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How well do antivirals shorten genital herpes pain duration?
Oral and intravenous (IV) acyclovir each shorten the duration of pain for a first primary outbreak of herpes by about 50%; topical acyclovir shortens it by about 25% (strength of recommendation [SOR]: B, small randomized controlled trials [RCTs] with some methodological flaws).
Oral valacyclovir and famciclovir are equivalent to oral acyclovir. Adding topical acyclovir to oral acyclovir doesn’t produce additional benefit (SOR: B, RCTs).
Patients with severe disease may require IV acyclovir (SOR: C, expert opinion).
General treatment measures that may improve patient comfort include keeping lesions clean and dry, avoiding tight clothing, taking analgesics, and using ice packs or taking warm baths (SOR: C, expert opinion).
Evidence for using complementary and alternative medicine to treat genital herpes is lacking or conflicting [SOR: C, narrative review of clinical trials].
EVIDENCE SUMMARY
A review of 3 double-blind, placebo-controlled RCTs compared topical, oral, and IV acyclovir in patients with a first episode of genital herpes.1 Researchers recruited a total of 138 patients and randomized them to receive either placebo or one of the following: oral acyclovir (200 mg 5 times daily for 10 days), IV acyclovir (5 mg/kg dose, 3 times daily for 5 days), or 5% topical acyclovir in polyethylene glycol (4 times daily for 6 days).
All treatments shortened duration of pain compared with placebo: oral (3 days vs 7 days, P<.01), IV (5 days vs 9 days, P<.05), and topical (5 days vs 7 days, P<.05).
A subsequent RCT with 50 patients found that adding topical acyclovir to oral acyclovir was no more effective than oral acyclovir alone.2
Oral acyclovir, valacyclovir, and famciclovir work equally well
Head-to-head trials comparing acyclovir with valacyclovir or famciclovir show no difference in decreased duration of pain caused by primary genital herpes. An RCT of 643 adults found valacyclovir (1000 mg twice daily for 10 days) to be as effective and well-tolerated as acyclovir (200 mg 5 times daily for 10 days).3 An RCT of 951 adults demonstrated that famciclovir (250 mg 3 times daily for either 5 or 10 days) worked as well as acyclovir (200 mg 5 times daily for 10 days).4
General treatment measures
Expert opinion recommends the following general treatment measures for genital herpes lesions: keeping the affected area clean and dry, wearing dry, loose-fitting clothing and cotton underwear, and not touching the lesions. Additional symptomatic treatments for local pain include ice packs, baking soda compresses, warm baths, oral analgesics, topical anesthetics, and drying the affected area with cool air.5-8
CAM approaches lack evidence of efficacy
A 2005 nonsystematic review of available scientific data on complementary and alternative medicine found a lack of evidence or conflicting evidence concerning the use of aloe vera, echinacea, L-lysine, bee products (honey pollen), zinc, and eleuthero for the treatment of pain in genital herpes.9
RECOMMENDATIONS
Clinical practice guidelines recommend prescribing oral antiviral therapy for patients with a first episode of genital herpes because patients with mild clinical findings at onset may develop severe or prolonged symptoms. Choices include a 7- to 10-day course of valacyclovir 1 g twice a day, famciclovir 250 mg 3 times a day, acyclovir 400 mg 3 times a day, or acyclovir 400 mg 5 times a day.5,10
The guidelines recommend treating patients with severe disease (such as disseminated infection, pneumonitis, hepatitis, or meningoencephalitis) with IV acyclovir (5-10 mg/kg every 8 hours for 2-7 days or until clinical improvement), followed by oral acyclovir for at least 10 days.
1. Corey L, Benedetti J, Critchlow C, et al. Treatment of primary first-episode genital herpes simplex virus infections with acyclovir: results of topical, intravenous and oral therapy. J Antimicrob Chemother. 1983;12(suppl B):79-88.
2. Kinghorn GR, Abeywickreme I, Jeavons M, et al. Efficacy of combined treatment with oral and topical acyclovir in first episode genital herpes. Genitourin Med. 1986;62:186-188.
