[Table of Contents]

Canadian STD Guidelines

Genital Herpes

Primary episode of genital herpes

• treatment should be considered and discussed with the patient. Treatment is useful in reducing symptoms, complications and virus shedding but is only effective if given in the early stages of the symptomatic episode.

Children- prepubertal


oral acyclovir probably effective but there are no data yet to support its use

Adults and adolescents


acyclovir 200 mg orally x 5/day for 7-10 days or until healing complete
OR
acyclovir 5 mg/kg IV x 3/day for patients requiring hospitalization, switch to oral therapy when possible to complete 10 days therapy or until healing complete

Note: initiation of treatment 6 days or more after onset of symptoms is unlikely to be of benefit



Recurrent genital herpes

Children


no data to support use of acyclovir although efficacy and safety are probably not different than for adults

Adults and adolescents

intermittent, early, preferably with prodrome, patient-initiated treatment of active recurrences of limited clinical benefit; (for chronic suppressive therapy see below)


acyclovir 200 mg orally x 5/day for 5 days


no role for topical acyclovir

Immuno- compromised adults and adolescents

intermittent, early, patient-initiated treatment of active recurrences

acyclovir 200 mg orally x 5/day for 5 days or until healing
-- chronic, suppressive therapy probably preferable (see below)
-- topical acyclovir may have minor role in a limited infection
-- severe or progressive lesions likely to be due to acyclovir resistance

Immuno-compromised children

acyclovir 600 mg/m² orally x 4/day for 5 days or until healing complete, may be effective

Immuno-compromised adults and adolescents and children with acyclovir resistance

foscarnet (investigational) 40-60 mg/kg 8 hourly
-- central venous access required for higher dose
-- restart acyclovir suppression at the conclusion of foscarnet



Chronic, suppressive treatment

• objectives:
  -- frequency and severity reduction

Children

no data available

Adults and adolescents

• more than 6 annual recurrences and considered likely to benefit from frequency reduction
• acyclovir 200-400 mg orally x 2-5/day (most commonly 200 mg x 3/day)
  -- safety established to 4 years (400 mg x 2/day)
  -- small subgroup require higher doses
  
• annual discontinuation 2 recurrent episodes warranted to re-establish continuing need
• suppression may decrease asymptomatic HSV shedding
• special occasions (dosage as for chronic suppression, but for a defined period beginning 5 days prior to the event), e.g.:
  -- vacations
  -- high-stress periods
  -- new relationships
  -- known exposure to trigger factor, e.g., sunlight

Immuno- compromised adults, adolescents

acyclovir 400-2000 mg/day orally in 2-5 divided doses in certain individuals

Immuno- compromised children

acyclovir 600 mg/m² orally x 2-10/day may be effective but there are no data yet to support its use





Pregnancy

a specialist knowledgable in this area should be consulted

use of acyclovir during pregnancy not adequately studied but possible roles include:
-- primary infection especially in third trimester
-- suppression late in pregnancy to prevent cesarean section





Neonatal herpes

Neonate and infants


acyclovir 30 mg/kg/day IV 8 hourly infusions for 14 days

oral therapy NOT adequate, but may be considered in infants exposed to active HSV infection but not yet ill

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