Let’s work together to stay apart.

Take a free Coronavirus Telehealth Assessment

If you think you may be experiencing signs or symptoms of the novel coronavirus (COVID-19), complete this online assessment and, if appropriate, we’ll connect you with a medical provider for a free consultation.


Our providers are online Mon-Fri, 8am-5pm based on your local timezone.

This is a triage service meant to assess your risk of COVID-19 based on your symptoms and other factors. You may be recommended to seek in-person care for further evaluation, testing, and diagnosis.

If you think you need immediate attention, please call 9-1-1 and let them know you are concerned about COVID-19.

Check your symptoms.

Fever

Cough

Shortness of breath

Signs and symptoms of coronavirus may include fever, cough, or shortness of breath. Risk factors include recently traveling to one of the countries listed on this page. For real-time updates on global cases, view this map.

Click below to get started if you think you may be at risk.

How to protect others.

If you are sick (with coronavirus or not), here’s how you can avoid spreading germs.

Cover your coughs and sneezes

Use a tissue, then throw it in the trash can. If tissues are unavailable, cough into the shoulder or elbow and wash your hands immediately after.

Wash your hands after blowing your nose

Use soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.

Stay home if you feel sick

Do not go to work, school, or public areas. Avoid using public transportation and limit activities outside your home, except for getting medical care.

How to protect yourself.

Here are a few key ways to stay healthy when there’s a bug going around.

Wash your hands frequently and before eating

Use soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.

Sanitize surfaces and avoid sick people

Routinely clean frequently touched objects (doorknobs, keyboards, and phones) and avoid close contact (6 feet or less) with others who are sick.

Practice healthy habits

Get plenty of sleep, stay physically active, eat healthy, manage your stress, and drink plenty of fluids to support your mucosal surfaces.

Novel Coronavirus (COVID-19) Resource Hub

For digestible and comprehensive articles on coronavirus, check out Ro’s Health Guide.

  • What is the novel coronavirus COVID-19?

    5 minute read

  • Signs and symptoms of coronavirus

    3 minute read

  • How useful is a mask in reducing coronavirus transmission?

    7 minute read

  • How can I help prevent and prepare for the coronavirus?

    3 minute read

  • The flu shot and the new coronavirus (COVID-19)

    4 minute read

  • Who is most at risk for contracting & getting ill from the coronavirus

    2 minute read

  • Can pets get the coronavirus? Can they infect me?

    3 minute read

  • Top coronavirus myths

    4 minute read

  • COVID-19: a timeline of events since its discovery

    3 minute read

  • Here’s how long coronavirus can live outside of the body

    4 minute read

Frequently asked questions

About Coronavirus (COVID-19)

All answers reviewed by our in-house medical team and authored by Rachel Kwon, MD.

Note: all the information relayed here is directly based on information and guidance from the CDC and WHO. This information is rapidly evolving, and it’s important to understand that there are still many unknowns about COVID-19 and how the disease spreads. Current knowledge and guidance is based in large part on what is known about similar viruses in the coronavirus family.

What is the difference between COVID-19 and coronavirus? What is SARS-CoV-2? What is novel coronavirus/nCoV?

Coronavirus is the name of a family of viruses, some of which cause respiratory infections in humans. For example, there are many coronaviruses that cause the common cold. “Novel coronavirus,” abbreviated as nCoV, is a general term assigned to any newly-discovered coronavirus before giving it a formal name. SARS-CoV-2 (previously called 2019-nCoV) is the formal name that the World Health Organization (WHO) has assigned to the coronavirus that causes COVID-19, the respiratory illness whose first case was identified in Wuhan, China in December 2019 (COVID-19 stands for Coronavirus Disease 2019). For simplicity, we’ll use the term “novel coronavirus” or “coronavirus” in these materials.

http://www.cdc.gov/coronavirus/2019-nCoV/summary.html

What are the symptoms of COVID-19?

COVID-19 is a respiratory infection, so typical symptoms are the same as any respiratory infection (like the common cold or flu): cough, fever/chills, and difficulty breathing. Symptoms can range from mild (most cases) to very severe, requiring hospitalization and the need for a ventilator (breathing machine). People with COVID-19 or any other respiratory infection might have any or all of the typical symptoms. There are some reports¹ of people later shown to have COVID-19 who initially had nausea or diarrhea but no respiratory symptoms, though these symptoms appear to be very uncommon in people with COVID-19.

¹ Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;

What should I do if I think I have symptoms of COVID-19?

Unless you have recently traveled to one of the areas (a searchable list of countries is available on the CDC website) with known cases of COVID-19 or had recent close contact with someone who has a known case of COVID-19, your symptoms are more likely to be due to the common cold or flu. However, viruses can spread quickly, and the best practices for avoiding spreading respiratory infections include staying at home if possible, washing your hands frequently and with proper technique, and consulting with a doctor or other qualified medical professional if your symptoms worsen or if you have other medical problems.

Note that information and guidance regarding COVID-19 are developing rapidly, and you should continue referring to the CDC website to stay up to date on the latest developments.

What should I do if I don’t have any symptoms, but I think I might have been exposed to novel coronavirus?

According to the CDC at the time of this writing, exposure to novel coronavirus is possible if you have recently traveled to any of the areas with known cases of COVID-19 (a searchable list of countries is available on the CDC website), or if you have been in close contact with someone who has a known case of COVID-19. If neither of the above is true, you are unlikely to have been exposed to novel coronavirus. However, viruses can spread quickly, so it is possible that at some point these criteria may change. If you think you have been exposed based on the current criteria and you don’t have any symptoms like cough, fever/chills, or difficulty breathing, the CDC recommends separating yourself from other people (quarantine) for 14 days from the last date you were potentially exposed, because 14 days is the longest incubation period seen for similar coronaviruses.

Note that information and guidance regarding COVID-19 are developing rapidly, and you should continue referring to the CDC website to stay up to date on the latest developments.

http://www.cdc.gov/coronavirus/2019-ncov/faq.html

How does novel coronavirus spread? How can I minimize the risk of getting an infection or spreading infection to other people?

Novel coronavirus is spread from person to person through respiratory droplets (from coughing, sneezing, or touching). The likelihood that a person will become infected with any virus after exposure is different for all viruses and is a spectrum. Novel coronavirus appears to be relatively easily spread from person to person. The CDC recommends the following best practices to help minimize the chances of spreading respiratory infections:
– Avoid close contact with people who are sick.
– Avoid touching your eyes, nose, and mouth.
– If you are sick, stay home.
– If you cough or sneeze, cover your mouth and nose with a tissue, then throw the tissue away and wash your hands.
– Clean and disinfect frequently touched objects and surfaces using regular household cleaning spray or cleaning wipe.
– Follow CDC’s recommendations for using a facemask:
– CDC does not recommend that people who have no symptoms wear a facemask to protect themselves from respiratory diseases, including COVID-19.
– People who show symptoms of COVID-19 should wear facemasks, in order to help prevent spreading the disease to others. Healthcare workers and people who are taking care of someone in close settings (like at home or in a health care facility) should also wear facemasks.
– Wash your hands frequently with soap and water for at least 20 seconds (one tip is to wash for the duration of singing the song “Happy Birthday” twice), especially after:
– Using the bathroom
– Before eating
– After blowing your nose, coughing, or sneezing
– If you’re not near a sink with soap and water, an alcohol-based hand sanitizer with at least 60% alcohol can be used. Always wash with soap and water if your hands are visibly dirty.

http://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html

Can my pets get infected or infect me?

Although novel coronavirus appears to have come from an animal source initially, the CDC states that “there is no reason to think that any animals including pets in the United States might be a source of infection with this new coronavirus.” Animals do sometimes spread other diseases to people, so washing your hands after being around animals is recommended in general.

I’m an employer. Should I tell my employees to stay home?

The CDC currently recommends the following to assess risk for COVID-19:
– Sick employees should be actively encouraged to stay home
– Employees who appear to have symptoms (fever, cough, shortness of breath) or develop symptoms at work should be separated from other employees and sent home immediately
– Employers should emphasize staying home when sick, as well as etiquette for coughing/sneezing and handwashing by all employees
– Routine environmental cleaning of frequently-touched surfaces like workstations, countertops, and doorknobs
– Employees who are planning to travel should be advised to check the latest travel information from the CDC and check for symptoms of respiratory illness before traveling

Additionally, risk assessments should be based on the above, not on race or country of origin.

http://www.cdc.gov/coronavirus/2019-ncov/specific-groups/guidance-business-response.html

Is it safe to visit someone in the hospital, or to take a friend to their doctor’s office?

You should use routine precautions when visiting people who are in the hospital or need to see a doctor for other reasons than a respiratory infection or respiratory symptoms. In general, it is a good idea to practice etiquette for coughing/sneezing and hand hygiene. Of course, for some people who are hospitalized for respiratory infections, special precautions may be required.

Does wearing a mask or gloves protect me or those around me from getting infected with novel coronavirus?

It is not currently recommended for people in a community setting (i.e., not a hospital or health care facility) without respiratory symptoms to wear a facemask to protect against the virus. For people in a community setting, wearing gloves is not more effective than practicing good hand hygiene (wash hands frequently with soap and water for at least 20 seconds).

http://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf

Is there a treatment, vaccine, or cure for COVID-19?

There is no cure or specific antiviral treatment for COVID-19. The best treatment for COVID-19 (and other infections that don’t have a cure) is to relieve the symptoms. For mild symptoms, this usually involves rest, fluids, and medications to help with fever and cough as needed. People with severe symptoms (lots of trouble breathing, very high fever, inability to stay hydrated by drinking fluids by mouth) need hospitalization and potentially intensive care. Currently, there is no vaccine available to prevent COVID-19, and the best way to prevent exposure and illness is by using the techniques above (“How does novel coronavirus spread? How can I minimize the risk of getting an infection or spreading infection to other people?”).

About Ro’s Coronavirus Telehealth Assessment

What is Ro’s Coronavirus Telehealth Assessment?

