Guideline sources The following summarized guidelines for the evaluation and management of genital herpes are prepared by our editorial team based on guidelines from the U.S. Preventive Services Task Force (USPSTF 2023; 2014), the Infectious Diseases Society of America (IDSA/CDC/NIH/HIVMA 2023; 2018), the Center for Disease Control (CDC 2021), the French National College of Gynecologists and Obstetricians (CNGOF 2018), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2017), and the World Health Organization (WHO 2016). 1 2 3 4 5 6 7 8 9 10 10 11 12 13 Definition Genital herpes is a sexually transmitted viral infection characterized by primary and recurrent genital inflammation and lesions. 10 Epidemiology Genital herpes is mostly caused by HSV-2 and HSV-1 transmitted through sexual contact. 10 Pathophysiology The incidence of genital herpes in North America is estimated to range from 5000 to 24000 per 100,000 people per year. 11 https://web.pathway.md/diseases/recglkWFSOh6s6aIz 1/8 6/24/23, 3:19 AM Genital herpes Pathway Disease course Clinical manifestations include lesions of mucous membrane presenting as bilateral clusters of macules, papules, followed by vesicles, pustules, and ulcers on the external genitalia with symptoms of pain, itching, burning, dysuria, lymphadenopathy, fever, cervicitis (women), and proctitis (homosexual men). Complications in women include aseptic meningitis and urinary retention. Recurrent episodes may show prodromal symptoms of paresthesia and pains in the area of lumbosacral dermatomes. Asymptomatic genital shedding without any clinical symptoms is quite frequent. The disease increases psychological stress with frequent recurrences. 12 Prognosis and risk of recurrence Untreated pregnancy-related genital herpes is associated with a mortality of 0.062 per 1,000 births in neonates. 13 Guidelines 1. Screening and diagnosis Indications for screening: do not obtain routine serologic screening for genital HSV infection in asymptomatic adolescents and adults, including pregnant persons. D 2. Diagnostic investigations Laboratory testing: obtain laboratory testing to confirm the diagnosis of genital herpes. B 3. Medical management Management of first episode: As per CDC 2021 guidelines: Administer any of the following antiviral regimens for 7-10 days in patients with a first clinical episode of genital herpes: Situation Guidance 400 mg PO TID Acyclovir 250 mg PO TID Famciclovir 1,000 mg PO BID. E Valacyclovir Consider extending treatment if healing is incomplete after 10 days of therapy. E https://web.pathway.md/diseases/recglkWFSOh6s6aIz 2/8 6/24/23, 3:19 AM Genital herpes Pathway As per SOGC 2017 guidelines, administer antiviral therapy with valacyclovir in patients with proven genital herpes. B As per WHO 2016 guidelines, consider administering antiviral therapy with a standard dose of aciclovir C in adult and adolescent patients with a first clinical episode of genital HSV infection. B Management of recurrent episode: As per CDC 2021 guidelines, administer any of the following regimens for episodic therapy in patients with recurrent HSV-2 genital herpes: Situation Guidance 800 mg PO BID for 5 days Acyclovir 800 mg PO TID for 2 days 1,000 mg PO BID for 1 day Famciclovir 500 mg PO once, followed by 250 mg BID for 2 days 125 mg PO BID for 5 days 500 mg PO BID for 3 days Valacyclovir 1,000 mg PO once daily for 5 days. E As per WHO 2016 guidelines, consider administering antiviral therapy with acyclovir in adult and adolescent patients with a recurrent episode of genital HSV infection. C 4. Specific circumstances Pregnant patients, evaluation: As per CNGOF 2018 guidelines: Do not obtain virologic confirmation for genital herpes lesions during pregnancy in patients with a history of genital herpes. D Obtain virological confirmation with PCR and assess for the specific IgG type in pregnant patients with genital lesions with no previous history of genital herpes. E As per SOGC 2017 guidelines, assess for the history of genital herpes early in pregnancy. B Show 2 more Pregnant patients, suppressive therapy: As per CDC 2021 guidelines, initiate suppression therapy with acyclovir (400 mg PO TID) or valacyclovir (500 mg PO BID) at 36 weeks of gestation in pregnant patients with recurrent genital herpes. E As per CNGOF 2018 guidelines: https://web.pathway.md/diseases/recglkWFSOh6s6aIz 3/8 6/24/23, 3:19 AM Genital herpes Pathway Initiate antiviral prophylaxis from 36 weeks of gestation until delivery in patients with either a first or recurrent episode of genital herpes during pregnancy. B Do not initiate routine prophylaxis in patients with a history of genital herpes but no recurrence during pregnancy. D As per SOGC 2017 guidelines, initiate suppression therapy with acyclovir or valacyclovir at 36 weeks of gestation to decrease the risk of clinical lesions and viral shedding at the time of delivery and decrease the need for C-section in pregnant patients with known recurrent genital HSV infection. A Pregnant patients (antiviral therapy): administer antiviral therapy with aciclovir (200 mg 5 times daily) or valaciclovir (1,000 mg BID for the first episode, 500 mg BID for a recurrent episode) for 5- 10 days in patients with a first or recurrent episode of genital herpes during pregnancy. B Pregnant patients, considerations for delivery: As per CNGOF 2018 guidelines: Offer Cesarean delivery in patients with a suspected or confirmed first episode of genital herpes at the onset of labor, (Grade B) < 6 weeks before delivery, or in the event of premature rupture of membranes at term. E Consider offering Cesarean delivery in patients with a recurrence of genital herpes at the onset of labor when the membranes are intact. Consider offering vaginal delivery in cases of prolonged rupture of membranes. E As per SOGC 2017 