice daily for 5 days or
      4. 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
   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
7. Management: Suppression/Prophylaxis
   1. Indications for suppression
      1. More than 6 episodes per year
      2. Consider for disabling episodes less often
   2. Acyclovir
      1. Acyclovir 400 mg orally twice daily or
      2. Acyclovir 200 mg orally three to five times daily
      3. Duration
         1. Typically used for 12 months (Appears safe for up to 6 years)
         2. Consider as prophylaxis at stress times
      4. Effiacy
         1. Decreases episodes from 11.4 to 1.8 per year
         2. Kaplowitz (1991) JAMA 265:747-51
   3. Famciclovir
      1. Famciclovir 250 mg orally twice daily
   4. Valacyclovir
      1. Valacyclovir 500 mg orally daily
      2. Efficacy
         1. Reduces HSV-2 transmission to partner by 50%
         2. Corey (2004) N Engl J Med 350:11-20
8. 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
9. References
   1. Beauman (2005) Am Fam Physician 72(8):1527-34
   2. Kimberlin (2004) N Engl J Med 350(19): 1970-7
   3. Nadelman (2000) Postgrad Med 107(3):189-95