Ro has created a free telehealth triage service for people who are seeking guidance and information about the novel coronavirus (COVID-19).

If an individual thinks they may be experiencing signs or symptoms of the novel coronavirus (COVID-19), they complete Ro’s online assessment and, if appropriate, we’ll connect them with a medical provider for a free consultation.

How does it work?

Developed with guidance from infectious disease specialists, Ro’s telehealth assessment collects self-reported health information (e.g., health history, symptoms, travel history, locale, proximity to confirmed cases). Based on that information and using the most up-to-date guidelines from the Centers for Disease Control (CDC), the World Health Organization (WHO), and state/local public health departments, we provide an initial risk assessment.

Those who are symptomatic or have other risk factors (e.g., travel history or proximity to confirmed cases, pre-existing/underlying conditions) will be connected to a licensed medical provider for a free consultation.

During the consultation, the medical provider will collect additional information about the patient’s symptoms and concerns, recommend the proper course of action (which may include self-quarantine), and, if recommended, instruct them to follow up with a local provider for testing and diagnosis. For patients who are recommended to seek in-person care, we will provide them resources to find a local provider so they can get the help they need. We also report suspected cases to the applicable public health authorities, as required, to help inform local and national response efforts.

Individuals who are at low risk of having contracted COVID-19 will be guided to a number of resources at our Coronavirus Resource Hub and will be encouraged to keep monitoring their symptoms. These resources are regularly updated and are based on the latest government guidelines and best practices. Our goal is that these resources will help the public understand this complex virus and help keep themselves, their families, and their communities safe.

Why are you doing this?

We want to do everything we can to provide assistance to people who are concerned about COVID-19. Ro’s telehealth platform is uniquely suited to help in a number of ways:

Unburdening hospitals and clinics.

We have consulted with public health experts who are worried that coronavirus fears will overcrowd and overburden our health system, making it more challenging and costly for people who need in-person or emergency care to find it.

We’re hopeful that Ro’s triage system will reduce strain on providers who are treating higher-risk and sicker patients.

Advising symptomatic patients

We expect that people suffering from the common cold or the flu will be concerned about COVID-19. Initially talking to a remote doctor via telehealth, as the CDC has recommended, can provide comfort and guidance on how to address their symptoms, get healthy, and reduce the spread to others. For those at risk of COVID-19, Ro-affiliated doctors can advise them on appropriate next steps, whether that’s to self-quarantine or seek additional care.

Providing trusted health information.

As more cases are reported, we expect public fears to increase and misinformation to spread. We believe that providing people with easily-accessible, updated information about COVID-19 will help calm their concerns. For people who don’t have an established provider and aren’t sure where to turn, Ro can be an initial entry point into the healthcare system.

Are medical providers diagnosing or testing for COVID-19 on your platform?

No. This is a triage program that will allow people to easily access a risk assessment tool, and if appropriate, a medical provider consultation at no cost. We are not diagnosing or testing for COVID-19.

Does Ro have access to approved COVID-19 tests?

No. Ro is not providing testing for COVID-19.

Will Ro provide consultation to caregivers for those who may be at-risk and unable to use the platform (e.g., elderly, children)?

Caregivers can access a number of resources through Ro’s Coronavirus Resource Hub. These resources are regularly updated and are based on the latest government guidelines and best practices so patients can understand this complex virus and how they can help keep themselves and their families safe.

Will Ro share any of its data with public health officials?

We have the ability to collect and provide relevant and anonymized data to public health officials. We would welcome their advice on the types of data that would aid their efforts. If you are part of an agency or healthcare institution that is responding to the COVID-19 outbreak and think Ro could be helpful in any way, please contact covid19-feedback@ro.co.

What is the source of the information in Ro’s Coronavirus Resource Hub?

We are updating the information provided in our Coronavirus Resource Hub regularly using the most up-to-date guidelines from CDC, WHO, and state/local, public health departments.

Will Ro be offering services internationally?

Ro’s services are only available in the U.S.

Additional resources

From Ro, the parent company of Roman.

Take a free Coronavirus Telehealth Assessment

If you think you may be experiencing signs or symptoms of the novel coronavirus (COVID-19), complete this online assessment and, if appropriate, we’ll connect you with a medical provider for a free consultation.


Our providers are online Mon-Fri, 8am-5pm based on your local timezone.

If you think you need immediate attention, please call 9-1-1 and let them know you are concerned about COVID-19.

Please note: No personal or medical information will be shared with your employer or other third parties.

Check your symptoms.

Fever

Cough

Shortness of breath

Signs and symptoms of COVID-19 may include fever, cough, or shortness of breath. Risk factors include recently traveling to one of the countries listed on this page. For real-time updates on global cases, view this map.

Click below to get started if you think you may be at risk.

How to protect others.

If you are sick (with coronavirus or not), here’s how you can avoid spreading germs.

Cover your coughs and sneezes

Use a tissue, then throw it in the trash can. If tissues are unavailable, cough into the shoulder or elbow and wash your hands immediately after.

Wash your hands after blowing your nose

Use soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.

Stay home if you feel sick

Do not go to work, school, or public areas. Avoid using public transportation and limit activities outside your home, except for getting medical care.

How to protect yourself.

Here are a few key ways to stay healthy when there’s a bug going around.

Wash your hands frequently and before eating

Use soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.

Sanitize surfaces and avoid sick people

Routinely clean frequently touched objects (doorknobs, keyboards, and phones) and avoid close contact (6 feet or less) with others who are sick.

Practice healthy habits

Get plenty of sleep, stay physically active, eat healthy, manage your stress, and drink plenty of fluids to support your mucosal surfaces.

Novel Coronavirus (COVID-19) Resource Hub

For digestible and comprehensive articles on coronavirus, check out Ro’s Health Guide.

  • What is the novel coronavirus COVID-19?

    5 minute read

  • Signs and symptoms of coronavirus

    3 minute read

  • How useful is a mask in reducing coronavirus transmission?

    7 minute read

  • How can I help prevent and prepare for the coronavirus?

    3 minute read

  • The flu shot and the new coronavirus (COVID-19)

    4 minute read

  • Who is most at risk for contracting & getting ill from the coronavirus

    2 minute read

  • Can pets get the coronavirus? Can they infect me?

    3 minute read

  • Top coronavirus myths

    4 minute read

  • COVID-19: a timeline of events since its discovery

    3 minute read

  • Here’s how long coronavirus can live outside of the body

    4 minute read

Frequently asked questions

About Coronavirus (COVID-19)

All answers reviewed by our in-house medical team and authored by Rachel Kwon, MD.

Note: all the information relayed here is directly based on information and guidance from the CDC and WHO. This information is rapidly evolving, and it’s important to understand that there are still many unknowns about COVID-19 and how the disease spreads. Current knowledge and guidance is based in large part on what is known about similar viruses in the coronavirus family.

What is the difference between COVID-19 and coronavirus? What is SARS-CoV-2? What is novel coronavirus/nCoV?

Coronavirus is the name of a family of viruses, some of which cause respiratory infections in humans. For example, there are many coronaviruses that cause the common cold. “Novel coronavirus,” abbreviated as nCoV, is a general term assigned to any newly-discovered coronavirus before giving it a formal name. SARS-CoV-2 (previously called 2019-nCoV) is the formal name that the World Health Organization (WHO) has assigned to the coronavirus that causes COVID-19, the respiratory illness whose first case was identified in Wuhan, China in December 2019 (COVID-19 stands for Coronavirus Disease 2019). For simplicity, we’ll use the term “novel coronavirus” or “coronavirus” in these materials.

http://www.cdc.gov/coronavirus/2019-nCoV/summary.html

What are the symptoms of COVID-19?

COVID-19 is a respiratory infection, so typical symptoms are the same as any respiratory infection (like the common cold or flu): cough, fever/chills, and difficulty breathing. Symptoms can range from mild (most cases) to very severe, requiring hospitalization and the need for a ventilator (breathing machine). People with COVID-19 or any other respiratory infection might have any or all of the typical symptoms. There are some reports¹ of people later shown to have COVID-19 who initially had nausea or diarrhea but no respiratory symptoms, though these symptoms appear to be very uncommon in people with COVID-19.

¹ Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;

What should I do if I think I have symptoms of COVID-19?

Unless you have recently traveled to one of the areas (a searchable list of countries is available on the CDC website) with known cases of COVID-19 or had recent close contact with someone who has a known case of COVID-19, your symptoms are more likely to be due to the common cold or flu. However, viruses can spread quickly, and the best practices for avoiding spreading respiratory infections include staying at home if possible, washing your hands frequently and with proper technique, and consulting with a doctor or other qualified medical professional if your symptoms worsen or if you have other medical problems.

Note that information and guidance regarding COVID-19 are developing rapidly, and you should continue referring to the CDC website to stay up to date on the latest developments.

What should I do if I don’t have any symptoms, but I think I might have been exposed to novel coronavirus?

According to the CDC at the time of this writing, exposure to novel coronavirus is possible if you have recently traveled to any of the areas with known cases of COVID-19 (a searchable list of countries is available on the CDC website), or if you have been in close contact with someone who has a known case of COVID-19. If neither of the above is true, you are unlikely to have been exposed to novel coronavirus. However, viruses can spread quickly, so it is possible that at some point these criteria may change. If you think you have been exposed based on the current criteria and you don’t have any symptoms like cough, fever/chills, or difficulty breathing, the CDC recommends separating yourself from other people (quarantine) for 14 days from the last date you were potentially exposed, because 14 days is the longest incubation period seen for similar coronaviruses.

Note that information and guidance regarding COVID-19 are developing rapidly, and you should continue referring to the CDC website to stay up to date on the latest developments.

http://www.cdc.gov/coronavirus/2019-ncov/faq.html

How does novel coronavirus spread? How can I minimize the risk of getting an infection or spreading infection to other people?