3. Fife KH, Barabarash RA, Rudolph T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection. Results of an international, multicenter, double-blind, randomized clinic trial. The Valaciclovir International Herpes Simplex Virus Study Group. Sex Transm Dis. 1997;24:481-486.
4. Loveless M, Sacks SL, Harris JRW. Famciclovir in the management of first-episode genital herpes. Infect Dis Clin Prac. 1997;6(suppl 1):S12-S16.
5. ACOG Committee on Practice Bulletins—Gynecology. ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists, number 57, November 2004. Gynecologic herpes simplex virus infections. Obstet Gynecol. 2004;104(5 pt 1):1111-1118.
6. Beauman JG. Genital herpes: a review. Am Fam Physician. 2005;72:1527-1534.
7. Patel R. Progress in meeting today’s demands in genital herpes: an overview of current management. J Infect Dis. 2002;186(suppl 1):S847-S856.
8. Stanberry LR, Rosenthal SL. Genital herpes simplex virus infection in the adolescent: special considerations for management. Pediatr Drugs. 2002;4:291-297.
9. Perfect MM, Bourne N, Ebel C, et al. Use of complementary and alternative medicine for the treatment of genital herpes. Herpes. 2005;12:38-41.
10. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59:1-110.
Oral and intravenous (IV) acyclovir each shorten the duration of pain for a first primary outbreak of herpes by about 50%; topical acyclovir shortens it by about 25% (strength of recommendation [SOR]: B, small randomized controlled trials [RCTs] with some methodological flaws).
Oral valacyclovir and famciclovir are equivalent to oral acyclovir. Adding topical acyclovir to oral acyclovir doesn’t produce additional benefit (SOR: B, RCTs).
Patients with severe disease may require IV acyclovir (SOR: C, expert opinion).
General treatment measures that may improve patient comfort include keeping lesions clean and dry, avoiding tight clothing, taking analgesics, and using ice packs or taking warm baths (SOR: C, expert opinion).
Evidence for using complementary and alternative medicine to treat genital herpes is lacking or conflicting [SOR: C, narrative review of clinical trials].
EVIDENCE SUMMARY
A review of 3 double-blind, placebo-controlled RCTs compared topical, oral, and IV acyclovir in patients with a first episode of genital herpes.1 Researchers recruited a total of 138 patients and randomized them to receive either placebo or one of the following: oral acyclovir (200 mg 5 times daily for 10 days), IV acyclovir (5 mg/kg dose, 3 times daily for 5 days), or 5% topical acyclovir in polyethylene glycol (4 times daily for 6 days).
All treatments shortened duration of pain compared with placebo: oral (3 days vs 7 days, P<.01), IV (5 days vs 9 days, P<.05), and topical (5 days vs 7 days, P<.05).
A subsequent RCT with 50 patients found that adding topical acyclovir to oral acyclovir was no more effective than oral acyclovir alone.2
Oral acyclovir, valacyclovir, and famciclovir work equally well
Head-to-head trials comparing acyclovir with valacyclovir or famciclovir show no difference in decreased duration of pain caused by primary genital herpes. An RCT of 643 adults found valacyclovir (1000 mg twice daily for 10 days) to be as effective and well-tolerated as acyclovir (200 mg 5 times daily for 10 days).3 An RCT of 951 adults demonstrated that famciclovir (250 mg 3 times daily for either 5 or 10 days) worked as well as acyclovir (200 mg 5 times daily for 10 days).4
General treatment measures
Expert opinion recommends the following general treatment measures for genital herpes lesions: keeping the affected area clean and dry, wearing dry, loose-fitting clothing and cotton underwear, and not touching the lesions. Additional symptomatic treatments for local pain include ice packs, baking soda compresses, warm baths, oral analgesics, topical anesthetics, and drying the affected area with cool air.5-8
CAM approaches lack evidence of efficacy
A 2005 nonsystematic review of available scientific data on complementary and alternative medicine found a lack of evidence or conflicting evidence concerning the use of aloe vera, echinacea, L-lysine, bee products (honey pollen), zinc, and eleuthero for the treatment of pain in genital herpes.9
RECOMMENDATIONS
Clinical practice guidelines recommend prescribing oral antiviral therapy for patients with a first episode of genital herpes because patients with mild clinical findings at onset may develop severe or prolonged symptoms. Choices include a 7- to 10-day course of valacyclovir 1 g twice a day, famciclovir 250 mg 3 times a day, acyclovir 400 mg 3 times a day, or acyclovir 400 mg 5 times a day.5,10
The guidelines recommend treating patients with severe disease (such as disseminated infection, pneumonitis, hepatitis, or meningoencephalitis) with IV acyclovir (5-10 mg/kg every 8 hours for 2-7 days or until clinical improvement), followed by oral acyclovir for at least 10 days.
