- When Treatments for Genital Herpes Are Given
- Genital Herpes Treatment and Care
- New Genital Herpes Drug Proves More Promising Than Existing Treatment in Clinical Trial
- A new class of drug to treat herpes simplex virus infection
When Treatments for Genital Herpes Are Given
- Initial treatment. If you have symptoms such as sores when you’re first diagnosed with genital herpes, your doctor will usually give you a brief course (seven to 10 days) of antiviral therapy to relieve them or prevent them from getting worse. Your doctor may keep you on the drugs longer if the sores don’t heal in that time.
After the first treatment, work with your doctor to come up with the best way to take antiviral therapies. There are two options:
- Intermittent treatment. Your doctor may prescribe an antiviral drug for you to keep on hand in case you have another flare-up; this is called intermittent therapy. You can take the pills for two to five days as soon as you notice sores or when you feel an outbreak coming on. Sores will heal and disappear on their own, but taking the drugs can make the symptoms less severe and make them go away faster.
- Suppressive treatment. If you have outbreaks often, you may want to consider taking an antiviral drug every day. Doctors call this suppressive therapy. For someone who has more than six outbreaks a year, suppressive therapy can reduce the number of outbreaks by 70% to 80%. Many people who take the antiviral drugs daily have no outbreaks at all.
There is no set number of outbreaks per year that doctors use to decide when someone should start suppressive therapy. Rather, more important factors are how often the outbreaks happen and if they are severe enough to interfere with your life.
Taking daily suppressive therapy may also reduce the risk of transmitting the virus to a sex partner. Antiviral drugs reduce viral shedding, when the virus makes new copies of itself on the skin’s surface.
A recent study of people taking daily doses of valacyclovir shows the drug may help protect sex partners from being infected, although you should still use a latex condom. Half the partners of people taking daily valacyclovir became infected with the virus, and half did not. Moreover, 75% of the partners did not show any symptoms of genital herpes, even if they had acquired the virus.
Not all herpes infections are the same. Herpes zoster (shingles) is an infection caused by the varicella-zoster virus, which is the virus that causes chickenpox. Genital herpes is an infection caused by the herpes simplex virus (HSV). Medications can help decrease the severity of the herpes lesions and prevent recurrences, but they do not cure the infection. The dose of the medication is different, depending on which herpes virus is being treated, and whether the medication is for an initial episode or a recurrent episode or chronic treatment to prevent outbreaks.
After an attack of chickenpox, the virus stays in the nerve cells. It is called a dormant infection. Anyone who has had chickenpox carries the virus. Shingles is more common in people with immune systems that are weakened from HIV infection, chemotherapy or radiation treatment, transplant operations, or stress. A stress on the body may allow the virus to become active and produce an “outbreak,” causing a painful rash or blisters.
Herpes Simplex Virus
There are 2 types of herpes simplex virus. HSV-1 most commonly infects the lips and produces what is often referred to as “cold sores”or “fever blisters,” but it also can cause genital herpes. HSV-2 is the usual cause of genital herpes, but it also can infect the mouth. HSV remains in the infected nerve cell of the body for life and can produce symptoms off and on.
What Medications Are Used to Treat and Prevent Herpes?
The first antiviral medication used to treat herpes was acyclovir. Acyclovir tablets and capsules are available in a generic form and therefore are less expensive, but they must be taken frequently throughout the day.
Acyclovir also is available as a liquid for people who have trouble swallowing, as eyedrops for eye infections, as an injection for severe life-threatening infections, and topically as a cream 5% or an ointment 5%. Famciclovir and valacyclovir tablets are as effective as acyclovir, are slightly more expensive, and are taken less frequently throughout the day (Table).
How Should Patients Use the Medications?
Patients should begin to take a medication immediately and take it exactly as directed, even if they are feeling better. Although the medication will not cure the herpes infection, patients should take the full course in order to prevent resistance to the medication. The medication also may help to prevent a recurrent infection.
If patients miss a dose, they should take the missed dose as soon as possible. If, however, it is time for the next dose, they should skip the missed dose and return to their regular schedule.
In fighting an infection, it is important to drink plenty of water, because these medications go through the kidneys. The recommended amount is 8 full glasses of water each day, but some people may need more. Patients should take their medication with a full glass of water. They may take it with food if it upsets the stomach otherwise.