Novel coronavirus is spread from person to person through respiratory droplets (from coughing, sneezing, or touching). The likelihood that a person will become infected with any virus after exposure is different for all viruses and is a spectrum. Novel coronavirus appears to be relatively easily spread from person to person. The CDC recommends the following best practices to help minimize the chances of spreading respiratory infections:
– Avoid close contact with people who are sick.
– Avoid touching your eyes, nose, and mouth.
– If you are sick, stay home.
– If you cough or sneeze, cover your mouth and nose with a tissue, then throw the tissue away and wash your hands.
– Clean and disinfect frequently touched objects and surfaces using regular household cleaning spray or cleaning wipe.
– Follow CDC’s recommendations for using a facemask:
– CDC does not recommend that people who have no symptoms wear a facemask to protect themselves from respiratory diseases, including COVID-19.
– People who show symptoms of COVID-19 should wear facemasks, in order to help prevent spreading the disease to others. Healthcare workers and people who are taking care of someone in close settings (like at home or in a health care facility) should also wear facemasks.
– Wash your hands frequently with soap and water for at least 20 seconds (one tip is to wash for the duration of singing the song “Happy Birthday” twice), especially after:
– Using the bathroom
– Before eating
– After blowing your nose, coughing, or sneezing
– If you’re not near a sink with soap and water, an alcohol-based hand sanitizer with at least 60% alcohol can be used. Always wash with soap and water if your hands are visibly dirty.

http://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html

Can my pets get infected or infect me?

Although novel coronavirus appears to have come from an animal source initially, the CDC states that “there is no reason to think that any animals including pets in the United States might be a source of infection with this new coronavirus.” Animals do sometimes spread other diseases to people, so washing your hands after being around animals is recommended in general.

I’m an employer. Should I tell my employees to stay home?

The CDC currently recommends the following to assess risk for COVID-19:
– Sick employees should be actively encouraged to stay home
– Employees who appear to have symptoms (fever, cough, shortness of breath) or develop symptoms at work should be separated from other employees and sent home immediately
– Employers should emphasize staying home when sick, as well as etiquette for coughing/sneezing and handwashing by all employees
– Routine environmental cleaning of frequently-touched surfaces like workstations, countertops, and doorknobs
– Employees who are planning to travel should be advised to check the latest travel information from the CDC and check for symptoms of respiratory illness before traveling

Additionally, risk assessments should be based on the above, not on race or country of origin.

http://www.cdc.gov/coronavirus/2019-ncov/specific-groups/guidance-business-response.html

Is it safe to visit someone in the hospital, or to take a friend to their doctor’s office?

You should use routine precautions when visiting people who are in the hospital or need to see a doctor for other reasons than a respiratory infection or respiratory symptoms. In general, it is a good idea to practice etiquette for coughing/sneezing and hand hygiene. Of course, for some people who are hospitalized for respiratory infections, special precautions may be required.

Does wearing a mask or gloves protect me or those around me from getting infected with novel coronavirus?

It is not currently recommended for people in a community setting (i.e., not a hospital or health care facility) without respiratory symptoms to wear a facemask to protect against the virus. For people in a community setting, wearing gloves is not more effective than practicing good hand hygiene (wash hands frequently with soap and water for at least 20 seconds).

http://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf

Is there a treatment, vaccine, or cure for COVID-19?

There is no cure or specific antiviral treatment for COVID-19. The best treatment for COVID-19 (and other infections that don’t have a cure) is to relieve the symptoms. For mild symptoms, this usually involves rest, fluids, and medications to help with fever and cough as needed. People with severe symptoms (lots of trouble breathing, very high fever, inability to stay hydrated by drinking fluids by mouth) need hospitalization and potentially intensive care. Currently, there is no vaccine available to prevent COVID-19, and the best way to prevent exposure and illness is by using the techniques above (“How does novel coronavirus spread? How can I minimize the risk of getting an infection or spreading infection to other people?”).

About Ro’s Coronavirus Telehealth Assessment

What is Ro’s Coronavirus Telehealth Assessment?

Ro has created a free telehealth triage service for people who are seeking guidance and information about the novel coronavirus (COVID-19).

If an individual thinks they may be experiencing signs or symptoms of the COVID-19, they complete Ro’s online assessment and, if appropriate, we’ll connect them with a medical provider for a free consultation.

How does it work?

Developed with guidance from infectious disease specialists, Ro’s telehealth assessment collects self-reported health information (e.g., health history, symptoms, travel history, locale, proximity to confirmed cases). Based on that information and using the most up-to-date guidelines from the Centers for Disease Control (CDC), the World Health Organization (WHO), and state/local public health departments, we provide an initial risk assessment.

Those who are symptomatic or have other risk factors (e.g., travel history or proximity to confirmed cases, pre-existing/underlying conditions) will be connected to a licensed medical provider for a free consultation.

During the consultation, the medical provider will collect additional information about the patient’s symptoms and concerns, recommend the proper course of action (which may include self-quarantine), and, if recommended, instruct them to follow up with a local provider for testing and diagnosis. For patients who are recommended to seek in-person care, we will provide them resources to find a local provider so they can get the help they need. We also report suspected cases to the applicable public health authorities, as required, to help inform local and national response efforts.

Individuals who are at low risk of having contracted COVID-19 will be guided to a number of resources at our Coronavirus Resource Hub and will be encouraged to keep monitoring their symptoms. These resources are regularly updated and are based on the latest government guidelines and best practices. Our goal is that these resources will help the public understand this complex virus and help keep themselves, their families, and their communities safe.

Why are you doing this?

We want to do everything we can to provide assistance to people who are concerned about COVID-19. Ro’s telehealth platform is uniquely suited to help in a number of ways:

Unburdening hospitals and clinics.

We have consulted with public health experts who are worried that coronavirus fears will overcrowd and overburden our health system, making it more challenging and costly for people who need in-person or emergency care to find it.

We’re hopeful that Ro’s triage system will reduce strain on providers who are treating higher-risk and sicker patients.

Advising symptomatic patients

We expect that people suffering from the common cold or the flu will be concerned about COVID-19. Initially talking to a remote medical provider via telehealth, as the CDC has recommended, can provide comfort and guidance on how to address their symptoms, get healthy, and reduce the spread to others. For those at risk of COVID-19, Ro-affiliated medical providers can advise them on appropriate next steps, whether that’s to self-quarantine or seek additional care.

Providing trusted health information.

As more cases are reported, we expect public fears to increase and misinformation to spread. We believe that providing people with easily-accessible, updated information about COVID-19 will help calm their concerns. For people who don’t have an established provider and aren’t sure where to turn, Ro can be an initial entry point into the healthcare system.

Are doctors diagnosing or testing for COVID-19 on your platform?

No. This is a triage program that will allow people to easily access a risk assessment tool, and if appropriate, a medical provider consultation at no cost. We are not diagnosing or testing for COVID-19.

Does Ro have access to approved COVID-19 tests?

No. Ro is not providing testing for COVID-19.

Will Ro provide consultation to caregivers for those who may be at-risk and unable to use the platform (e.g., elderly, children)?

Caregivers can access a number of resources through Ro’s Coronavirus Resource Hub. These resources are regularly updated and are based on the latest government guidelines and best practices so patients can understand this complex virus and how they can help keep themselves and their families safe.

Will Ro share any of its data with public health officials?

We have the ability to collect and provide relevant and anonymized data to public health officials. We would welcome their advice on the types of data that would aid their efforts. If you are part of an agency or healthcare institution that is responding to the COVID-19 outbreak and think Ro could be helpful in any way, please contact covid19-feedback@ro.co.

What is the source of the information in Ro’s Coronavirus Resource Hub?

We are updating the information provided in our Coronavirus Resource Hub regularly using the most up-to-date guidelines from CDC, WHO, and state/local, public health departments.

Will Ro be offering services internationally?

Ro’s services are only available in the U.S.

Additional resources

From Ro, the parent company of Rory.

Take a free Coronavirus Telehealth Assessment

If you think you may be experiencing signs or symptoms of the novel coronavirus (COVID-19), complete this online assessment and, if appropriate, we’ll connect you with a medical provider for a free consultation.


Our providers are online Mon-Fri, 8am-5pm based on your local timezone.

If you think you need immediate attention, please call 9-1-1 and let them know you are concerned about COVID-19.

Please note: No personal or medical information will be shared with your employer or other third parties.

Check your symptoms.

Fever

Cough

Shortness of breath

Signs and symptoms of COVID-19 may include fever, cough, or shortness of breath. Risk factors include recently traveling to one of the countries listed on this page. For real-time updates on global cases, view this map.

Click below to get started if you think you may be at risk.

How to protect others.

If you are sick (with coronavirus or not), here’s how you can avoid spreading germs.

Cover your coughs and sneezes

Use a tissue, then throw it in the trash can. If tissues are unavailable, cough into the shoulder or elbow and wash your hands immediately after.

Wash your hands after blowing your nose

Use soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.

Stay home if you feel sick

Do not go to work, school, or public areas. Avoid using public transportation and limit activities outside your home, except for getting medical care.

How to protect yourself.

Here are a few key ways to stay healthy when there’s a bug going around.

Wash your hands frequently and before eating

Use soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.

Sanitize surfaces and avoid sick people

Routinely clean frequently touched objects (doorknobs, keyboards, and phones) and avoid close contact (6 feet or less) with others who are sick.

Practice healthy habits

Get plenty of sleep, stay physically active, eat healthy, manage your stress, and drink plenty of fluids to support your mucosal surfaces.

Novel Coronavirus (COVID-19) Resource Hub

For digestible and comprehensive articles on coronavirus, check out Ro’s Health Guide.

  • What is the novel coronavirus COVID-19?

    5 minute read

  • Signs and symptoms of coronavirus

    3 minute read

  • How useful is a mask in reducing coronavirus transmission?

    7 minute read

  • How can I help prevent and prepare for the coronavirus?

    3 minute read

  • The flu shot and the new coronavirus (COVID-19)

    4 minute read

  • Who is most at risk for contracting & getting ill from the coronavirus

    2 minute read

  • Can pets get the coronavirus? Can they infect me?

