guidelines

genital herpes (hsv): first episode, recurrence, suppression

nice cks-aligned genital hsv summary: diagnosis/testing, antivirals with practical doses, recurrence strategies, suppression, and pregnancy red flags.

last reviewed: 2026-02-13
based on: NICE CKS Herpes simplex – genital (accessed Feb 2026)
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Executive summary

  • Diagnosis: painful vesicles/ulcers ± dysuria, systemic symptoms (primary infection). Confirm with PCR swab where possible.
  • First episode: treat early—antivirals reduce symptom duration and viral shedding.
  • Recurrences: many are self-limiting; consider patient-initiated episodic therapy for distressing episodes.
  • Pregnancy: first episode in late pregnancy is high-risk—manage with specialist obstetric/sexual health pathways.

First episode treatment (CKS dosing)

  • Aciclovir: 400 mg tds for 5 days (first-line option).
  • Valaciclovir: 500 mg bd for 5 days (first-line option).
  • Supportive care: simple analgesia, topical lidocaine gel (where appropriate), saline bathing, hydration; manage dysuria (e.g., voiding in bath/shower) and counsel on transmission.

Recurrent episodes (when antivirals help)

  • Consider episodic antivirals if episodes are frequent, severe, or predictably triggered and the patient can start early.
  • CKS options include: aciclovir (various episodic regimens) or valaciclovir 500 mg bd (regimen duration depends on pathway/local protocol).
  • Suppressive therapy: consider for frequent recurrences or major QoL impact; typically specialist/sexual health led, but primary care may continue on advice.

Pregnancy and neonatal risk (don’t wing this)

First episode genital herpes in the 3rd trimester (especially within ~6 weeks of delivery) requires urgent obstetric/sexual health management due to neonatal transmission risk. Document and refer via local pathway.

Partner advice, testing and safety-netting

  • Offer/advise full STI screen per local sexual health service if risk factors or patient preference.
  • Counsel on condoms and avoiding sex during symptomatic periods; discuss asymptomatic shedding.
  • Review if symptoms are not improving after 5 days, new lesions continue to appear, or immunocompromise is present.

Frequently asked questions

Do I treat all recurrent episodes?
Not necessarily—many are mild and self-limiting. Offer patient-initiated episodic therapy for distressing episodes, and consider suppression if recurrences are frequent or severely impact quality of life.
Should I always swab?
Swabbing (PCR) is helpful when available, especially for first presentations, atypical ulcers, or when diagnosis is uncertain.

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.