Treatment regimen for the first herpes outbreak
The first herpes outbreak is the most severe: there is more discomfort and more skin lesions and it lasts longer. For that reason, the treatment for a first outbreak is slightly different from treatment for later outbreaks—it lasts longer and more medication is given.
In this table, we summarize:
- the optimal treatment regimen for your first herpes outbreak
- alternative treatment options if the primary medication is unavailable or too costly
| Ideal medication | Alternative Treatment |
|---|
First herpes outbreak | Valacyclovir (Valtrex) 1 1g tablet twice a day for 7–10 days
OR
Famciclovir (Famvir) 1 250 mg tablet 3 times a day for 7–10 days | Acyclovir (Zovirax) 1 400mg tablet 3 times a day for 7–10 days
OR
Acyclovir (Zovirax) 1 200mg tablet 5 times a day for 7–10 days |
Treatment regimen for each recurrent herpes outbreak
Recurrent outbreaks are all outbreaks after the initial one. (They’re also referred to as flare-ups.) Here are a few important points:
- Outbreaks are more common with herpes 1 than herpes 2
- HSV-1: 25% chance
- HSV-2: 60%–90 % chance
- Outbreaks are more common during the first few years and become less and less common over time
This table summarize the treatment regimen for recurrent herpes outbreaks.
Please note that the treatment regimen (dose and duration of medication) depends on the anatomic location of the outbreak, not the herpes type.
| Recurrent herpes | Ideal medication | Alternative medications |
|---|
Genital area | Valacyclovir 1 500mg tablet twice a day for 3 days
OR
Valacyclovir 1 1g tablet once a day for 5 days | Acyclovir 1 400mg tablet three times a day for 5 days
OR
Acyclovir 1 800mg tablet twice a day for 5 days
OR
Acyclovir 1 800mg tablet three times a day for 2 days
OR
Famciclovir 1 125mg tablet twice a day for 5 days
OR
Famciclovir 1 1g tablet twice a day for 1 day |
Oral herpes | Valacyclovir Two 1g tablets twice a day for 1 day | Famciclovir One 1500mg tablet |
Suppressive herpes medication to reduce frequent outbreaks
A very small number of herpes-positive people have frequent herpes outbreaks (meaning more than five a year). Taking medication will reduce the frequency of outbreaks by 70%–80%.
People with frequent herpes outbreaks are advised to take daily antiviral medication. This treatment should be reevaluated by your doctor 6–12 months after the onset of this therapy.
This is considered a safe and effective method of outbreak reduction (safety and efficacy have been studied for six years for acyclovir and one year for valacyclovir and famciclovir).
| Ideal medication | Other medications |
|---|
Herpes recurrence | Valacyclovir 1 500mg tablet once a day
OR
Valacyclovir* 1 1g tablet once a day | Acyclovir 1 400mg tablet twice a day
OR
Famciclovir (Famvir) 1 250mg tablet twice a day |
* For those who have outbreaks on the initial suppressive dose or have 10 outbreaks per year.
Treatment regimen to reduce the rate of transmission
Here are a few points that are relevant to the information in the table below:
- Herpes-positive persons transmit the virus regardless of whether they currently have symptoms
- The probability of passing the infection is much lower (50% lower) when the person is asymptomatic as compared to when they’re symptomatic (10.2% versus 20.1%).
- Most people contract the virus during their partner’s asymptomatic virus shedding, when their partner is unaware of passing it. This accounts for over 80% of all herpes transmissions.
- Taking medication will decrease viral shedding and the transmission rate by another 50%: from 10.2% while asymptomatic to 5.1%.
In this table, we summarize the approved suppressive regimens. Your treatment should be reevaluated by your doctor 6–12 months after the onset of the therapy.
| Ideal medication | Other medications |
|---|
Prevention of transmission | Valacyclovir 1 500mg tablet once a day
OR
Valacyclovir* 1 1g tablet once a day | Acyclovir 1 400mg tablet twice a day
OR
Famciclovir (Famvir) 1 250mg tablet twice a day |
* For those who have over 10 outbreaks per year or have an outbreak on the starting dose.
Frequently Asked Questions
Here we summarize real patients’ questions, grouped by topic, and Dr. Fuzayloff’s answers to them.
What does treatment of herpes accomplish? 
Cure versus treatment
“Cure” means complete recovery. There is no cure for herpes (it’s not possible to get rid of the herpes virus). Treatment improves the infected person’s quality of life and overall health status.