The tablets, capsules, or oral liquid should be kept at room temperature, away from heat, light, and moisture. All medications should be kept out of the reach of children.
If using the acyclovir topical cream 5% or ointment 5%, patients should be sure to wash their hands before and after they apply the product. They should apply a thin layer to the affected area and rub gently. The use of gloves will help prevent the spread of the infection. Acyclovir cream 5% or ointment 5% should not be placed in the eyes?these products are for external use only. These products should be stored at room temperature, away from heat and light. If using the acyclovir eyedrops, patients should be sure to wash their hands before and after use.
What Should Patients Expect from Taking the Medications?
Whenever taking a new medication, it is important to be aware of signs of a life-threatening reaction. These signs include wheezing; chest tightness; fever; itching; a bad cough; a blue skin color; fits; or swelling of the face, lips, tongue, or throat. Anyone who develops these signs should seek medical attention immediately.
While taking antiviral medications, patients may get sunburned more easily. They should avoid sun, sunlamps, and tanning beds. They should use sunscreen and wear protective clothing and eyewear.
Some people develop headaches from antiviral medications, and these headaches usually are mild and self-limiting. Mild pain medicine may help. Anyone who develops a sudden or severe headache should seek medical attention immediately.
Antiviral medications may cause nausea or vomiting. Small frequent meals, frequent mouth care, sucking on hard candy, or chewing gum may help. If the nausea or vomiting becomes severe, patients should contact their health care provider.
About 1% to 10% of people may experience lightheadedness, dizziness, or headache. If the symptoms become severe, patients should seek medical attention immediately.
If using the acyclovir topical cream 5% or ointment 5%, patients may experience some local irritation, such as mild pain, itching, or stinging. If the irritation is severe, they should seek medical attention immediately.
If using the acyclovir eyedrops, patients may experience some local irritation, such as mild pain or stinging. If the irritation is severe, or if patients experience a loss of vision from using the eyedrops, they should seek medical attention immediately.
As with any medication for an infection, patients should monitor their condition and contact their provider if they do not notice an improvement or if they are feeling worse. Even if patients have no signs of a herpes infection, it is still possible to spread the virus to others during sex. Patients should talk with their doctor about ways to keep from spreading the virus.
Dr. DeKorte is director of pharmacy education and training and manager of clinical pharmacy services at George E. Wahlen Dept VA Medical Center. She also is a clinical assistant professor of pharmacy practice at the University of Utah.
Antiviral medications are the only known treatment for genital herpes, although these medications do not cure the condition. There is no known cure for herpes infection, but antiviral drugs have been developed that can reduce the severity and length of outbreaks. Antiviral medications are taken by mouth or, in certain situations, are given intravenously. There are few effective medications that can be applied topically to the blisters of genital herpes, and these medications are not commonly used since oral medications are more effective.
What Are Medications for Genital Herpes?
Acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) are examples of antiviral drugs that have been used to treat genital herpes. Because the first outbreak of herpes is usually the most severe, most doctors recommend treatment for the initial attack. With subsequent attacks, treatment is only useful if it is given prior to the outbreak or within the first 24 hours after the outbreak has started.
Suppressive treatment is also given for people who have more than six genital herpes outbreaks a year. With suppressive therapy, antiviral medications are taken continuously in order to lessen the frequency of recurrences.
Your doctor can help you decide whether antiviral drug treatment is right for you and can guide the choice of drug.
While there is no cure for herpes simplex virus (HSV) infections, there are various treatment options available.
Treatment for Genital Herpes
There are three antiviral medications that are FDA-approved for the treatment of genital herpes:
- Acyclovir: The oldest antiviral medication for herpes is acyclovir. It has been available since 1982 in a topical form (as an ointment) and sold since 1985 in pill form. Acyclovir has been shown to be safe in persons who have used it continuously (every day) for as long as 10 years.
- Valacyclovir: A newer drug, valacyclovir, actually uses acyclovir as its active ingredient. This medication delivers acyclovir more efficiently so that the body absorbs much of the drug, which has the advantage of taking the medication fewer times during the day.
- Famciclovir: Famciclovir uses penciclovir as its active ingredient to stop HSV from replicating. Like valacyclovir, it is well absorbed, persists for a longer time in the body, and can be taken less frequently than acyclovir.