Oral and intravenous (IV) acyclovir each shorten the duration of pain for a first primary outbreak of herpes by about 50%; topical acyclovir shortens it by about 25% (strength of recommendation [SOR]: B, small randomized controlled trials [RCTs] with some methodological flaws).
Oral valacyclovir and famciclovir are equivalent to oral acyclovir. Adding topical acyclovir to oral acyclovir doesn’t produce additional benefit (SOR: B, RCTs).
Patients with severe disease may require IV acyclovir (SOR: C, expert opinion).
General treatment measures that may improve patient comfort include keeping lesions clean and dry, avoiding tight clothing, taking analgesics, and using ice packs or taking warm baths (SOR: C, expert opinion).
Evidence for using complementary and alternative medicine to treat genital herpes is lacking or conflicting [SOR: C, narrative review of clinical trials].
EVIDENCE SUMMARY
A review of 3 double-blind, placebo-controlled RCTs compared topical, oral, and IV acyclovir in patients with a first episode of genital herpes.1 Researchers recruited a total of 138 patients and randomized them to receive either placebo or one of the following: oral acyclovir (200 mg 5 times daily for 10 days), IV acyclovir (5 mg/kg dose, 3 times daily for 5 days), or 5% topical acyclovir in polyethylene glycol (4 times daily for 6 days).
All treatments shortened duration of pain compared with placebo: oral (3 days vs 7 days, P<.01), IV (5 days vs 9 days, P<.05), and topical (5 days vs 7 days, P<.05).
A subsequent RCT with 50 patients found that adding topical acyclovir to oral acyclovir was no more effective than oral acyclovir alone.2
Oral acyclovir, valacyclovir, and famciclovir work equally well
Head-to-head trials comparing acyclovir with valacyclovir or famciclovir show no difference in decreased duration of pain caused by primary genital herpes. An RCT of 643 adults found valacyclovir (1000 mg twice daily for 10 days) to be as effective and well-tolerated as acyclovir (200 mg 5 times daily for 10 days).3 An RCT of 951 adults demonstrated that famciclovir (250 mg 3 times daily for either 5 or 10 days) worked as well as acyclovir (200 mg 5 times daily for 10 days).4
General treatment measures
Expert opinion recommends the following general treatment measures for genital herpes lesions: keeping the affected area clean and dry, wearing dry, loose-fitting clothing and cotton underwear, and not touching the lesions. Additional symptomatic treatments for local pain include ice packs, baking soda compresses, warm baths, oral analgesics, topical anesthetics, and drying the affected area with cool air.5-8
CAM approaches lack evidence of efficacy
A 2005 nonsystematic review of available scientific data on complementary and alternative medicine found a lack of evidence or conflicting evidence concerning the use of aloe vera, echinacea, L-lysine, bee products (honey pollen), zinc, and eleuthero for the treatment of pain in genital herpes.9
RECOMMENDATIONS
Clinical practice guidelines recommend prescribing oral antiviral therapy for patients with a first episode of genital herpes because patients with mild clinical findings at onset may develop severe or prolonged symptoms. Choices include a 7- to 10-day course of valacyclovir 1 g twice a day, famciclovir 250 mg 3 times a day, acyclovir 400 mg 3 times a day, or acyclovir 400 mg 5 times a day.5,10
The guidelines recommend treating patients with severe disease (such as disseminated infection, pneumonitis, hepatitis, or meningoencephalitis) with IV acyclovir (5-10 mg/kg every 8 hours for 2-7 days or until clinical improvement), followed by oral acyclovir for at least 10 days.
