First Episode Genital Herpes
All clients with suspected first episode HSV should be reviewed by a practitioner competent to give all relevant information
Antivirals
Patients presenting within 5 days of the start of the episode, or while new lesions are still forming, should be given oral antiviral drugs. There is no evidence of benefit for greater than 5 days but it can be considered if new vesicles are forming. Aciclovir is the preferred treatment choice at Sandyford as there is no evidence of additional benefit from other antivirals.
Immunocompetent: Aciclovir 400 mg three times daily for FIVE days
Immunosuppressed (incl advanced HIV): Aciclovir 400mg five times daily for TEN days or Valaciclovir 1g bd for TEN days
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Sexual Health Screen
Chlamydia/gonorrhoea NAAT and Syphilis/HIV serology should be done at first presentation; full examination with eg speculum or proctoscope if needed may need to be deferred depending on local symptoms.
Supportive measures
If clients with first diagnosis HSV require more information or support, refer to the sexual health advisers on that day or at a follow up appointment when HSV type available.
Saline bathing and the use of appropriate analgesia is recommended. Topical anaesthetic agents (e.g. 5% lidocaine ointment) should be used with caution, because of the potential for sensitisation and delayed healing, but may help with severe dysuria.
Management of complications
Hospital admission may be required for:
- severe pain or constitutional symptoms
- meningism (aseptic spinal meningitis and encephalitis rare complications)
- urinary retention (secondary to pain and sacral radiculopathy)
GP correspondence
Clarify and document if GP can be contacted and informed of HSV diagnosis and management plan. A template letter can be sent by SHA office when they are texting/phoning the positive result. If diagnosis confirmed a letter can be sent to the GP advising to put treatment course on repeat prescription for any future outbreaks.
Immunosuppressed and HIV positive Individuals
There are no recent data regarding optimum management of people living with HIV (PLWHIV) who are well established on effective antiretroviral therapy. It is therefore suggested, particularly if a patient is profoundly immunosuppressed, to seek advice from a senior GUM physician regarding management.
Recurrent Genital Herpes
Recurrences of genital herpes are generally self-limiting and usually cause minor symptoms. Management strategies include supportive therapy only, episodic antiviral treatments and suppressive antiviral therapy. The most appropriate strategy for managing an individual patient will vary over time, dependent on the patient’s psychological coping strategies, recurrence frequency, symptom severity and relationship status. Frequent recurrent episodes can be managed with supportive therapy only, episodic therapy or suppressive therapy. If patient re-attends service offer full sexual health screen if new contacts especially if they have not been tested for HIV previously.
– see Table below.
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Management Options for Recurrent Genital Herpes
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Supportive only
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Episodic Treatment
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Suppressive Treatment*
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Frequency of episodes
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Infrequent/ rare
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Infrequent - frequent
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Consider the clinical context and impact on patient quality of life; Recurrence rate >6/yr
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Duration of each episode
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Minimal
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>4 days
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Clinical context
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Severity of each episode
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Minimal
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Moderate/severe
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Moderate/severe
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Other factors
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-
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Patient opts not to take suppressive Rx; Recurrences respond rapidly
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Distressed, relationship difficulties, underlying medical issues, immunosuppression;
Special event i.e. holiday or exams
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Regimen
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-
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Aciclovir 800 mg three times daily for 2 days
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Aciclovir 400 mg BD
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Supportive only
Saline bathing, Yellow soft paraffin (“Vaseline”), analgesia advice
Episodic antiviral treatment
Oral antiviral therapy shortens recurrent episodes in patients who have recurrences lasting more than 4 days and will abort approximately 10% of lesional recurrences when started early (within 24 hours of symptoms developing). This is best managed as a self-start medication. Patients are best arranging a supply via GP repeat prescription.
The regimen recommended is:-
Aciclovir 800 mg three times daily for 2 days*
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*No evidence to support this regime in PLWHIV discuss patients with immunosuppressive illnesses with a senior GUM physician
Suppressive therapy
*Patients with confirmed genital herpes and a recurrence rate of more than six episodes of genital herpes in 12 months will benefit from daily suppressive treatment. Patients do not have to have experienced 6 painful recurrences to be eligible – someone with a recurrence every month for 3 months meets this recurrence rate and should be offered suppressive therapy. There may also be psychosocial indications for initiating suppressive therapy.
All patients with genital herpes should be made aware of the option of suppressive therapy. Patients do not need to see a consultant to start suppressive therapy if the above criteria are met. GUM consultant clinic referral should only be offered to patients where problematic recurrence of HSV is an issue (or in pregnancy or women trying to conceive)
Experience with suppressive therapy is most extensive with aciclovir. Safety and resistance data on patients taking long term therapy now extend to over 20 years of continuous surveillance. There is NO need for any routine monitoring or baseline tests except in known severe renal disease
There is no evidence of clinical superiority of valaciclovir or famciclovir over aciclovir; on economic grounds, aciclovir is therefore the drug of choice at Sandyford.
The regimen recommended is:-
Aciclovir 400 mg twice daily for 6-12 months (initial supply for ONE month)
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Prescription
Please give one month worth of aciclovir 400mg BD and send standard GP letter (“HSV Suppressive Therapy” on NaSH) with patients consent to request GP continue this on repeat prescription for up to one year.
We do NOT supply multiple months of therapy to patients, but can give them a one month starter pack while they arrange to see their GP. If patients feel unable to disclose the diagnosis to their GP then these concerns should be explored and a senior clinician involved as we cannot provide an ongoing supply from limited clinic stock
Advice to patient
If they experience flare up of symptoms whilst on suppressive therapy, they should increase the dose to 400mg TDS for 5 days and then step down again. If they have frequent recurrences on suppression, they should call sexual health department for a review appointment.
Dosage reductions are clinically inappropriate.
Twenty percent of patients will experience a reduction in recurrence frequency compared with pre-suppression symptomatic levels.
Please inform the patient that most people will have an episode on stopping suppressive treatment which should be managed symptomatically and to ensure they have medications for treatment on hand if needed. They should then monitor symptoms the recommended minimum period of assessment should include two recurrences If they have persistent symptoms they should call sexual health department for a review appointment.