- Antiviral medication is commonly prescribed for patients having a first episode of genital herpes, but they can be used for recurrent episodes as well. There are two kinds of treatment regimens: episodic therapy and suppressive therapy.
In this approach, a person begins taking medication at the first sign of an outbreak (or ideally at first signs of prodrome) and continues taking medication for several days, in order to speed healing or even prevent an outbreak from fully occurring. All three of the antiviral treatments mentioned above have been proven to help shorten the amount of time that a person may experience symptoms of herpes. However, keep in mind that results may vary from person to person.
Many people feel the advantages of using medication for recurrent episodes are marginal compared with use in a primary episode. But for others, episodic therapy offers a useful way to manage outbreaks by cutting the length of an outbreak by a day or two, on average. The benefits may be greater for those whose outbreaks tend to last longer.
Also, episodic therapy has its best results when treatment begins at the very first sign of prodrome. If lesions are already present, therapy may offer little benefit. Because the medications differ in their absorption rate and duration of effectiveness, dosages vary with episodic therapy treatment ranging from one to five pills every day for three to five days during an outbreak.
People with genital herpes who want to eliminate (suppress) outbreaks can take antiviral medication daily to hold HSV in check so that it’s less likely to flare up and cause symptoms. For individuals who have frequent recurrences (six or more per year), studies have shown that suppressive therapy can reduce the number of outbreaks by at least 75% while the medication is being taken. Also, for some, taking an antiviral on a daily basis can prevent outbreaks altogether.
While antivirals can be successful in controlling herpes symptoms, researchers also have turned their attention to the important issue of antiviral therapy and asymptomatic shedding. Does suppressive therapy lower the risk of unrecognized herpes reactivation as well as curb recognized outbreaks? One study addressing this question found that women on suppressive acyclovir (400 mg, twice daily) had a 94% reduction in subclinical shedding while taking daily therapy. This type of study has also been done with famciclovir and valacyclovir, with similar reductions seen in both men and women.
Suppressive therapy has been studied in thousands of patients and it appears to be both safe and effective. Because the medications differ in their absorption rate and duration of effectiveness, dosages vary with suppressive therapy treatment ranging from one to two pills every day.
Treatment for Oral Herpes
The antiviral medications available in pill form (acyclovir, valacyclovir, famciclovir) have been specifically developed for the treatment of genital herpes. However, it is not uncommon for healthcare providers to prescribe the antiviral drugs to those who have frequent or severe outbreaks of oral herpes. A recent study found valacyclovir to be effective for treating oral herpes in a one-day treatment of 2 grams taken at the first sign of a cold sore, and then again about 12 hours later.
There are two topical antiviral medications prescribed for the treatment of oral HSV symptoms: acyclovir ointment (brand name Zovirax®) and penciclovir cream (brand name Denavir®). Both work to speed up the healing process and reduce the viral activity. These topical drugs are put directly on the lesions themselves, but can also be used at the onset of prodrome.
Other topical treatments for oral herpes are available over-the-counter (OTC), but are not antiviral compounds like acyclovir and penciclovir. Some also contain ingredients that numb the area and induce temporary relief from the discomfort of an outbreak. Unfortunately, some OTC treatments may actually delay the healing time of symptoms because they can further irritate the area with repeated applications. There is only one OTC FDA-approved cream, called Abreva®, which has been clinically proven to help speed the healing process.
Over-the-counter creams and/or ointments are not recommended for genital herpes, since they can interfere with the healing process in a number of ways, causing genital outbreaks to last longer. Keeping the area clean and as dry as possible and allowing the area to get air can help to speed the healing process.
Many people find that outbreaks tend to lessen in severity and frequency with time. What triggers an outbreak is highly individual, but with time, many people learn to recognize, and sometimes avoid, factors that seem to reactivate HSV in their own bodies. For example, illness, poor diet, emotional or physical stress, friction in the genital area, prolonged exposure to ultraviolet light (commonly for oral herpes, such as a beach trip or skiing weekend), surgical trauma, or steroidal medication (such as asthma treatment) may trigger a herpes outbreak.
The frequency of outbreaks can often be managed through effective stress management, and getting adequate rest, nutrition, and exercise.
