Intended for healthcare professionals

Practice Therapeutics

Antivirals for herpes simplex viruses

BMJ 2015; 351 doi: (Published 09 July 2015) Cite this as: BMJ 2015;351:h3350
  1. Shailendra Sawleshwarkar, senior lecturer1,
  2. Dominic E Dwyer, professor, director2
  1. 1Western Sydney Sexual Health Centre, University of Sydney, Parramatta, NSW, 2150, Australia
  2. 2Institute of Clinical Pathology and Medical Research and University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia
  1. Correspondence to: S Sawleshwarkar shailendra.sawleshwarkar{at}

The bottom line

  • Aciclovir, valaciclovir, and famciclovir are similarly effective in healing lesions, and in reducing duration of symptoms and of viral shedding, in genital herpes

  • Long term suppressive treatment is safe and effectively reduces recurrences in genital and orolabial herpes; however, it does not completely eliminate recurrences or risk of transmission of genital herpes simplex virus infection to sexual partners

  • In older patients, and those with impaired renal function or taking nephrotoxic drugs, monitor renal function closely and consider using lower doses; owing to the risk of renal toxicity, intravenous aciclovir requires good hydration

  • Suppressive aciclovir or valaciclovir in the last weeks of pregnancy reduces clinical disease in the mother and transmission to the baby at the time of delivery but does not completely eliminate the risk of neonatal transmission

  • Neonates with central nervous system infection require high dose intravenous aciclovir for 21 days, and suppressive treatment with valaciclovir improves neurodevelopmental outcomes

A 25 year old woman presents to her general practitioner with a two day history of painful vulval lesions. She has not had previous episodes and does not have any significant previous medical history. She is in a new relationship with a male partner. Genital examination shows multiple vulval ulcers.

What diseases are caused by herpes simplex viruses?

Herpes simplex viruses type 1 and type 2 (HSV-1 and HSV-2) commonly cause mucocutaneous disease, including orolabial infections (more commonly HSV-1; for example, gingivostomatitis and “cold sores”) and genital herpes (HSV-2 or HSV-1).1 Infections may be asymptomatic (see box for classification). Other important manifestations include perinatal infection following symptomatic or asymptomatic maternal genital infection, encephalitis in children and adults, other neurological conditions (radiculitis, myelitis, and meningitis), eye disease (corneal ulceration, keratitis, iridocyclitis, acute retinal necrosis), and disseminated infections. This review will focus on use of antivirals in orolabial, genital, and neurological HSV infections.

Classification of genital and labial herpes infection

  • Primary infection—Recently acquired HSV-1 or …

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