    3 minute read

  • Top coronavirus myths

    4 minute read

  • COVID-19: a timeline of events since its discovery

    3 minute read

  • Here’s how long coronavirus can live outside of the body

    4 minute read

Frequently asked questions

About Coronavirus (COVID-19)

All answers reviewed by our in-house medical team and authored by Rachel Kwon, MD.

Note: all the information relayed here is directly based on information and guidance from the CDC and WHO. This information is rapidly evolving, and it’s important to understand that there are still many unknowns about COVID-19 and how the disease spreads. Current knowledge and guidance is based in large part on what is known about similar viruses in the coronavirus family.

What is the difference between COVID-19 and coronavirus? What is SARS-CoV-2? What is novel coronavirus/nCoV?

Coronavirus is the name of a family of viruses, some of which cause respiratory infections in humans. For example, there are many coronaviruses that cause the common cold. “Novel coronavirus,” abbreviated as nCoV, is a general term assigned to any newly-discovered coronavirus before giving it a formal name. SARS-CoV-2 (previously called 2019-nCoV) is the formal name that the World Health Organization (WHO) has assigned to the coronavirus that causes COVID-19, the respiratory illness whose first case was identified in Wuhan, China in December 2019 (COVID-19 stands for Coronavirus Disease 2019). For simplicity, we’ll use the term “novel coronavirus” or “coronavirus” in these materials.

http://www.cdc.gov/coronavirus/2019-nCoV/summary.html

What are the symptoms of COVID-19?

COVID-19 is a respiratory infection, so typical symptoms are the same as any respiratory infection (like the common cold or flu): cough, fever/chills, and difficulty breathing. Symptoms can range from mild (most cases) to very severe, requiring hospitalization and the need for a ventilator (breathing machine). People with COVID-19 or any other respiratory infection might have any or all of the typical symptoms. There are some reports¹ of people later shown to have COVID-19 who initially had nausea or diarrhea but no respiratory symptoms, though these symptoms appear to be very uncommon in people with COVID-19.

¹ Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;

What should I do if I think I have symptoms of COVID-19?

Unless you have recently traveled to one of the areas (a searchable list of countries is available on the CDC website) with known cases of COVID-19 or had recent close contact with someone who has a known case of COVID-19, your symptoms are more likely to be due to the common cold or flu. However, viruses can spread quickly, and the best practices for avoiding spreading respiratory infections include staying at home if possible, washing your hands frequently and with proper technique, and consulting with a doctor or other qualified medical professional if your symptoms worsen or if you have other medical problems.

Note that information and guidance regarding COVID-19 are developing rapidly, and you should continue referring to the CDC website to stay up to date on the latest developments.

What should I do if I don’t have any symptoms, but I think I might have been exposed to novel coronavirus?

According to the CDC at the time of this writing, exposure to novel coronavirus is possible if you have recently traveled to any of the areas with known cases of COVID-19 (a searchable list of countries is available on the CDC website), or if you have been in close contact with someone who has a known case of COVID-19. If neither of the above is true, you are unlikely to have been exposed to novel coronavirus. However, viruses can spread quickly, so it is possible that at some point these criteria may change. If you think you have been exposed based on the current criteria and you don’t have any symptoms like cough, fever/chills, or difficulty breathing, the CDC recommends separating yourself from other people (quarantine) for 14 days from the last date you were potentially exposed, because 14 days is the longest incubation period seen for similar coronaviruses.

Note that information and guidance regarding COVID-19 are developing rapidly, and you should continue referring to the CDC website to stay up to date on the latest developments.

http://www.cdc.gov/coronavirus/2019-ncov/faq.html

How does novel coronavirus spread? How can I minimize the risk of getting an infection or spreading infection to other people?

Novel coronavirus is spread from person to person through respiratory droplets (from coughing, sneezing, or touching). The likelihood that a person will become infected with any virus after exposure is different for all viruses and is a spectrum. Novel coronavirus appears to be relatively easily spread from person to person. The CDC recommends the following best practices to help minimize the chances of spreading respiratory infections:
– Avoid close contact with people who are sick.
– Avoid touching your eyes, nose, and mouth.
– If you are sick, stay home.
– If you cough or sneeze, cover your mouth and nose with a tissue, then throw the tissue away and wash your hands.
– Clean and disinfect frequently touched objects and surfaces using regular household cleaning spray or cleaning wipe.
– Follow CDC’s recommendations for using a facemask:
– CDC does not recommend that people who have no symptoms wear a facemask to protect themselves from respiratory diseases, including COVID-19.
– People who show symptoms of COVID-19 should wear facemasks, in order to help prevent spreading the disease to others. Healthcare workers and people who are taking care of someone in close settings (like at home or in a health care facility) should also wear facemasks.
– Wash your hands frequently with soap and water for at least 20 seconds (one tip is to wash for the duration of singing the song “Happy Birthday” twice), especially after:
– Using the bathroom
– Before eating
– After blowing your nose, coughing, or sneezing
– If you’re not near a sink with soap and water, an alcohol-based hand sanitizer with at least 60% alcohol can be used. Always wash with soap and water if your hands are visibly dirty.

http://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html

Can my pets get infected or infect me?

Although novel coronavirus appears to have come from an animal source initially, the CDC states that “there is no reason to think that any animals including pets in the United States might be a source of infection with this new coronavirus.” Animals do sometimes spread other diseases to people, so washing your hands after being around animals is recommended in general.

I’m an employer. Should I tell my employees to stay home?

The CDC currently recommends the following to assess risk for COVID-19:
– Sick employees should be actively encouraged to stay home
– Employees who appear to have symptoms (fever, cough, shortness of breath) or develop symptoms at work should be separated from other employees and sent home immediately
– Employers should emphasize staying home when sick, as well as etiquette for coughing/sneezing and handwashing by all employees
– Routine environmental cleaning of frequently-touched surfaces like workstations, countertops, and doorknobs
– Employees who are planning to travel should be advised to check the latest travel information from the CDC and check for symptoms of respiratory illness before traveling

Additionally, risk assessments should be based on the above, not on race or country of origin.

http://www.cdc.gov/coronavirus/2019-ncov/specific-groups/guidance-business-response.html

Is it safe to visit someone in the hospital, or to take a friend to their doctor’s office?

You should use routine precautions when visiting people who are in the hospital or need to see a doctor for other reasons than a respiratory infection or respiratory symptoms. In general, it is a good idea to practice etiquette for coughing/sneezing and hand hygiene. Of course, for some people who are hospitalized for respiratory infections, special precautions may be required.

Does wearing a mask or gloves protect me or those around me from getting infected with novel coronavirus?

It is not currently recommended for people in a community setting (i.e., not a hospital or health care facility) without respiratory symptoms to wear a facemask to protect against the virus. For people in a community setting, wearing gloves is not more effective than practicing good hand hygiene (wash hands frequently with soap and water for at least 20 seconds).

http://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf

Is there a treatment, vaccine, or cure for COVID-19?

There is no cure or specific antiviral treatment for COVID-19. The best treatment for COVID-19 (and other infections that don’t have a cure) is to relieve the symptoms. For mild symptoms, this usually involves rest, fluids, and medications to help with fever and cough as needed. People with severe symptoms (lots of trouble breathing, very high fever, inability to stay hydrated by drinking fluids by mouth) need hospitalization and potentially intensive care. Currently, there is no vaccine available to prevent COVID-19, and the best way to prevent exposure and illness is by using the techniques above (“How does novel coronavirus spread? How can I minimize the risk of getting an infection or spreading infection to other people?”).

About Ro’s Coronavirus Telehealth Assessment

What is Ro’s Coronavirus Telehealth Assessment?

Ro has created a free telehealth triage service for people who are seeking guidance and information about the novel coronavirus (COVID-19).

If an individual thinks they may be experiencing signs or symptoms of the COVID-19, they complete Ro’s online assessment and, if appropriate, we’ll connect them with a medical provider for a free consultation.

How does it work?

Developed with guidance from infectious disease specialists, Ro’s telehealth assessment collects self-reported health information (e.g., health history, symptoms, travel history, locale, proximity to confirmed cases). Based on that information and using the most up-to-date guidelines from the Centers for Disease Control (CDC), the World Health Organization (WHO), and state/local public health departments, we provide an initial risk assessment.

Those who are symptomatic or have other risk factors (e.g., travel history or proximity to confirmed cases, pre-existing/underlying conditions) will be connected to a licensed medical provider for a free consultation.

During the consultation, the medical provider will collect additional information about the patient’s symptoms and concerns, recommend the proper course of action (which may include self-quarantine), and, if recommended, instruct them to follow up with a local provider for testing and diagnosis. For patients who are recommended to seek in-person care, we will provide them resources to find a local provider so they can get the help they need. We also report suspected cases to the applicable public health authorities, as required, to help inform local and national response efforts.

Individuals who are at low risk of having contracted COVID-19 will be guided to a number of resources at our Coronavirus Resource Hub and will be encouraged to keep monitoring their symptoms. These resources are regularly updated and are based on the latest government guidelines and best practices. Our goal is that these resources will help the public understand this complex virus and help keep themselves, their families, and their communities safe.

Why are you doing this?

We want to do everything we can to provide assistance to people who are concerned about COVID-19. Ro’s telehealth platform is uniquely suited to help in a number of ways:

Unburdening hospitals and clinics.

We have consulted with public health experts who are worried that coronavirus fears will overcrowd and overburden our health system, making it more challenging and costly for people who need in-person or emergency care to find it.

We’re hopeful that Ro’s triage system will reduce strain on providers who are treating higher-risk and sicker patients.

Advising symptomatic patients

We expect that people suffering from the common cold or the flu will be concerned about COVID-19. Initially talking to a remote medical provider via telehealth, as the CDC has recommended, can provide comfort and guidance on how to address their symptoms, get healthy, and reduce the spread to others. For those at risk of COVID-19, Ro-affiliated medical providers can advise them on appropriate next steps, whether that’s to self-quarantine or seek additional care.

