A 25-year-old man presents with painful grouped vesicles on an erythematous base on the penis. Tzanck smear shows multinucleated giant cells with intranuclear inclusions. PCR on vesicle fluid is positive for HSV-2. He reports 4 recurrences in the past year. What is the most appropriate management?

• A Episodic oral acyclovir for each outbreak only
• B Topical acyclovir cream applied at the first sign of tingling
• C Daily suppressive oral valacyclovir (500 mg OD) to reduce recurrence frequency and transmission ✓
• D Foscarnet IV because HSV-2 is inherently more resistant than HSV-1 to acyclovir

Explanation

Patients with 6 or more episodes per year (or ≥4 in some guidelines) are candidates for daily suppressive antiviral therapy. Valacyclovir (500 mg daily) or acyclovir (400 mg BD) reduces recurrence frequency by about 70-80% and reduces asymptomatic shedding and transmission to partners. Topical acyclovir has poor penetration and clinical efficacy for genital HSV. Foscarnet is reserved for acyclovir-resistant HSV (usually in immunocompromised patients with TK-deficient mutants), not standard HSV-2.

Reference: Ananthanarayan & Paniker's Textbook of Microbiology, 11th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.