Treatment of herpes is initiated to accomplish one of three goals:
1. To decrease the duration and severity of a current outbreak
2. To decrease the frequency of outbreaks for a person who has more than 10 outbreaks a year
3. To reduce the chance of transmitting the herpes infection to other people
The first two goals are medical reasons to be on the medication. The third is a personal decision of a patient.
If I’m having a herpes skin outbreak now, is it necessary for me to go on medication?
No. The symptoms will gradually resolve without any treatment. Medication is taken by people who want to the duration of symptoms or the amount of viral shedding during flare-ups.
The table below summarizes the effects of the medication on different aspects of herpes flare-ups:
- Viral shedding—when a person is most infectious
- How fast herpes skin lesions crust and heal
- Local pain duration (herpes lesions can be quite painful)
- Duration of systemic symptoms (fever, chills, fatigue, flu-like symptoms, etc.)
Please pay attention to the significant reduction of viral shedding with medication.
| Herpes symptoms or signs | Without medication | With medication |
|---|
| Days |
|---|
| Viral shedding | 9 | 2 |
| How long it takes for herpes skin lesions to crust | 10 | 7 |
| How long it takes for herpes skin lesions to heal | 16 | 10 |
| Duration of local pain | 7 | 5 |
| Duration of systemic symptoms and signs | 6 | 3 |
Ideal time for taking antiviral medication:
It is recommended that antiviral medication be taken when the first symptoms appear (the optimal time to start the treatment is within 24 hours of the onset of symptoms onset).
I had treatment for a herpes outbreak. Am I still infectious? When can I have sex again?
Am I still infectious?
- If a herpes diagnosis is established (by a blood test or swab), it is not a curable condition; you will remain infectious forever.
- When you’re having symptoms, the chance of passing the infection is 20.1%. When you’re not having symptoms, the risk of passing it is 50% lower, 10.2%.
- The most virus is shed a few days before getting symptoms, while you have symptoms, and up to a few days after the sores have healed.
When can I have sex again?
- You are most contagious when you have fluid-filled blisters.
- It is recommended that you avoid sex until the sores are completely healed. This might take from a few days to a few weeks. Wait until a few days after the scab has fallen off and pink skin is revealed.
Preventative herpes medications: what are my options?
The word “preventative” in the herpes context can mean two different things:
- Prevention of frequent outbreaks
- Prevention of transmission to partners
We’ll discuss both below:
Herpes medication for prevention of frequent outbreaks
- “Frequent outbreaks” means more than five herpes outbreaks a year (confirmed by a doctor unless you’re very familiar with herpes outbreaks)
- Preventative medication might reduce the number of outbreaks by as much as 70%–80%.
- Antiviral medications are safe and effective. Valtrex is most commonly used one. Its safety and efficacy for at least a year have been confirmed by multiple studies.
Herpes medication for reducing transmission to a partner
Whether you choose to be on herpes medication to reduce the risk of transmission to a partner is an ethical question. It is a personal question that herpes-positive persons must answer for themselves. Here are a few important practical things that I think are helpful to know in making your decision:
- Medication will reduce the chance of transmission by 50%, from 10% to 5%.
- These medications do not help you (improve your health) in any way. You are taking it for the other person. You should understand and be OK with that.
- You need to be on the medication all the time to reduce silent transmission of the infection to your partner (for as long as your partner is negative). There is no end date. Fortunately, the medication is not addictive and can be stopped at any time.
- The medication is considered “very safe”—people rarely have any major side effects and most side effects are reversible. The most common herpes medication is Valtrex (valacyclovir).
Potential side effects:
- Depression
- Anxiety
- Fatigue
- Sleep issues
- Diarrhea
- Others
- Always ask your partner to get tested for herpes before you start taking the medication. Most people have never been tested because most people are asymptomatic. Remember, this is not a routinely run test even if a “full panel STD test” is requested. Ideally, ask for the written report from the lab so you can see the herpes test “positive” on it. There is no need for you to be on the medication if you and your partner are both positive for the same type of herpes virus (which is not uncommon with HSV-1).
Health clinics that offer herpes treatment
If you assume you have herpes or you’ve already been diagnosed with it, you can get the needed treatment from a primary care doctor, gynecologist, urgent care clinic, or urologist. Or you can visit our certified clinic at 35 W 36 Street, Suite 7 E New York, NY 10018, or contact us (212.696.5900) for a video conference. We will carefully examine you and suggest the treatment suitable for your situation.
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