Providing trusted health information.

As more cases are reported, we expect public fears to increase and misinformation to spread. We believe that providing people with easily-accessible, updated information about COVID-19 will help calm their concerns. For people who don’t have an established provider and aren’t sure where to turn, Ro can be an initial entry point into the healthcare system.

Are doctors diagnosing or testing for COVID-19 on your platform?

No. This is a triage program that will allow people to easily access a risk assessment tool, and if appropriate, a medical provider consultation at no cost. We are not diagnosing or testing for COVID-19.

Does Ro have access to approved COVID-19 tests?

No. Ro is not providing testing for COVID-19.

Will Ro provide consultation to caregivers for those who may be at-risk and unable to use the platform (e.g., elderly, children)?

Caregivers can access a number of resources through Ro’s Coronavirus Resource Hub. These resources are regularly updated and are based on the latest government guidelines and best practices so patients can understand this complex virus and how they can help keep themselves and their families safe.

Will Ro share any of its data with public health officials?

We have the ability to collect and provide relevant and anonymized data to public health officials. We would welcome their advice on the types of data that would aid their efforts. If you are part of an agency or healthcare institution that is responding to the COVID-19 outbreak and think Ro could be helpful in any way, please contact covid19-feedback@ro.co.

What is the source of the information in Ro’s Coronavirus Resource Hub?

We are updating the information provided in our Coronavirus Resource Hub regularly using the most up-to-date guidelines from CDC, WHO, and state/local, public health departments.

Will Ro be offering services internationally?

Ro’s services are only available in the U.S.

Additional resources

BRAND_HEADING

Take a free Coronavirus Telehealth Assessment

We’ll connect you with a medical provider for a free consultation, if appropriate.


Our providers are online Mon-Fri, 8am-5pm ET.

If you think you need immediate attention, please call 9-1-1 and let them know you are concerned about COVID-19.

Check your symptoms.

Fever

Cough

Shortness of breath

Signs and symptoms of COVID-19 may include fever, cough, or shortness of breath. Risk factors include recently traveling to one of the countries listed on this page. For real-time updates on global cases, view this map.

Click below to get started if you think you may be at risk.

How to protect others.

If you are sick (with coronavirus or not), here’s how you can avoid spreading germs.

Cover your coughs and sneezes

Use a tissue, then throw it in the trash can. If tissues are unavailable, cough into the shoulder or elbow and wash your hands immediately after.

Wash your hands after blowing your nose

Use soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.

Stay home if you feel sick

Do not go to work, school, or public areas. Avoid using public transportation and limit activities outside your home, except for getting medical care.

How to protect yourself.

Here are a few key ways to stay healthy when there’s a bug going around.

Wash your hands frequently and before eating

Use soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.

Sanitize surfaces and avoid sick people

Routinely clean frequently touched objects (doorknobs, keyboards, and phones) and avoid close contact (6 feet or less) with others who are sick.

Practice healthy habits

Get plenty of sleep, stay physically active, eat healthy, manage your stress, and drink plenty of fluids to support your mucosal surfaces.

Novel Coronavirus (COVID-19) Resource Hub

For digestible and comprehensive articles on coronavirus, check out Ro’s Health Guide.

  • What is the novel coronavirus COVID-19?

    5 minute read

  • Signs and symptoms of coronavirus

    3 minute read

  • How useful is a mask in reducing coronavirus transmission?

    7 minute read

  • How can I help prevent and prepare for the coronavirus?

    3 minute read

  • The flu shot and the new coronavirus (COVID-19)

    4 minute read

  • Who is most at risk for contracting & getting ill from the coronavirus

    2 minute read

  • Can pets get the coronavirus? Can they infect me?

    3 minute read

  • Top coronavirus myths

    4 minute read

  • COVID-19: a timeline of events since its discovery

    3 minute read

  • Here’s how long coronavirus can live outside of the body

    4 minute read

Frequently asked questions

About Coronavirus (COVID-19)

All answers reviewed by our in-house medical team and authored by Rachel Kwon, MD.

Note: all the information relayed here is directly based on information and guidance from the CDC and WHO. This information is rapidly evolving, and it’s important to understand that there are still many unknowns about COVID-19 and how the disease spreads. Current knowledge and guidance is based in large part on what is known about similar viruses in the coronavirus family.

What is the difference between COVID-19 and coronavirus? What is SARS-CoV-2? What is novel coronavirus/nCoV?

Coronavirus is the name of a family of viruses, some of which cause respiratory infections in humans. For example, there are many coronaviruses that cause the common cold. “Novel coronavirus,” abbreviated as nCoV, is a general term assigned to any newly-discovered coronavirus before giving it a formal name. SARS-CoV-2 (previously called 2019-nCoV) is the formal name that the World Health Organization (WHO) has assigned to the coronavirus that causes COVID-19, the respiratory illness whose first case was identified in Wuhan, China in December 2019 (COVID-19 stands for Coronavirus Disease 2019). For simplicity, we’ll use the term “novel coronavirus” or “coronavirus” in these materials.

http://www.cdc.gov/coronavirus/2019-nCoV/summary.html

What are the symptoms of COVID-19?

COVID-19 is a respiratory infection, so typical symptoms are the same as any respiratory infection (like the common cold or flu): cough, fever/chills, and difficulty breathing. Symptoms can range from mild (most cases) to very severe, requiring hospitalization and the need for a ventilator (breathing machine). People with COVID-19 or any other respiratory infection might have any or all of the typical symptoms. There are some reports¹ of people later shown to have COVID-19 who initially had nausea or diarrhea but no respiratory symptoms, though these symptoms appear to be very uncommon in people with COVID-19.

¹ Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;

What should I do if I think I have symptoms of COVID-19?

Unless you have recently traveled to one of the areas (a searchable list of countries is available on the CDC website) with known cases of COVID-19 or had recent close contact with someone who has a known case of COVID-19, your symptoms are more likely to be due to the common cold or flu. However, viruses can spread quickly, and the best practices for avoiding spreading respiratory infections include staying at home if possible, washing your hands frequently and with proper technique, and consulting with a doctor or other qualified medical professional if your symptoms worsen or if you have other medical problems.

Note that information and guidance regarding COVID-19 are developing rapidly, and you should continue referring to the CDC website to stay up to date on the latest developments.

What should I do if I don’t have any symptoms, but I think I might have been exposed to novel coronavirus?

According to the CDC at the time of this writing, exposure to novel coronavirus is possible if you have recently traveled to any of the areas with known cases of COVID-19 (a searchable list of countries is available on the CDC website), or if you have been in close contact with someone who has a known case of COVID-19. If neither of the above is true, you are unlikely to have been exposed to novel coronavirus. However, viruses can spread quickly, so it is possible that at some point these criteria may change. If you think you have been exposed based on the current criteria and you don’t have any symptoms like cough, fever/chills, or difficulty breathing, the CDC recommends separating yourself from other people (quarantine) for 14 days from the last date you were potentially exposed, because 14 days is the longest incubation period seen for similar coronaviruses.

Note that information and guidance regarding COVID-19 are developing rapidly, and you should continue referring to the CDC website to stay up to date on the latest developments.

http://www.cdc.gov/coronavirus/2019-ncov/faq.html

How does novel coronavirus spread? How can I minimize the risk of getting an infection or spreading infection to other people?

Novel coronavirus is spread from person to person through respiratory droplets (from coughing, sneezing, or touching). The likelihood that a person will become infected with any virus after exposure is different for all viruses and is a spectrum. Novel coronavirus appears to be relatively easily spread from person to person. The CDC recommends the following best practices to help minimize the chances of spreading respiratory infections:
– Avoid close contact with people who are sick.
– Avoid touching your eyes, nose, and mouth.
– If you are sick, stay home.
– If you cough or sneeze, cover your mouth and nose with a tissue, then throw the tissue away and wash your hands.
– Clean and disinfect frequently touched objects and surfaces using regular household cleaning spray or cleaning wipe.
– Follow CDC’s recommendations for using a facemask:
– CDC does not recommend that people who have no symptoms wear a facemask to protect themselves from respiratory diseases, including COVID-19.
– People who show symptoms of COVID-19 should wear facemasks, in order to help prevent spreading the disease to others. Healthcare workers and people who are taking care of someone in close settings (like at home or in a health care facility) should also wear facemasks.
– Wash your hands frequently with soap and water for at least 20 seconds (one tip is to wash for the duration of singing the song “Happy Birthday” twice), especially after:
– Using the bathroom
– Before eating
– After blowing your nose, coughing, or sneezing
– If you’re not near a sink with soap and water, an alcohol-based hand sanitizer with at least 60% alcohol can be used. Always wash with soap and water if your hands are visibly dirty.

http://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html

Can my pets get infected or infect me?

Although novel coronavirus appears to have come from an animal source initially, the CDC states that “there is no reason to think that any animals including pets in the United States might be a source of infection with this new coronavirus.” Animals do sometimes spread other diseases to people, so washing your hands after being around animals is recommended in general.

I’m an employer. Should I tell my employees to stay home?

The CDC currently recommends the following to assess risk for COVID-19:
– Sick employees should be actively encouraged to stay home
– Employees who appear to have symptoms (fever, cough, shortness of breath) or develop symptoms at work should be separated from other employees and sent home immediately
– Employers should emphasize staying home when sick, as well as etiquette for coughing/sneezing and handwashing by all employees
– Routine environmental cleaning of frequently-touched surfaces like workstations, countertops, and doorknobs
– Employees who are planning to travel should be advised to check the latest travel information from the CDC and check for symptoms of respiratory illness before traveling

Additionally, risk assessments should be based on the above, not on race or country of origin.

http://www.cdc.gov/coronavirus/2019-ncov/specific-groups/guidance-business-response.html

Is it safe to visit someone in the hospital, or to take a friend to their doctor’s office?