1. Corey L, Benedetti J, Critchlow C, et al. Treatment of primary first-episode genital herpes simplex virus infections with acyclovir: results of topical, intravenous and oral therapy. J Antimicrob Chemother. 1983;12(suppl B):79-88.
2. Kinghorn GR, Abeywickreme I, Jeavons M, et al. Efficacy of combined treatment with oral and topical acyclovir in first episode genital herpes. Genitourin Med. 1986;62:186-188.
3. Fife KH, Barabarash RA, Rudolph T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection. Results of an international, multicenter, double-blind, randomized clinic trial. The Valaciclovir International Herpes Simplex Virus Study Group. Sex Transm Dis. 1997;24:481-486.
4. Loveless M, Sacks SL, Harris JRW. Famciclovir in the management of first-episode genital herpes. Infect Dis Clin Prac. 1997;6(suppl 1):S12-S16.
5. ACOG Committee on Practice Bulletins—Gynecology. ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists, number 57, November 2004. Gynecologic herpes simplex virus infections. Obstet Gynecol. 2004;104(5 pt 1):1111-1118.
6. Beauman JG. Genital herpes: a review. Am Fam Physician. 2005;72:1527-1534.
7. Patel R. Progress in meeting today’s demands in genital herpes: an overview of current management. J Infect Dis. 2002;186(suppl 1):S847-S856.
8. Stanberry LR, Rosenthal SL. Genital herpes simplex virus infection in the adolescent: special considerations for management. Pediatr Drugs. 2002;4:291-297.
9. Perfect MM, Bourne N, Ebel C, et al. Use of complementary and alternative medicine for the treatment of genital herpes. Herpes. 2005;12:38-41.
10. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59:1-110.
1. Corey L, Benedetti J, Critchlow C, et al. Treatment of primary first-episode genital herpes simplex virus infections with acyclovir: results of topical, intravenous and oral therapy. J Antimicrob Chemother. 1983;12(suppl B):79-88.
2. Kinghorn GR, Abeywickreme I, Jeavons M, et al. Efficacy of combined treatment with oral and topical acyclovir in first episode genital herpes. Genitourin Med. 1986;62:186-188.
3. Fife KH, Barabarash RA, Rudolph T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection. Results of an international, multicenter, double-blind, randomized clinic trial. The Valaciclovir International Herpes Simplex Virus Study Group. Sex Transm Dis. 1997;24:481-486.
4. Loveless M, Sacks SL, Harris JRW. Famciclovir in the management of first-episode genital herpes. Infect Dis Clin Prac. 1997;6(suppl 1):S12-S16.
5. ACOG Committee on Practice Bulletins—Gynecology. ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists, number 57, November 2004. Gynecologic herpes simplex virus infections. Obstet Gynecol. 2004;104(5 pt 1):1111-1118.
6. Beauman JG. Genital herpes: a review. Am Fam Physician. 2005;72:1527-1534.
7. Patel R. Progress in meeting today’s demands in genital herpes: an overview of current management. J Infect Dis. 2002;186(suppl 1):S847-S856.
8. Stanberry LR, Rosenthal SL. Genital herpes simplex virus infection in the adolescent: special considerations for management. Pediatr Drugs. 2002;4:291-297.
9. Perfect MM, Bourne N, Ebel C, et al. Use of complementary and alternative medicine for the treatment of genital herpes. Herpes. 2005;12:38-41.
10. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59:1-110.
Evidence-based answers from the Family Physicians Inquiries Network