Previous changes

January 2023 — minor update. Tubulointerstitial nephritis added as a potential adverse effect of valaciclovir in line with an update to the manufacturer's summary of product characteristics. 

September to October 2022 — reviewed. A literature search was conducted in August 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. The recommendations have been updated in line with current evidence. The topic has undergone minor restructuring to improve clarity and navigation. A Prescribing information section has been added for oral antiviral drugs that may be used for episodic or suppressive therapy in primary care.

April to May 2017 — reviewed. A literature search was conducted in April 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. 

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.

September 2010 — minor update. The Health Protection Agency (HPA) figures for new diagnoses of genital herpes in 2008/9 have been added. 

April to June 2010 — updated to include advice regarding the management of genital herpes in people with HIV. 

August 2009 — minor update. Advice from the National Institute for Health and Care Excellence (NICE) guideline on when to suspect child maltreatment has been added to this topic. The advice to avoid sharing towels and flannels with others has been clarified to explain that although it is very unlikely that the herpes virus would survive on an object long enough to be passed on, it is sensible to take steps to prevent this. 

June to September 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

July 2005 — reviewed. Validated in September 2005 and issued in November 2005.

December 2001 — reviewed. Validated in March 2002 and issued in April 2002.

July 1999 — rewritten. Validated in October 1999 and issued in January 2000.

New evidence

Evidence-based guidelines

• Patel, R., Green, J., Moran, B., Clarke, E., et al. (2024). British Association of Sexual Health and HIV UK national guideline for the management of anogenital herpes, 2024. International journal of STD & AIDS, 09564624241282396. [Abstract]

HTAs (Health Technology Assessments)

No new HTAs since 1 August 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 August 2022.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 August 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 August 2022.

New policies

No new national policies or guidelines since 1 August 2022.

New safety alerts

No new safety alerts since 1 August 2022.

Changes in product availability

No changes in product availability since 1 August 2022.

Basis for recommendation

The information on when to suspect genital herpes is based on the British Association for Sexual Health and HIV (BASHH) publication UK national guideline for the management of anogenital herpes [BASHH, 2014b], the BASHH and Royal College of General Practitioners (RCGP) joint guideline Sexually transmitted infections in primary care [BASHH, 2013], the consensus publication European guidelines for the management of genital herpes [Patel, 2017], and expert opinion in review articles on genital herpes [Gnann, 2016; Groves, 2016] and on the differential diagnosis of genital ulcers [Roett, 2020].

Clinical features on history-taking

• The information on typical clinical symptoms is based on the BASHH publication [BASHH, 2014b], the joint BASHH/RCGP guideline [BASHH, 2013], and the European consensus guidelines [Patel, 2017].
  • Early recognition and treatment of genital herpes infection is essential to reduce the duration of illness and risk of complications or subsequent hospitalization [Patel, 2017].
  • The information about the incubation period of herpes simplex virus (HSV) is based on expert opinion in a review article [Gnann, 2016].
  • The information about prodromal symptoms in recurrent episodes is based on the joint BASHH/RCGP guideline [BASHH, 2013] and the European consensus guidelines [Patel, 2017].
  • The information about the relative duration and severity of first and recurrent episodes is based on the joint BASHH/RCGP guideline [BASHH, 2013] and expert opinion in review articles [Gnann, 2016; Groves, 2016].

Clinical features on examination

• The information about typical and atypical signs on examination is based on the BASHH publication [BASHH, 2014b] and the joint BASHH/RCGP guideline [BASHH, 2013].

Basis for recommendation

The recommendations on assessment are largely based on the National Institute for Health and Care Excellence (NICE) clinical guideline Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2017], the British Association for Sexual Health and HIV (BASHH) publication UK national guideline for the management of anogenital herpes [BASHH, 2014b], the BASHH and Royal College of General Practitioners (RCGP) joint guideline Sexually transmitted infections in primary care [BASHH, 2013], the consensus publication European guidelines for the management of genital herpes [Patel, 2017], and expert opinion in review articles on genital herpes [Groves, 2016; Gnann, 2016].

Clinical features on history-taking

• The recommendation that confirmation of the diagnosis of genital herpes simplex should ideally be made by a specialist sexual health service is based on the fact this requires herpes simplex virus (HSV) identification and typing before counselling, treatment, and follow-up is arranged [BASHH, 2013; BASHH, 2014b; Patel, 2017].
• The recommendation to ask about symptom onset and whether lesions are still forming is based on the fact oral antiviral treatment should be started within five days of an acute episode [BASHH, 2014b].
• The information about when to suspect or consider sexual abuse is based on the NICE clinical guideline [NICE, 2017].