People often ask about an amino acid by the name of lysine (L-lysine), because of Internet claims or claims from other people that it helps control outbreaks. While some studies have suggested that lysine supplements can reduce the frequency of recurrences or healing time, other trials have been unable to replicate those results. Therefore, there is not sufficient information to discern how effective it may be, in addition to what the effective dosages or frequency of L-lysine may be.
Lysine can be found with other nutrients and supplements at your local grocery or drug store, but people should only take the recommended dosage if it is taken and always check with their health care provider first before starting any new medication or supplement. Megadoses of lysine may throw other amino acids out of balance and interfere with the absorption of other nutrients such as vitamins and minerals.
In regard to possible foods to avoid, some people feel that foods that contain high amounts of the amino acid arginine may cause herpes outbreaks. Arginine is found in numerous foods that are eaten on a regular basis; therefore, we do not encourage someone to stop eating foods simply because they contain arginine. However, an individual may want to consider adjusting their diet if she or he is having frequent outbreaks and believes food is a contributing factor. Again, while some individuals believe arginine can trigger outbreaks, there is no clinical evidence to support these claims.
Genital Herpes Treatment and Care
There is no cure for herpes, but medication is available to reduce symptoms and make it less likely that you will spread herpes to a sex partner.
Is there a cure or treatment for herpes?
There is no cure for herpes. Antiviral medications can, however, prevent or shorten outbreaks during the period of time the person takes the medication. In addition, daily suppressive therapy (i.e. daily use of antiviral medication) for herpes can reduce the likelihood of transmission to partners.
Several clinical trials have tested vaccines against genital herpes infection, but there is currently no commercially available vaccine that is protective against genital herpes infection. One vaccine trial showed efficacy among women whose partners were HSV-2 infected, but only among women who were not infected with HSV-1. No efficacy was observed among men whose partners were HSV-2 infected. A subsequent trial testing the same vaccine showed some protection from genital HSV-1 infection, but no protection from HSV-2 infection.
Treatment Guidelines and Updates
- 2015 STD Treatment Guidelines – Genital HSV Infections (June 4, 2015)
Resources for Clinicians
- Herpes Simplex Self-Study ModuleExternal – An online learning experience that helps users learn how to manage herpes. It is continuously updated and integrates the most recent STD Treatment Guidelines. Free CME/CNE available. (November 1, 2017)
- STD & Pregnancy Treatment
New Genital Herpes Drug Proves More Promising Than Existing Treatment in Clinical Trial
As what may be one of the most promising treatments for the herpes simplex virus 2 (HSV-2) in two decades, pritelivir, has demonstrated in a recent trial that it provides greater viral suppression than the present standard treatment, valacyclovir.
In the study, conducted by a research team led by Anna Wald, MD, medical director of virology research at the University of Washington, Fred Hutchinson Cancer Research Center in Seattle, patients who took pritelivir not only experienced less HSV shedding than those who took valacyclovir (2.4% vs. 5.3%), but they also had fewer lesions (1.9% vs. 3.9%), less pain, and fewer treatment-emergent adverse events (62% vs. 69%).
Pritelivir, which is still in the relatively early stages of development, is particularly attractive to patients with HSV-2 (otherwise known as genital herpes) because it not only limits their symptoms, but also appears to reduce the likelihood of passing the infection on to a susceptible partner. Of note: pritelivir did not completely eliminate viral shedding; practitioners and patients must remember that the protection is only partial. Given that many infected individuals often do not show signs of infection but still shed viral cells intermittently, “management of genital HSV should address the chronic nature of the disease rather than focusing solely on treatment of acute episodes of genital lesions,” a CDC spokesperson also noted. The spokesperson added that HSV-2 infections tend to have “much more frequent” recurrences and shedding.
In the double-blind study, Dr. Wald and her team studied 91 adults—who reported having had between four and nine annual genital HSV-2 recurrences—randomized into two groups. One group received pritelivir for 28 days, followed by a 28-day “washout” period, and then received valacyclovir for 28 days. The second group received valacyclovir first, and then the 28-day washout period, followed by pritelivir.