You should use routine precautions when visiting people who are in the hospital or need to see a doctor for other reasons than a respiratory infection or respiratory symptoms. In general, it is a good idea to practice etiquette for coughing/sneezing and hand hygiene. Of course, for some people who are hospitalized for respiratory infections, special precautions may be required.

Does wearing a mask or gloves protect me or those around me from getting infected with novel coronavirus?

It is not currently recommended for people in a community setting (i.e., not a hospital or health care facility) without respiratory symptoms to wear a facemask to protect against the virus. For people in a community setting, wearing gloves is not more effective than practicing good hand hygiene (wash hands frequently with soap and water for at least 20 seconds).

http://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf

Is there a treatment, vaccine, or cure for COVID-19?

There is no cure or specific antiviral treatment for COVID-19. The best treatment for COVID-19 (and other infections that don’t have a cure) is to relieve the symptoms. For mild symptoms, this usually involves rest, fluids, and medications to help with fever and cough as needed. People with severe symptoms (lots of trouble breathing, very high fever, inability to stay hydrated by drinking fluids by mouth) need hospitalization and potentially intensive care. Currently, there is no vaccine available to prevent COVID-19, and the best way to prevent exposure and illness is by using the techniques above (“How does novel coronavirus spread? How can I minimize the risk of getting an infection or spreading infection to other people?”).

About Ro’s Coronavirus Telehealth Assessment

What is Ro’s Coronavirus Telehealth Assessment?

Ro has created a free telehealth triage service for people who are seeking guidance and information about the novel coronavirus (COVID-19).

If an individual thinks they may be experiencing signs or symptoms of the COVID-19, they complete Ro’s online assessment and, if appropriate, we’ll connect them with a medical provider for a free consultation.

How does it work?

Developed with guidance from infectious disease specialists, Ro’s telehealth assessment collects self-reported health information (e.g., health history, symptoms, travel history, locale, proximity to confirmed cases). Based on that information and using the most up-to-date guidelines from the Centers for Disease Control (CDC), the World Health Organization (WHO), and state/local public health departments, we provide an initial risk assessment.

Those who are symptomatic or have other risk factors (e.g., travel history or proximity to confirmed cases, pre-existing/underlying conditions) will be connected to a licensed medical provider for a free consultation.

During the consultation, the medical provider will collect additional information about the patient’s symptoms and concerns, recommend the proper course of action (which may include self-quarantine), and, if recommended, instruct them to follow up with a local provider for testing and diagnosis. For patients who are recommended to seek in-person care, we will provide them resources to find a local provider so they can get the help they need. We also report suspected cases to the applicable public health authorities, as required, to help inform local and national response efforts.

Individuals who are at low risk of having contracted COVID-19 will be guided to a number of resources at our Coronavirus Resource Hub and will be encouraged to keep monitoring their symptoms. These resources are regularly updated and are based on the latest government guidelines and best practices. Our goal is that these resources will help the public understand this complex virus and help keep themselves, their families, and their communities safe.

Why are you doing this?

We want to do everything we can to provide assistance to people who are concerned about COVID-19. Ro’s telehealth platform is uniquely suited to help in a number of ways:

Unburdening hospitals and clinics.

We have consulted with public health experts who are worried that coronavirus fears will overcrowd and overburden our health system, making it more challenging and costly for people who need in-person or emergency care to find it.

We’re hopeful that Ro’s triage system will reduce strain on providers who are treating higher-risk and sicker patients.

Advising symptomatic patients

We expect that people suffering from the common cold or the flu will be concerned about COVID-19. Initially talking to a remote medical provider via telehealth, as the CDC has recommended, can provide comfort and guidance on how to address their symptoms, get healthy, and reduce the spread to others. For those at risk of COVID-19, Ro-affiliated medical providers can advise them on appropriate next steps, whether that’s to self-quarantine or seek additional care.

Providing trusted health information.

As more cases are reported, we expect public fears to increase and misinformation to spread. We believe that providing people with easily-accessible, updated information about COVID-19 will help calm their concerns. For people who don’t have an established provider and aren’t sure where to turn, Ro can be an initial entry point into the healthcare system.

Are doctors diagnosing or testing for COVID-19 on your platform?

No. This is a triage program that will allow people to easily access a risk assessment tool, and if appropriate, a medical provider consultation at no cost. We are not diagnosing or testing for COVID-19.

Does Ro have access to approved COVID-19 tests?

No. Ro is not providing testing for COVID-19.

Will Ro provide consultation to caregivers for those who may be at-risk and unable to use the platform (e.g., elderly, children)?

Caregivers can access a number of resources through Ro’s Coronavirus Resource Hub. These resources are regularly updated and are based on the latest government guidelines and best practices so patients can understand this complex virus and how they can help keep themselves and their families safe.

Will Ro share any of its data with public health officials?

We have the ability to collect and provide relevant and anonymized data to public health officials. We would welcome their advice on the types of data that would aid their efforts. If you are part of an agency or healthcare institution that is responding to the COVID-19 outbreak and think Ro could be helpful in any way, please contact covid19-feedback@ro.co.

What is the source of the information in Ro’s Coronavirus Resource Hub?

We are updating the information provided in our Coronavirus Resource Hub regularly using the most up-to-date guidelines from CDC, WHO, and state/local, public health departments.

Will Ro be offering services internationally?

Ro’s services are only available in the U.S.

Additional resources

Ro is here to help

Take a free Coronavirus Telehealth Assessment

If you think you may be experiencing signs or symptoms of the novel coronavirus (COVID-19), complete this online assessment and, if appropriate, Ro will connect you with a medical provider for a free video consultation.


Our providers are online Mon-Fri, 8am-5pm based on your local timezone.

If you think you need immediate attention, please call 9-1-1 and let them know you are concerned about COVID-19.

Please note: No personal or medical information will be shared with Fiverr or any other third parties.

Check your symptoms.

Fever

Cough

Shortness of breath

Signs and symptoms of coronavirus may include fever, cough, or shortness of breath. Risk factors include recently traveling to one of the countries listed on this page. For real-time updates on global cases, view this map.

Click below to get started if you think you may be at risk.

How to protect others.

If you are sick (with coronavirus or not), here’s how you can avoid spreading germs.

Cover your coughs and sneezes

Use a tissue, then throw it in the trash can. If tissues are unavailable, cough into the shoulder or elbow and wash your hands immediately after.

Wash your hands after blowing your nose

Use soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.

Stay home if you feel sick

Do not go to work, school, or public areas. Avoid using public transportation and limit activities outside your home, except for getting medical care.

How to protect yourself.

Here are a few key ways to stay healthy when there’s a bug going around.

Wash your hands frequently and before eating

Use soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.

Sanitize surfaces and avoid sick people

Routinely clean frequently touched objects (doorknobs, keyboards, and phones) and avoid close contact (6 feet or less) with others who are sick.

Practice healthy habits

Get plenty of sleep, stay physically active, eat healthy, manage your stress, and drink plenty of fluids to support your mucosal surfaces.

Novel Coronavirus (COVID-19) Resource Hub

For digestible and comprehensive articles on coronavirus, check out Ro’s Health Guide.

  • What is the novel coronavirus COVID-19?

    5 minute read

  • Signs and symptoms of coronavirus

    3 minute read

  • How useful is a mask in reducing coronavirus transmission?

    7 minute read

  • How can I help prevent and prepare for the coronavirus?

    3 minute read

  • The flu shot and the new coronavirus (COVID-19)

    4 minute read

  • Who is most at risk for contracting & getting ill from the coronavirus

    2 minute read

  • Can pets get the coronavirus? Can they infect me?

    3 minute read

  • Top coronavirus myths

    4 minute read

  • COVID-19: a timeline of events since its discovery

    3 minute read

  • Here’s how long coronavirus can live outside of the body

    4 minute read

Frequently asked questions

About Coronavirus (COVID-19)

All answers reviewed by our in-house medical team and authored by Rachel Kwon, MD.

Note: all the information relayed here is directly based on information and guidance from the CDC and WHO. This information is rapidly evolving, and it’s important to understand that there are still many unknowns about COVID-19 and how the disease spreads. Current knowledge and guidance is based in large part on what is known about similar viruses in the coronavirus family.

What is the difference between COVID-19 and coronavirus? What is SARS-CoV-2? What is novel coronavirus/nCoV?

Coronavirus is the name of a family of viruses, some of which cause respiratory infections in humans. For example, there are many coronaviruses that cause the common cold. “Novel coronavirus,” abbreviated as nCoV, is a general term assigned to any newly-discovered coronavirus before giving it a formal name. SARS-CoV-2 (previously called 2019-nCoV) is the formal name that the World Health Organization (WHO) has assigned to the coronavirus that causes COVID-19, the respiratory illness whose first case was identified in Wuhan, China in December 2019 (COVID-19 stands for Coronavirus Disease 2019). For simplicity, we’ll use the term “novel coronavirus” or “coronavirus” in these materials.

http://www.cdc.gov/coronavirus/2019-nCoV/summary.html

What are the symptoms of COVID-19?

COVID-19 is a respiratory infection, and the most typical symptoms are fever or chills, dry cough, and difficulty breathing. Muscle aches and generally feeling tired are also common.

Symptoms can range from mild (most cases) to very severe (requiring intensive care in the hospital and the need for respiratory support).

Most, but not all, severe illness occurs in older adults and adults with underlying medical conditions. 

Less common symptoms include nausea, vomiting, and/or diarrhea (WHO Feb 2020, Huang Jan 2020).

What should I do if I think I have symptoms of COVID-19?

If you have recently traveled to one of the areas (a searchable list of countries is available on the CDC website) with known cases of COVID-19, had recent close contact with someone who has a known case of COVID-19, or live in an area where there is community spread of COVID-19, it is possible you have been exposed to the novel coronavirus.

If you think you may have COVID-19, best practices for recovering and avoiding spreading illness include staying home, separating yourself from others in your home as much as possible, covering your coughs and sneezes, and washing your hands frequently. 

