A first episode of genital herpes should be treated with acyclovir, 400 mg orally three times a day; or famciclovir, 250 mg orally three times a day; or valacyclovir, 1.0 orally twice a day for 7 to 10 days or until clinical resolution is attained. Although these agents provide partial control of the symptoms and signs of clinical herpes, it neither eradicates latent virus nor affects subsequent risk, frequency, or severity of recurrences after the drug is discontinued. Daily suppressive therapy (acyclovir, 400 mg orally twice daily; or famciclovir, 250 mg twice daily; or valacyclovir, 1.0 g orally once a day) reduces the frequency of HSV recurrences by at least 75% among patients with six or more recurrences of HSV per year. Suppressive treatment partially, but not totally, decreases symptomatic and asymptomatic viral shedding and the potential for transmission (49).
Parenteral administration of penicillin G is the preferred treatment of all stages of syphilis.
Benzathine penicillin G, 2.4 million units intramuscularly in a single dose, is the recommended treatment for adults with primary, secondary, or early latent syphilis. The Jarisch-Herxheimer reaction—an acute febrile response accompanied by headache, myalgia, and other symptoms— may occur within the first 24 hours after any therapy for syphilis; patients should be advised of this possible adverse reaction.
Table 18.6 Treatment Options for External Genital and Perianal Warts
ND, no data. a May be self-applied by patients at home. bExpensive; reserve for patients who have not responded to other regimens.
Latent syphilis is defined as those periods after infection with T. pallidum when patients are seroreactive but show no other evidence of disease. Patients with latent syphilis of longer than 1 year’s duration or of unknown duration should be treated with benzathine penicillin G, 7.2 million units total, administered as three doses of 2.4 million units intramuscularly each, at 1-week intervals. All patients with latent syphilis should be evaluated clinically for evidence of tertiary disease (e.g., aortitis, neurosyphilis, gumma, and iritis). Quantitative nontreponemal serologic tests should be repeated at 6 months and again at 12 months. An initially high titer (1:32) should decline at least fourfold (two dilutions) within 12 to 24 months.
Genital Warts External genital warts are a manifestation of human papillomavirus (HPV) infection (51). The nononcogenic HPV types 6 and 11 are usually responsible for external genital warts. The warts tend to occur in areas most directly affected by coitus, namely the posterior fourchette and lateral areas on the vulva. Less frequently, warts can be found throughout the vulva, in the vagina, and on the cervix. Minor trauma associated with coitus can cause breaks in the vulvar skin, allowing direct contact between the viral particles from an infected man and the basal layer of the epidermis of his susceptible sexual partner. Infection may be latent or may cause viral particles to replicate and produce a wart. External genital warts are highly contagious; more than 75% of sexual partners develop this manifestation of HPV infection when exposed.