The study was terminated before all subjects had completed the entire treatment period for both drugs due to the US Food and Drug Administration (FDA) putting a hold on the drug’s clinical use because of skin and blood abnormalities that had presented in a concurrent animal trial. Dr. Wald noted that there have been no serious side effects in humans so far, and German drug maker AiCuris is working with the FDA to partially lift the hold so that patients who are resistant to drugs in the “standard treatment family,”—which includes the drugs acyclovir, famciclovir, and valacyclovir—could participate in a new clinical trial. At the time of termination, 56 patients had completed both treatments.
A new class of drug to treat herpes simplex virus infection
If patients develop resistance to these drugs, there are even fewer choices left to treat the infection, which lasts for life.
Researchers at the University of Illinois at Chicago have now identified a small drug molecule that can clear the HSV-1 infection in the cells of the cornea — the clear outer layer of the eyeball — and works completely differently than the currently-available drugs, making it a promising potential option for patients who have developed resistance.
The researchers believe the drug could be equally effective in treating HSV-1 in the mouth and HSV-2 — which primarily affects the genitals — and possibly even other viral infections like HIV. The findings are reported in the journal Science Translational Medicine.
HSV-1 is one of the most common human pathogens, affecting between 50 percent and 90 percent of people worldwide. HSV-1 primarily infects the mouth and eyes, although genital cases of HSV-1 infection are on the rise. The virus is transmitted through bodily fluids. It establishes a lifelong infection that leads to sores in affected tissues when active and hides in nerve cells during its latent phase. The infection can be temporarily eliminated in the eye using oral and topical antiviral drugs, but inflammation of the cornea can persist indefinitely, requiring ongoing treatment with steroid-based eye drops. HSV-1 infection is a leading cause of infectious blindness in the U.S.
Currently available drugs to treat HSV-1 infection work by preventing the virus from producing the proteins it needs to replicate and are known as nucleoside analogs. Resistance is a significant problem with the ongoing use of nucleoside analogs, which when applied topically to the eye can cause serious side effects including glaucoma.
“We have needed alternative drugs that work on new targets for a very long time because patients who develop resistance to nucleoside analogs have very few good options for treating their infection,” said Deepak Shukla, the Marion Schenk Professor of Ophthalmology and professor of microbiology and immunology in the UIC College of Medicine, and corresponding author on the paper. “We have found a molecule that works in a totally novel fashion. Instead of working on the virus, it works in the host cells and helps them to clear the virus.”
Shukla and colleagues discovered that a small drug molecule called BX795, which is sold to labs for use in experiments, helped clear HSV-1 infection in cultured human corneal cells, in donated human corneas, and in the corneas of mice infected with HSV-1.
The researchers were quite surprised by their finding because BX795 is known as an inhibitor of TBK1, an enzyme involved in innate immunity and neuroinflammation. When TBK1 is suppressed in cells, infection is actually promoted. But when the researchers added higher concentrations of BX795 to cultured human corneal cells infected with HSV-1, the infection was quickly cleared. They had the same result in intact human corneas, and in mice whose eyes had been infected with HSV-1.
“This isn’t what we expected,” said Tejabhiram Yadavalli, a postdoctoral fellow studying herpes viruses at UIC and a co-author of the paper. “Instead of promoting infection, at higher concentrations, BX795 actually helped cells clear the infection.”
Additionally, the concentration of BX795 needed to clear HSV-1 infection is quite low.
“We saw clearance of the virus at concentrations of BX795 that were five times lower than concentrations of antiviral compounds in available nucleoside analogs,” Shukla said.
The researchers also found that BX795 only worked in cells infected with the HSV-1 virus.
“There was no discernable toxicity or negative side effects at therapeutic concentrations in cells that are not infected with the virus,” Shukla said.
“Because BX795 targets a common pathway that many viruses use to replicate inside the cell, it could be a new kind of broad-spectrum antiviral that might be used to treat other viral infections, including HSV-2, which primarily affects the genitals, and HIV, although we have not yet tested it on viruses other than HSV-1.”
“It will be very exciting to see if the study can move to a clinical trial soon,” said Alex Agelidis, a graduate student at UIC and co-author on the paper. “Because of BX795’s low toxicity, it has a great potential for systemic use as well as topical application.”
Dinesh Jaishankar, Abraam Yakoub, Alex Agelidis, Neel Thakkar, Satvik Hadigal and Joshua Ames, from the University of Illinois at Chicago, are co-authors on the paper.
This work was supported by grant R01 EY024710 from the National Eye Institute.