Clinical features on examination

• These recommendations are largely based on the BASHH guideline [BASHH, 2014b], the BASHH/RCGP joint guideline [BASHH, 2013], and the European consensus guidelines [Patel, 2017].

Arranging investigations in primary care

• The recommendation that confirmation of the diagnosis should ideally be made by a specialist sexual health service is based on the BASHH guideline [BASHH, 2014b], the BASHH/RCGP joint guideline [BASHH, 2013], and is also extrapolated from expert opinion in a review article [Gnann, 2016].
  • Confirmation and virus typing by direct virus detection in genital lesions is essential for diagnosis, prognosis, counselling, and management [BASHH, 2014b; Patel, 2017].
  • Typing of HSV is important to distinguish between HSV-1 and HSV-2 in all first presentations of suspected genital herpes infection, to guide counselling about the expected natural history of infection and prognosis [BASHH, 2014b; Gnann, 2016].
• The recommendation to take a viral swab for polymerase chain reaction (PCR) testing if available (rather than viral culture) is based on the BASHH guideline [BASHH, 2014b], the BASHH/RCGP joint guideline [BASHH, 2013], the European consensus guidelines [Patel, 2017], and expert opinion in a review article [Groves, 2016].
  • The BASHH guideline states that HSV DNA detection by PCR provides improved viral detection rates compared with viral culture techniques, and nucleic acid amplification test (NAAT) methods are the test of choice. HSV culture misses approximately 30% of PCR-positive samples, most significantly in people presenting with late or with mild recurrent disease. In addition, although viral culture has a specificity of nearly 100%, it is influenced by virus shedding, the quality of specimens, storage of samples, and transport conditions [BASHH, 2014b].
  • Similarly, the European consensus guidelines note that viral detection in early disease is more likely to be successful than in delayed presentations [Patel, 2017].
• The recommendation to consider taking a rectal swab for HSV detection if there is suspected herpes proctitis is based on the BASHH guideline [BASHH, 2014b].

Basis for recommendation

The information on differential diagnosis is based on the Royal College of General Practitioners (RCGP) and British Association for Sexual Health and HIV (BASHH) joint guideline Sexually transmitted infections in primary care [BASHH, 2013] and expert opinion in a review article on the differential diagnosis of genital ulcers [Roett, 2020] and on genital herpes [Groves, 2016].

How should I manage a person with a first episode of genital herpes?

If a person has a suspected first episode of genital herpes infection, advise to attend a specialist sexual health service for confirmation of the diagnosis, treatment, screening for other sexually transmitted infections (STIs), and follow-up.

• Advise about sources of information and support, such as:
  • The Family Planning Association (website www.fpa.org.uk) has a patient leaflet Genital herpes.
  • The Herpes Viruses Association (website www.herpes.org.uk) has patient information Genital herpes - questions and answers and a confidential helpline 0845 123 2305 (on weekdays).
  • The British Association for Sexual Health and HIV (BASHH) patient leaflet Genital herpes - the basics.
• Advise on possible self-care measures, such as:
  • Saline bathing — wash the affected area using saline (1 teaspoon salt in 560 ml of warm water) as needed to ease symptoms, promote healing of lesions, and prevent secondary infection.
  • Take over-the-counter analgesia, such as paracetamol or ibuprofen, if needed and there are no contraindications. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for more information.
  • Consider applying topical petroleum jelly or a topical anaesthetic (for example lidocaine 5% gel or ointment) to lesions, for example before passing urine if there is dysuria.
  • Increase fluid intake to produce dilute urine, which may be less painful to void. Try to urinate in a bath or with water flowing over the area to reduce stinging.
  • Avoid wearing tight clothing, which may irritate lesions.
• Advise about minimizing transmission of infection to others.
  • Advise to abstain from sexual activity (including non-penetrative and oro-genital sex) if lesions are present, until follow-up or until lesions have cleared.
    
