Treatment Guideline Chart
Primary herpes simplex virus (HSV) infection is first infection with either herpes simplex virus-1 (HSV-1) or herpes simplex virus-2 (HSV-2) in individuals who do not have antibodies to either HSV-1 or HSV-2.
First episode-non primary infection is infection with either HSV-1 or HSV-2 in individuals who have previously existing antibodies against HSV-1 or HSV-2 respectively.
Recurrent HSV infection results from reactivation of latent virus. It is usually brought about by triggering factors eg UV light, immunosuppression.
Orolabial HSV disease is mostly caused by HSV-1 that occurs most commonly in children <5 years of age. It is transmitted through close contact with individuals who have active viral shedding.
Genital HSV disease is caused by HSV-2 that is the usual cause of herpes genitalis. It typically occurs in adults and transmitted through sexual contact.

Herpes%20simplex%20virus%20infection Management

Patient and Parent Counseling

  • Reduce patient’s anxiety and help patients to cope with the infection by educating them on the natural history of the disease, recurrent episodes, risk for human immunodeficiency virus (HIV), diagnostic testings, antiviral treatments, sexual relationships and perinatal transmission
  • Discuss treatment options:
    • Episodic treatment vs suppressive treatment
    • If patient has ≥6 episodes/year, consider suppressive treatment
      • Suppressive treatment may incur higher costs and inconvenience
    • Increase fluid intake to dilute urine


  • Recurrences of herpes labialis can be prevented by avoiding triggers (eg UV light exposure) and sunscreen use 
  • Educate patient on how to prevent transmission of genital herpes by:
    • Abstaining from sexual contact during lesion recurrences or prodromes
    • Limiting the number of sexual partners
    • Informing sexual partner or former sexual partner(s) from preceding 60 days prior to diagnosis to seek evaluation and treatment
    • Understanding that asymptomatic viral shedding may cause transmission
      • Asymptomatic viral shedding is more likely to occur with HSV-2 infection, in the 1st year following an infection, or if recurrences are symptomatic; however, shedding decreases with time
    • Using a condom to protect against transmission (not foolproof)
      • Correct use of condoms reduces the risk of genital herpes because the infected area or site of potential exposure is covered

Management Strategies for Recurrent Genital Herpes

Supportive Treatment Alone
  • Recurrent infections are generally self-limiting, less severe with a shorter duration of symptoms and supportive treatment alone may be effective to control symptoms
Episodic Antiviral Treatment
  • Patient-initiated therapy that needs to be pre-prescribed
    • Start antiviral therapy as soon as possible within 1 day of lesion onset or during the prodrome that heralds some outbreak
  • Best for HSV-infected patients who have mild symptoms and infrequent recurrences
  • Reduces duration of symptoms by 1-2 days
Suppressive Antiviral Therapy
  • Recommended in patients with frequent recurrent genital herpes (≥6 episodes/year), severe or painful prodromes, pregnant patients with herpetic lesions in the last trimester, patients with psychological problems due to the infection, and in immunocompromised patients
  • Used to decrease frequency of recurrences, chance of transmission and provide relief of symptoms
  • Antiviral suppress symptomatic and asymptomatic viral shedding
    • Reduces clinical outbreaks and viral shedding by 80% and 95% respectively
  • Full suppressive effect is usually obtained when in treatment for 5 days
  • Outbreaks during therapy should investigate for poor compliance, need for dose adjustments, resistance or incorrect diagnosis
  • Annual evaluation and cessation of therapy after 1 year is required to assess frequency of recurrences
    • Period of assessment should include 2 recurrences to view both severity and frequency
    • It is safe and advisable to restart suppressive treatment in patients who continue to have significant infection
  • Suppressive treatment may incur higher costs and inconvenience

Follow Up

  • Interrupt treatment after 6 months-1 year to assess frequency of recurrence
  • Restart treatment if high rate of recurrences
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