guidelines: Offer Cesarean delivery at delivery in pregnant patients with recurrent HSV in the presence of prodromal symptoms or a lesion suggestive of HSV. B Counsel pregnant patients with primary genital herpes in the third trimester of pregnancy about the high risk of transmitting HSV to their neonates. Offer Cesarean delivery to decrease this risk. B Patients with HIV (primary prevention): encourage using latex condoms to to prevent transmission of HSV-2 and other sexually transmitted pathogens. B Show 5 more Patients with HIV, suppressive therapy: As per IDSA/HIVMA/CDC/NIH 2023 guidelines, initiate suppressive therapy with acyclovir (400 mg PO BID), valacyclovir (500 mg PO BID), or famciclovir (500 mg PO BID) to prevent recurrences of HSV lesions in human immunodeficiency virus-positive patients with severe or frequent HSV recurrences or wishing to minimize the frequency of recurrences, including pregnant patients. A Show 2 more As per CDC 2021 guidelines, initiate daily suppressive therapy with any of the following antiviral regimens in human immunodeficiency virus-positive patients with genital herpes: Situation Guidance 400-800 mg PO BID or TID Acyclovir https://web.pathway.md/diseases/recglkWFSOh6s6aIz 4/8 6/24/23, 3:19 AM Genital herpes Pathway 500 mg PO BID Famciclovir 500 mg PO BID. E Valacyclovir Patients with HIV, antiviral therapy: As per IDSA/HIVMA/CDC/NIH 2023 guidelines, administer acyclovir (400 mg PO TID), valacyclovir (1,000 mg PO BID), or famciclovir (500 mg PO BID) for 7-10 days for the first episode and 5-10 days for a recurrent episode of genital herpes in human immunodeficiency virus-positive patients. A Show 3 more As per CDC 2021 guidelines, administer any of the following antiviral regimens for 5-10 days as episodic therapy in human immunodeficiency virus-positive patients with recurrent genital herpes: Situation Guidance 400 mg PO TID Acyclovir 500 mg PO BID Famciclovir 1,000 mg PO BID. E Valacyclovir Patients with HIV (pregnant patients): administer acyclovir as the antiviral drug of choice during pregnancy, particularly during the second and third trimesters. B Show 4 more Patients with HIV (pediatric patients): advise adolescent and young adult patients with human immunodeficiency virus infection to use condoms to prevent HSV infection and other sexually transmitted diseases. B Show 3 more Neonate patients: Obtain various samples (blood and CSF) for HSV PCR to confirm the diagnosis in neonates with suspected neonatal herpes. E Administer IV acyclovir 20 mg/kg TID A in neonates with suspected neonatal herpes before the PCR results are available. Decide on the duration of the treatment depending on the clinical form. E 5. Patient education General counseling: As per SOGC 2017 guidelines, counsel on condom use and safe sex in patients with proven genital herpes. B https://web.pathway.md/diseases/recglkWFSOh6s6aIz 5/8 6/24/23, 3:19 AM Genital herpes Pathway As per USPSTF 2014 guidelines, provide intensive behavioral counseling to all sexually active adolescents and adults at increased risk for STIs. B 6. Preventative measures Condom use: advise using condoms to reduce the risk of genital herpes transmission. B Suppressive therapy: As per CDC 2021 guidelines, initiate suppressive therapy with any of the following regimens in patients with recurrent HSV-2 genital herpes: Situation Guidance 400 mg PO BID Acyclovir 500-1,000 mg PO once daily Valacyclovir 250 mg PO BID. E Famciclovir As per SOGC 2017 guidelines: Consider initiating suppressive therapy in patients with 6 recurrences per year, < 6 recurrences per year but with significant complications, significantly affected quality of life, or social and sexual dysfunction. C Consider initiating suppressive therapy to reduce the risk of transmission to a sexual partner or fetus/neonate. C As per WHO 2016 guidelines, consider initiating suppressive therapy with aciclovir C in adolescent and adult patients with recurrent episodes of severe, or distress-causing genital HSV infection. Reassess the need for continued therapy after 1 year C References 1. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in Children with and Exposed to HIV Herpes Simplex Virus. Department of Health and Human Services. 2018. Open 2. No authors listed. WHO Guidelines for the Treatment of Genital Herpes Simplex Virus. Geneva: World Health Organization; 2016. Open 3. US Preventive Services Task Force, Carol M Mangione, Michael J Barry et al. Serologic Screening for Genital Herpes Infection: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. 2023 Feb 14;329 6 502 507. Open 4. Kimberly A Workowski, Laura H Bachmann, Philip A Chan et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70 4 1 187. Open https://web.pathway.md/diseases/recglkWFSOh6s6aIz 6/8 6/24/23, 3:19 AM Genital herpes Pathway 5. 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Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Department of Health and Human Services. 2023. Open 10. Dinesh Jaishankar, Deepak Shukla. Genital Herpes: Insights into Sexually Transmitted Infectious Disease. Microb Cell. 2016 Jun 27;3 9 438 450. Open 11. Jean-Elie Malkin. Epidemiology of genital herpes simplex virus infection in developed countries. Herpes. 2004 Apr;11 Suppl 1 2A 23A. Open 12. Andreas Sauerbrei. Optimal management of genital herpes: current perspectives. 2016 Jun 13;9 129 41.2016 Jun 13;9 129 41. Open 13. Katharine J Looker, Amalia S Magaret, Margaret T May et al. First estimates of the global and regional incidence of neonatal herpes infection. 2017 Mar;5 3):e300-e309.2017 Mar;5 3):e300-e309. Open 14. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC et al. Serologic Screening for Genital Herpes Infection: US Preventive Services Task Force Recommendation Statement. 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