You should consult with a doctor or other qualified medical professional, at first by phone, if your symptoms worsen, or if you have other medical problems.

Note that information and guidance regarding COVID-19 are developing rapidly, and you should continue referring to the CDC website to stay up to date on the latest developments. 

Do I need to get a coronavirus test? How do I get tested?

There is currently a relative shortage of coronavirus tests in the US, and testing is being done through healthcare professionals. 

The CDC currently advises people to remember that treatment for COVID-19 or suspected COVID-19 is the same regardless of testing, and people who have mild illness and are otherwise healthy may be able to isolate and safely take care themselves at home.

Information regarding testing is subject to change quickly as more tests are developed and access to testing is increased.

What should I do if I don’t have any symptoms, but I think I might have been exposed to novel coronavirus?

If you have been exposed to someone with a confirmed case of COVID-19, or if you recently traveled to a high-risk area, it is possible you have been exposed to novel coronavirus according to CDC criteria.

If any of the above is true, but you don’t have any symptoms like fever/chills, dry cough, or difficulty breathing, the CDC recommends separating yourself from other people (quarantine) for 14 days from the last date you were potentially exposed. (14 days is suggested because it is generally considered the longest incubation period for this virus.)

If you live in an area where there is community spread of COVID-19, it is also possible you have been exposed to novel coronavirus. Many of these areas are encouraging or mandating social distancing.

Note that information and guidance regarding COVID-19 are developing rapidly, and you should continue referring to the CDC website to stay up to date on the latest developments. 

What are social distancing, self-quarantine, and isolation?

Social distancing is a form of physical separation from others that means staying away from crowded public places and mass gatherings where you are likely to have close contact with other people, such as malls, movie theaters, sporting events, and others. It also includes keeping distance (approximately 6 feet or 2 meters) from other people whenever possible. Social distancing applies to people without symptoms, or those who have mild symptoms but no COVID-19 risk factors.

Self-quarantine is also a form of physical separation from others and applies to people without symptoms who have been exposed to COVID-19 (either by travel to a high-risk area or by close contact with someone who has COVID-19). In comparison with social distancing, people who are self-quarantining should stay at home for 14 days and monitor for symptoms.

Isolation is a form of physical separation from others that applies to people with symptoms who are thought to be potentially infectious.

See the CDC website for more info.

How does novel coronavirus spread? How can I minimize the risk of getting an infection or spreading infection to other people?

Novel coronavirus is spread from person to person through respiratory droplets (from coughing, sneezing, or touching). The likelihood that a person will become infected with any virus after exposure is different for all viruses and is a spectrum. Novel coronavirus appears to be relatively easily spread from person to person. The CDC recommends the following best practices to help minimize the chances of spreading respiratory infections:
– Avoid close contact with people who are sick.
– Avoid touching your eyes, nose, and mouth.
– If you are sick, stay home.
– If you cough or sneeze, cover your mouth and nose with a tissue, then throw the tissue away and wash your hands.
– Clean and disinfect frequently touched objects and surfaces using regular household cleaning spray or cleaning wipe.
– Follow CDC’s recommendations for using a facemask:
– CDC does not recommend that people who have no symptoms wear a facemask to protect themselves from respiratory diseases, including COVID-19.
– People who show symptoms of COVID-19 should wear facemasks, in order to help prevent spreading the disease to others. Healthcare workers and people who are taking care of someone in close settings (like at home or in a health care facility) should also wear facemasks.
– Wash your hands frequently with soap and water for at least 20 seconds (one tip is to wash for the duration of singing the song “Happy Birthday” twice), especially after:
– Using the bathroom
– Before eating
– After blowing your nose, coughing, or sneezing
– If you’re not near a sink with soap and water, an alcohol-based hand sanitizer with at least 60% alcohol can be used. Always wash with soap and water if your hands are visibly dirty.

http://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html

Can my pets get infected or infect me?

Although novel coronavirus appears to have come from an animal source initially, the CDC states that “there is no reason to think that any animals including pets in the United States might be a source of infection with this new coronavirus.” Animals do sometimes spread other diseases to people, so washing your hands after being around animals is recommended in general.

I’m an employer. Should I tell my employees to stay home?

The CDC currently recommends the following to assess risk for COVID-19:
– Sick employees should be actively encouraged to stay home
– Employees who appear to have symptoms (fever, cough, shortness of breath) or develop symptoms at work should be separated from other employees and sent home immediately
– Employers should emphasize staying home when sick, as well as etiquette for coughing/sneezing and handwashing by all employees
– Routine environmental cleaning of frequently-touched surfaces like workstations, countertops, and doorknobs
– Employees who are planning to travel should be advised to check the latest travel information from the CDC and check for symptoms of respiratory illness before traveling

Additionally, risk assessments should be based on the above, not on race or country of origin.

http://www.cdc.gov/coronavirus/2019-ncov/specific-groups/guidance-business-response.html

Is it safe to visit someone in the hospital, or to take a friend to their doctor’s office?

You should use routine precautions when visiting people who are in the hospital or need to see a doctor for other reasons than a respiratory infection or respiratory symptoms. In general, it is a good idea to practice etiquette for coughing/sneezing and hand hygiene. Of course, for some people who are hospitalized for respiratory infections, special precautions may be required.

Does wearing a mask or gloves protect me or those around me from getting infected with novel coronavirus?


On April 3, the Centers for Disease Control and Prevention (CDC) updated their recommendation regarding wearing face coverings in public. Citing that many cases of COVID-19 may be asymptomatic, the CDC now recommends people wear cloth face coverings in settings where social distancing is difficult (e.g. crowded areas). Wearing a face covering helps prevent you from spreading the virus to others, in case you happen to be infected but do not know it. The CDC still does not recommend the use of surgical masks (face masks) or N-95 respirators by the general public, stating that these should be reserved for healthcare workers and first responders.

For people in a community setting, wearing gloves is not more effective than practicing good hand hygiene (wash hands frequently with soap and water for at least 20 seconds).

See the CDC website for more info.

Is there a treatment, vaccine, or cure for COVID-19?

There is no cure or specific antiviral treatment for COVID-19. The best way to manage COVID-19 currently (and other infections that don’t have a cure) is to treat the symptoms.

For mild symptoms, this usually involves rest, fluids, and medications to help with fever and cough as needed. 
Currently, there is no vaccine available to prevent COVID-19, and the best way to prevent exposure and illness is by using the techniques above.

This is subject to change, as specific antiviral treatments and new use of existing medications are currently under investigation as potential treatments, as well as vaccines.

People with severe symptoms (lots of trouble breathing, very high fever, inability to stay hydrated by drinking fluids by mouth) need hospitalization and potentially intensive care regardless of the cause of their illness.

About Ro’s Coronavirus Telehealth Assessment

What is Ro’s Coronavirus Telehealth Assessment?

Ro has created a free telehealth triage service for people who are seeking guidance and information about the novel coronavirus (COVID-19).

If an individual thinks they may be experiencing signs or symptoms of the novel coronavirus (COVID-19), they complete Ro’s online assessment and, if appropriate, we’ll connect them with a doctor for a free video consultation.

How does it work?

Developed with guidance from infectious disease specialists, Ro’s telehealth assessment collects self-reported health information (e.g., health history, symptoms, travel history, locale, proximity to confirmed cases). Based on that information and using the most up-to-date guidelines from the Centers for Disease Control (CDC), the World Health Organization (WHO), and state/local public health departments, we provide an initial risk assessment.

Those who are symptomatic or have other risk factors (e.g., travel history or proximity to confirmed cases, pre-existing/underlying conditions) will be connected to a licensed physician for a free video consultation.

During the video consultation, the doctor will collect additional information about the patient’s symptoms and concerns, recommend the proper course of action (which may include self-quarantine), and, if recommended, instruct them to follow up with a local provider for testing and diagnosis. For patients who are recommended to seek in-person care, we will provide them resources to find a local provider so they can get the help they need. We also report suspected cases to the applicable public health authorities, as required, to help inform local and national response efforts.

Individuals who are at low risk of having contracted COVID-19 will be guided to a number of resources at our Coronavirus Resource Hub and will be encouraged to keep monitoring their symptoms. These resources are regularly updated and are based on the latest government guidelines and best practices. Our goal is that these resources will help the public understand this complex virus and help keep themselves, their families, and their communities safe.

Why are you doing this?

We want to do everything we can to provide assistance to people who are concerned about COVID-19. Ro’s telehealth platform is uniquely suited to help in a number of ways:

Unburdening hospitals and clinics.

We have consulted with public health experts who are worried that coronavirus fears will overcrowd and overburden our health system, making it more challenging and costly for people who need in-person or emergency care to find it.

We’re hopeful that Ro’s triage system will reduce strain on providers who are treating higher-risk and sicker patients.

Advising symptomatic patients

We expect that people suffering from the common cold or the flu will be concerned about COVID-19. Initially talking to a remote doctor via telehealth, as the CDC has recommended, can provide comfort and guidance on how to address their symptoms, get healthy, and reduce the spread to others. For those at risk of COVID-19, Ro-affiliated doctors can advise them on appropriate next steps, whether that’s to self-quarantine or seek additional care.

Providing trusted health information.

As more cases are reported, we expect public fears to increase and misinformation to spread. We believe that providing people with easily-accessible, updated information about COVID-19 will help calm their concerns. For people who don’t have an established provider and aren’t sure where to turn, Ro can be an initial entry point into the healthcare system.

Are doctors diagnosing or testing for COVID-19 on your platform?

No. This is a triage program that will allow people to easily access a risk assessment tool, and if appropriate, a doctor consultation at no cost. We are not diagnosing or testing for COVID-19.

Does Ro have access to approved COVID-19 tests?

No. Ro is not providing testing for COVID-19.

Will Ro provide consultation to caregivers for those who may be at-risk and unable to use the platform (e.g., elderly, children)?

Caregivers can access a number of resources through Ro’s Coronavirus Resource Hub. These resources are regularly updated and are based on the latest government guidelines and best practices so patients can understand this complex virus and how they can help keep themselves and their families safe.