    • Advise that transmission can occur when there are no symptoms ('asymptomatic shedding'), but the risk is higher when a person is symptomatic.
    • Advise that when used consistently and correctly, male condoms may reduce the risk of future transmission, but cannot prevent it completely. Transmission is still possible with close skin contact, or contact with infected secretions during foreplay.
  • Reassure that a first episode may not necessarily indicate recent infection, and transmission can occur from an asymptomatic partner years into a monogamous relationship.
    • In addition, herpes simplex virus type 1 (HSV-1) infection may have spread from elsewhere on the body, such as the lips or fingers.
  • Advise there is a risk of neonatal transmission if a pregnant woman has a first episode of genital herpes, particularly in the third trimester.
    • Advise a woman to inform a healthcare professional immediately if she is, or becomes, pregnant. See the section on Referral for more information.
    • Advise the consistent use of condoms for any sexual partner who is pregnant and seronegative, especially in the third trimester of pregnancy, to reduce the risk of transmission.
• If the person is unable or unwilling to attend a specialist sexual health service, advise about treatment options in primary care:
  • Do not prescribe or advise the use of topical antiviral treatment.
  • Advise that oral antiviral treatment should be started within 5 days of the start of a first episode, or while new lesions are forming.
    • Prescribe aciclovir 400 mg three times a day for 5 days, or valaciclovir 500 mg twice a day for 5 days first-line.
    • Prescribe aciclovir 200 mg five times a day for 5 days, or famciclovir 250 mg three times a day for 5 days second-line.
    • Consider extending the duration of treatment for up to 10 days if new lesions appear during treatment or healing is incomplete.
  • If the person is immunocompromised or has untreated HIV infection, and genital herpes infection is mild and uncomplicated:
    • Prescribe aciclovir 400 mg five times a day for 7–10 days, or valaciclovir 500–1000 mg twice a day for 10 days, or famciclovir 250–500 mg three times a day for 10 days.
    • If new lesions appear after 3–5 days of treatment, or if there is any uncertainty about management, seek specialist advice from the person's infectious diseases team or sexual health services, depending on clinical judgement. See the section on Referral for more information.
  • See the sections on Aciclovir, Valaciclovir, and Famciclovir in Prescribing information for more information on contraindications and cautions, adverse effects, and drug interactions.
• If treatment has been started in primary care, encourage the person to attend a specialist sexual health service for follow-up. If the person is unable or unwilling to attend, arrange a review 5–7 days after initial assessment and treatment, to:
  • Explain swab results (if taken and available), assess symptoms and any new lesions or complications needing referral, review treatment, and advise about the risk of recurrence.
    
    • If there is any uncertainty about management, seek specialist advice from sexual health services, depending on clinical judgement. See the section on Referral for more information.
    • See the Scenario on Recurrent episodes for more information, including the use of episodic or suppressive oral antiviral regimens for treatment or prevention of future episodes.

When should I refer a person with a first episode of genital herpes?

If a person has a suspected first episode of genital herpes infection, advise to attend a specialist sexual health service for confirmation of the diagnosis, treatment, screening for other sexually transmitted infections (STIs), and follow-up.

• Arrange emergency hospital admission if a person has suspected genital herpes infection and:
  • Is severely systemically unwell, and/or there is a suspected severe or potentially serious complication that cannot be managed in primary care.
• Arrange referral to an appropriate specialist if a person has suspected genital herpes infection and:
  • The diagnosis is uncertain.
  • There is an inadequate or no response to treatment in primary care.
  • Is pregnant at any gestation.
    • Refer urgently to a specialist sexual health service for confirmation of the diagnosis and treatment of a suspected first episode. Specialist liaison with the midwife and obstetrics may be needed to provide a care plan.
  • Is immunocompromised or has untreated HIV infection, with suspected severe genital herpes.
    • Seek specialist advice from the person's infectious diseases team or sexual health services, depending on clinical judgement.
  • Is immunocompromised or has untreated HIV infection, and there is an inadequate or no response to initial treatment, for example new lesions appear after 3–5 days of treatment.
    • Seek specialist advice from the person's infectious diseases team or sexual health services, depending on clinical judgement.
• Advise that the person's sexual partner(s) should attend a specialist sexual health service for advice on screening if:
  • A person with suspected genital herpes infection is concerned about transmitting herpes simplex virus (HSV) to a new or not knowingly infected sexual partner.

How should I manage a person with recurrent genital herpes?

If a person presents with recurrent genital herpes simplex infection, reassure the person that episodes are usually self-limiting and cause mild symptoms.

