Goals of treatment and management:

• Management of infection

• Prevent recurrences

• Prevent transmission

• Control spread of infection

• In primary episodes duration and severity of symptoms is lessened and shedding is shortened with
antiviral therapy. Antiviral therapy is recommended for use in all patients with primary episodes.
• Episodic therapy for recurrences can shorten duration of outbreak if started within 24 hours of prodromal
symptoms or lesion appearance.

Treatment of HSV-1 or HSV-2 may be used for three different clinical scenarios:

   1.    primary episode

   2.    recurrent episode
3.    daily suppression

 Three antiviral agents are currently approved for the treatment of initial and recurrent episodes of
genital herpes or as suppressive therapy: acyclovir, valacyclovir, and famciclovir. The goals of
episodic therapy include a reduction in the severity and duration of pain or other symptoms and
  
shortened duration of viral shredding, which may reduce the risk of transmission. The primary
goals for suppressive therapy include a reduction in the frequency of recurrences and a decrease in
episodes of asymptomatic viral shredding.

Antiviral therapy with acyclovir, famciclovir, and valacyclovir has been used for treatment of first - episode genital
herpes in nonpregnant women. Oral or parenteral preparations attenuate clinical infection as well as the duration
of viral shedding. Suppressive therapy with these agents has also been given to limit recurrent infections and to
reduce heterosexual transmissions. For intense discomfort, analgesics and topical anesthetics may provide some
relief, and severe urinary retention is treated with an indwelling bladder catheter.

Dosage Recommendations for Oral Acyclovir; Valacyclovir; and Famciclovir in Patients with Genital Herpes

DRUG FIRST CLINICAL EPISODE RECURRENT EPISODES SUPPRESSIVE THERAPY

Acyclovir 200 mg five times daily for 10 200 mg five times daily for 5 400 mg twice daily for up to 1
days days year (followed by re-evaluation)

Valacyclovir 1 g twice daily for 10 days 500 mg twice daily for 3 days • 1 g once daily for up
to 1 year
• 500 mg once daily
for up to 1 year
(patients with
</=recurrences per
year)

Famciclovir 250 mg three times daily for 10 1 g twice daily for 1 day 250 mg twice daily for up to 1
days year
Patient-initiated therapy has been found to be superior to therapy ordered by a physician because patients initiate
therapy earlier in the course of a recurrence. The antiviral medication should be started as early as possible during
the prodrome and definitely within 24 hours of the appearance of lesions. Daily suppressive therapy is
recommended when the patient has six or more episodes a year or for psychological distress. It is important for
patients to be aware that asymptomatic viral shedding can occur even when on daily suppressive therapy.

For recurrent infection, other than suppression, acyclovir is of little benefit in recurrent genital herpes. suppressive
therapy after 36 weeks reduced the risk of a clinical or asymptomatic recurrence at delivery
and of cesarean delivery for recurrent infection.

A vaccine would be the logical approach for optimum prevention of herpes. Research is ongoing (HSV-2
glycoprotein-D subunit vaccine).

CLINICAL COURSE DURING PREGNANCY

Women with a primary outbreak during pregnancy may be given antiviral therapy to attenuate and
decrease the duration of symptoms and viral shedding. Women with HIV co-infection may requirea longer
duration of treatment. Those with severe or disseminated HSV are given intravenous acyclovir, 5 to 10 mg/kg,
every 8 hours for 2 to 7 days until clinical improvement is observed. This is followed by oral antiviral therapoy to
complete at least 10 days of total therapy. Recurrent infections during pregnancy are treated with oral acyclovir as
well as are treated for symptomatic relief.

Antiviral Medications for Herpesvirus Infection in Pregnancy

Indication Acyclovir Valacyclovir Famciclovir

Primary or first clinical
episode
Recurrent episodes
Daily suppressive
therapy
400 mg orally three
times a day for 7–10
days
400 mg three times daily
for 800 mg twice daily
for 5 days
400 mg orally three times
daily from 36 weeks until
delivery
1g twice daily for 7–10
days
1g daily for 5 days or
500 mg twice daily for 3
days
500 mg twice daily from
36 weeks until delivery
250 mg three times daily
for 7–10
1g twice a day for 1 day
250 mg twice daily for up
to 1 year

FETAL AND NEONATAL DISEASE

According to Kimberlin (2004), neonatal infection is acquired in three ways: intrauterine (5 percent), peripartum
(85 percent), or postnatal (10 percent). The fetus becomes infected by virus shed from the cervix or lower genital
tract. The virus either invades the uterus following membrane rupture or contacts the fetus at delivery. Newborn
infection has three forms:

1. Skin, eye, or mouth disease with localized involvement (45 percent of cases).

2. Central nervous system disease with encephalitis, with or without above involvement (30 percent of cases).

3. Disseminated disease with involvement of multiple major organs (25 percent of cases)
PERIPARTUM SHEDDING PROPHYLAXIS

Acyclovir or valacyclovir suppression initiated at 36 weeks will decrease the number of HSV outbreaks at
term, decreasing the need for a cesarean delivery. Viral therapy at or beyond 36 weeks were recommended for
women who have any recurrence during pregnancy.

Upon presentation for delivery, a woman with a history of HSV should be questioned regarding
prodromal symptoms such as vulvar burning or itching. A careful examinationof the vulva, vagina, and cervix
should be performed and suspicious lesions should be cultured. Cesarean delivery is indicated for women with
active genital lesions or prodromal symptoms. In addition, remote recurrences - those on the buttocks, back, thigh,
and anus have low rates of concomitant cervical virus shedding, and this allows consideration for vaginal delivery.

CARE OF THE NEONATE

An exposed infant born to a mother known to have or suspected of having genital herpes initially should
be isolated from other neonates and cultures performed for herpes. It is not necessary to separate the pair.
Instead, the woman should wash her hands thoroughly and avoid contact between her lesions, her hands, and the
infant. Breast feeding is allowed, including if the woman is taking antiviral therapy. Acyclovir does not reach
appreciable levels in breast milk (Sheffield and colleagues, 2002a). Family members with oral herpetic lesions
should avoid kissing the newborn and should use careful hand-washing techniques.