• Advise about sources of information and support, such as:
  • The Family Planning Association (website www.fpa.org.uk) has a patient leaflet Genital herpes.
  • The Herpes Viruses Association (website www.herpes.org.uk) has patient information Genital herpes - questions and answers and a confidential helpline 0845 123 2305 (on weekdays).
  • The British Association for Sexual Health and HIV (BASHH) patient leaflet Genital herpes - the basics.
• Advise on possible self-care measures, such as:
  • Saline bathing — wash the affected area using saline (1 tsp salt in 560mls of warm water) as needed to ease symptoms, promote healing of lesions, and prevent secondary infection.
  • Take over-the-counter analgesia, such as paracetamol or ibuprofen, if needed and there are no contraindications. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for more information.
  • Consider applying topical petroleum jelly or a topical anaesthetic (for example lidocaine 5% gel or ointment) to lesions, for example before passing urine if there is dysuria.
  • Increase fluid intake to produce dilute urine, which may be less painful to void. Try to urinate in a bath or with water flowing over the area to reduce stinging.
  • Avoid wearing tight clothing, which may irritate lesions.
• Advise about minimizing transmission of infection to others.
  • Advise to abstain from sexual activity (including non-penetrative and oro-genital sex) if there are prodromal symptoms or lesions are present, until lesions have cleared.
    
    • Advise that transmission can occur when there are no symptoms ('asymptomatic shedding'), but the risk is higher when a person is symptomatic.
    • Advise that when used consistently and correctly, male condoms may reduce the risk of future transmission, but cannot prevent it completely. Transmission is still possible with close skin contact, or contact with infected secretions during foreplay.
  • Reassure that a first episode may not necessarily indicate recent infection, and transmission can occur from an asymptomatic partner years into a monogamous relationship.
    • In addition, herpes simplex virus type 1 (HSV-1) infection may have spread from elsewhere on the body, such as the lips or fingers.
  • Advise there is a low risk of neonatal transmission if a pregnant woman has a recurrent episode of genital herpes, even if lesions are present at the time of delivery.
    • Advise a woman to inform a healthcare professional if she is or becomes pregnant. See the section on Referral for more information.
    • Advise the consistent use of condoms for any sexual partner who is pregnant and seronegative, especially in the third trimester of pregnancy, to reduce the risk of transmission.
• If symptoms are not controlled using self-care measures alone, discuss the option of episodic antiviral treatment for acute episodes or suppressive antiviral treatment to prevent future episodes, depending on the person's wishes.
  • Do not prescribe or advise the use of topical antiviral treatment.
  • Offer episodic oral antiviral treatment if episodes are infrequent (fewer than six per year).
    • Prescribe short-course treatment first-line: aciclovir 800 mg three times a day for 2 days; famciclovir 1000 mg twice a day for 1 day; or valaciclovir 500 mg twice a day for 3 days.
    • Alternatively, prescribe aciclovir 200 mg five times a day or aciclovir 400 mg three times a day for 5 days; valaciclovir 500 mg twice a day for 5 days; or famciclovir 125 mg twice a day for 5 days.
    • If a person is immunocompromised or has untreated HIV, prescribe aciclovir 400 mg three times a day for 5–10 days; valaciclovir 1000 mg twice daily for 5–10 days; or famciclovir 500 mg twice daily for 5–10 days.
    • Be aware that a person with HIV infection who is not immunocompromised can be offered the same episodic treatment as other immunocompetent people. If new lesions continue to develop after 5 days of treatment, consider doubling the oral antiviral dose or extending the duration of treatment, depending on clinical judgement. Seek specialist advice from the person's infectious diseases team if needed.
    • Consider prescribing self-initiated oral antiviral treatment to be started early in the next episode, ideally within 24 hours of when prodromal symptoms or lesions develop.
  • Offer suppressive oral antiviral treatment if episodes are frequent (six or more per year).
    • Prescribe aciclovir 400 mg twice a day (or 200 mg four times a day); famciclovir 250 mg twice a day; or valaciclovir 500 mg once a day. Advise that the full suppressive effect is seen from 5 days after treatment is started.
    • If breakthrough recurrences occur on treatment, consider increasing the antiviral dose to aciclovir 400 mg three times a day, for example. Seek specialist advice if needed. See the section on Referral for more information.
    • Stop suppressive treatment after a maximum of one year, to reassess the frequency of recurrences. The minimum assessment period should include at least 2 further recurrent episodes. Consider restarting suppressive treatment if a person has a high rate of recurrence off treatment.
    • Note: if a person is immunocompromised or has untreated HIV infection, prescribe oral aciclovir 400 mg twice to three times a day; valaciclovir 500 mg twice a day; or famciclovir 500 mg twice a day. If breakthrough recurrences occur, consider doubling the oral antiviral dose. Seek specialist advice from the person's infectious diseases team if needed.
  • See the sections on Aciclovir, Valaciclovir, and Famciclovir in Prescribing information for more information on contraindications and cautions, adverse effects, and drug interactions.
• Advise that treatment options may change over time depending on the frequency of recurrences, symptom severity, the person's immunocompetency, relationship status and sexual behaviour, and concordance with medication.
  • See the section on Referral for more information on when to seek specialist advice.

When should I refer a person with recurrent genital herpes?

• Arrange emergency hospital admission if a person has recurrent genital herpes infection and:
  • Is severely systemically unwell, and/or there is a suspected severe or potentially serious complication that cannot be managed in primary care.
• Arrange referral to an appropriate specialist if a person has recurrent genital herpes infection and:
  
  • The diagnosis is uncertain.
  • There is an inadequate or no response to treatment in primary care.
  • Is pregnant at any gestation.
    • Specialist liaison with the midwife and obstetrics may be needed to provide a care plan.
  • Is immunocompromised or has untreated HIV infection, with severe genital herpes or new lesions developing while taking episodic antiviral treatment.
    • Seek specialist advice from the person's infectious diseases team or sexual health services, depending on clinical judgement.
  • There are breakthrough recurrent episodes while taking suppressive antiviral treatment.
    • Consider seeking specialist advice about increasing the oral antiviral dose.
• Advise that the person's sexual partner(s) should attend a specialist sexual health service for advice on screening if:
  • A person with recurrent genital herpes infection is concerned about transmitting herpes simplex virus (HSV) to a new or not knowingly infected sexual partner.

Contraindications and cautions

• Prescribe aciclovir with caution to a person who: 
  • Is elderly — risk of neurological reactions.
  • Has renal impairment — advise the person to maintain adequate hydration. Risk of neurological reactions is increased. Consider dose reduction.

[BNF, 2022]

Adverse effects

Possible adverse effects of aciclovir include:

• Gastrointestinal adverse effects (such as nausea, vomiting, diarrhoea, and abdominal pain), headache, dizziness, fatigue, fever, and skin reactions (including photosensitivity and urticaria).

[BNF, 2022]

Drug interactions

Possible drug interactions associated with aciclovir include:

• Aciclovir may increase the plasma concentration of aminophylline and theophylline — manufacturer advises monitor and adjust dose.
• Use with other nephrotoxic drugs increases the risk of renal impairment.

[BNF, 2022]

Contraindications and cautions

• Prescribe valaciclovir with caution to a person who:
  • Is elderly — risk of neurological reactions.
  • Has renal impairment — advise the person to maintain adequate hydration. Risk of neurological reactions is increased. Consider dose reduction.
  • Has hepatic impairment — manufacturer advises caution if taking doses of 4 g or more per day.

[BNF, 2022]

Adverse effects

Possible adverse effects of valaciclovir include:

• Gastrointestinal adverse effects (such as nausea, vomiting, diarrhoea, and abdominal pain), headache, dizziness, and skin reactions (including photosensitivity and urticaria).
• Tubulointerstitial nephritis.

[BNF, 2022; ABPI, 2023 Valtrex 500mg tablets]

Drug interactions

Possible drug interactions associated with valaciclovir include:

• Valaciclovir may increase the plasma concentration of aminophylline and theophylline — manufacturer advises monitor and adjust dose.
• Use with other nephrotoxic drugs increases the risk of renal impairment.

[BNF, 2022]

Contraindications and cautions

• Prescribe famciclovir with caution to a person who: 
  • Has hepatic impairment — manufacturer advises efficacy may be decreased in severe impairment (risk of impaired conversion to active metabolite).
  • Has renal impairment — advise the person to maintain adequate hydration. Risk of neurological reactions is increased. Consider dose reduction.

[BNF, 2022]

Adverse effects

Possible adverse effects of famciclovir include:

• Gastrointestinal adverse effects (such as nausea, vomiting, diarrhoea, and abdominal pain), headache, dizziness, and skin reactions (including photosensitivity and urticaria).

[BNF, 2022]

Drug interactions

• There are no clinically significant drug interactions associated with famciclovir.

[BNF, 2022]