Will Ro share any of its data with public health officials?

We have the ability to collect and provide relevant and anonymized data to public health officials. We would welcome their advice on the types of data that would aid their efforts. If you are part of an agency or healthcare institution that is responding to the COVID-19 outbreak and think Ro could be helpful in any way, please contact covid19-feedback@ro.co.

What is the source of the information in Ro’s Coronavirus Resource Hub?

We are updating the information provided in our Coronavirus Resource Hub regularly using the most up-to-date guidelines from CDC, WHO, and state/local, public health departments.

Will Ro be offering services internationally?

Ro’s services are only available in the U.S.

Additional resources

Zinc

Zinc sulfate

Zinc is an important trace mineral in the body that plays a role in many cellular processes, wound healing, growth, and development.

Sourced from Japan

Non-GMO


Available in:

Disclaimer: The information provided on this page is not a substitute for professional medical advice, diagnosis, or treatment. If you have any questions or concerns about your health, please talk to a healthcare provider.

Vitals

Some studies have shown that zinc supplementation can improve semen quality in subfertile men and increase testosterone levels in zinc-deficient men.

It is recommended that men have at least 11 mg per day of zinc, which can come from food or supplements. Having too much or too little can be dangerous for your health.

Zinc supplements can interact with certain medications. Talk to your healthcare provider before taking zinc if you are already taking antibiotics, penicillamine, or diuretics.

What is zinc?

Zinc is a mineral that is involved in several of the body’s processes. More specifically, zinc is an essential trace mineral, meaning that only small amounts are required but that it is vital to the proper functioning of the human body. Zinc is involved in numerous cellular reactions including cell division and the formation of DNA and proteins. Zinc also plays a role in wound healing, growth, development, taste, and smell.

Where does zinc come from?

Zinc can be found in a wide variety of foods. Oysters and certain other shellfish like crab and lobster are among the foods with the most zinc per serving. Other good sources of zinc include red meat, pork, chicken, yogurt, milk, and eggs. For those who do not eat animal products, zinc can be found in legumes, nuts, and seeds. However, plant-based foods may also contain phytates, which decrease the amount of zinc the body can absorb. Some foods, such as breakfast cereals, are fortified with zinc. This means that zinc is added to the food in a public health effort to help make sure everybody is getting enough each day.

What are the health benefits of zinc?

The health benefits of zinc are far-reaching since the mineral is a necessary part of numerous cellular processes. Purported but unconfirmed or understudied benefits of zinc include treating acne, age-related macular degeneration, anorexia, ADHD, burns, colorectal tumors, the common cold, cramps, depression, halitosis, rash, and sickle cell disease.

Zinc is essential to the immune system, which is the body’s natural defense against infection. White blood cells are a major component of the immune system and circulate through the bloodstream. Whenever foreign organisms (such as bacteria) are present, white blood cells release molecules that regulate inflammation and then work to isolate and kill the organisms. Zinc is necessary for white blood cells to be able to successfully execute each of these functions. This is why maintaining normal levels of zinc is vital to staying healthy; in the setting of a zinc deficiency, these basic immune processes are all negatively impacted (4).

In addition to oral zinc, topical zinc can be beneficial to health. Zinc oxide, when applied to wounds like leg ulcers, has been seen to promote healing by decreasing inflammation, inhibiting bacterial growth, and stimulating the migration of skin cells into the wound (1).

Zinc also has the following health benefits, which is why it was chosen to be an ingredient in the Roman Dailies:

Testosterone Support

Studies looking specifically at zinc’s effects on testosterone are limited. They include the following:

Semen: In one study of subfertile men in Sudan with reduced sperm count and mobility, supplementation with 110 mg of zinc sulfate (equivalent to 25 mg of elemental zinc) twice per day for three months led to an increase in follicle stimulating hormone (a hormone that stimulates testicular growth and helps maintain sperm cells), an increase in testosterone, and improvement in sperm motility percentages (6).

Sexual function: In one study on male rats, supplementation with zinc improved sexual competence by increasing thrusting and time to ejaculation. Increases in testosterone levels were also noted and the benefits were found to be dose-dependent. There was also a reduction in libido but these results were not statistically significant (2).

Testosterone: One study looked at the link between zinc concentrations and testosterone levels in forty men. When dietary zinc was restricted for twenty weeks in normal men, testosterone levels declined. When 30 mg per day of zinc supplementation was given for six months to elderly men who were deficient, testosterone levels rose (5).

In what forms is zinc available?

You can get omega-3 directly through the diet or by taking supplements. Supplements that contain EPA and DHA include fish oil, krill oil, cod liver oil, and algae oil (which is a vegetarian option). Depending on the type of supplement and oil you get, there may be different concentrations of triglycerides, phospholipids, and other compounds mixed in with the omega-3 fatty acids (4).

How much zinc is recommended?

Unlike some minerals, the human body does not have an effective way to store zinc, so it must be ingested every day with food. If you do not consume enough zinc, you may become zinc deficient, which can lead to a number of symptoms and health problems. The Recommended Dietary Allowance (RDA) of zinc is 11 mg per day for men over the age of 13. Women over the age of 18 should have 8 mg per day unless they are pregnant (11 mg per day) or breastfeeding (12 mg per day). The RDA represents the daily amount of a mineral that is considered sufficient for 97–98% of healthy individuals.

On the other end of the spectrum, the Tolerable Upper Intake Level (UL) for zinc is 40 mg per day for both men and women over the age of 18. Repeated intake of amounts greater than the UL can lead to poor health outcomes (3).

What are the symptoms of having too little zinc?

Worldwide, it is estimated that approximately 17.3% of the population is at risk of not consuming enough zinc (7). In the United States, an overt deficiency is far less common. However, it is still estimated that 20–25% of American adults ages 60 and older do not consume an adequate amount of zinc, even after supplementation is taken into account. Other groups of people who are at risk of developing a zinc inadequacy or deficiency are those with gastrointestinal diseases, people with sickle cell disease, alcoholics, vegetarians, and pregnant or breastfeeding women.

Because of how zinc is distributed in the body, there is no effective way to test for zinc deficiency. A healthcare provider may decide to test zinc levels in your blood but it is possible for this value to come back within the normal range even in the setting of a deficiency. Instead, those who have risk factors for deficiency who are also experiencing symptoms should consider zinc supplementation.

Symptoms of zinc deficiency can be severe. These include problems with growth and development and decreased effectiveness of the immune system. Other specific symptoms include:

  • Weight loss
  • Hair loss
  • Diarrhea
  • Sexual dysfunction
  • Impaired vision
  • Rash

What are the symptoms of having too much zinc?

Having too much zinc can also cause symptoms and health problems. Regularly ingesting more than the UL for zinc (40 mg per day) or ingesting a single high dose of zinc (for example, a single 4 g dose of zinc gluconate) can induce:

  • Nausea
  • Vomiting
  • Abdominal cramping
  • Diarrhea
  • Headache
  • Urinary tract infections


Since zinc has an effect on the way copper is absorbed, having too much zinc can lead to low copper and copper supplementation may be necessary. For this reason, Roman’s Testosterone Support supplement also includes copper as an ingredient. Excess zinc may also cause issues with iron function and immune function in the body.

What to look for in a good zinc supplement:

As a supplement, zinc can come in several forms including zinc acetate, zinc citrate, zinc gluconate, zinc picolinate, and zinc sulfate. Currently, no evidence exists to support the use of one formulation over another (3). Different supplements may contain different percentages of zinc, meaning different amounts are released into the bloodstream to become bioactive.

How does Roman offer zinc?

Roman obtains zinc from a non-GMO source in Japan. It is available synthetically as zinc sulfate.

Roman offers zinc in the following supplements:

Testosterone Support

Zinc is one of six main ingredients in Roman’s Testosterone Support supplement. The supplement consists of four tablets that should be taken with water. Each individual tablet contains 7.5 mg of zinc, for a total daily dose of 30 mg. This value falls between the RDA and the UL for zinc and closely approximates the amount that led to increased testosterone levels and improved semen quality in one study.

Other ingredients in the tablets include maca root powder, KSM-66® organic ashwagandha root extract, magnesium citrate, cupric oxide, cholecalciferol, microcrystalline cellulose, dicalcium phosphate, stearic acid, croscarmellose sodium, magnesium stearate, silicon dioxide, and pharmaceutical glaze (shellac, povidone).

Does zinc interact with any other drugs or medical conditions?

Zinc interacts with several other medications and may affect how those medications are absorbed or how they affect the body. If you are taking any of the following medications, it is important you talk to your healthcare provider before beginning zinc supplementation (please note that this list may not be exhaustive and other medications may also interact with zinc)
(3):

  • Quinolone antibiotics: Zinc interacts with these antibiotics in the gastrointestinal system, impairing the absorption of both the antibiotic and the zinc. Taking the antibiotic at least two hours before or at least four to six hours after taking zinc reduces this interaction. Examples of quinolone antibiotics include ciprofloxacin, levofloxacin, and moxifloxacin.
  • Tetracycline antibiotics: Zinc interacts with these antibiotics in the gastrointestinal system, impairing the absorption of both the antibiotic and the zinc. Taking the antibiotic at least two hours before or at least four to six hours after taking zinc reduces this interaction. Examples of tetracycline antibiotics include doxycycline, minocycline, demeclocycline, and tetracycline.
  • Penicillamine: Penicillamine (not to be confused with the antibiotic penicillin) is a medication that is used to treat rheumatoid arthritis and Wilson’s disease. Taking zinc may decrease both the absorption of penicillamine as well as its effectiveness in the body. To avoid this interaction, penicillamine and zinc should be taken at least two hours apart from each other.
  • Thiazide diuretics: Thiazide diuretics are also sometimes known as “water pills.” Taking thiazide diuretics may cause the body to excrete excess zinc through the urine, which can affect levels of zinc in the body. Being aware of the symptoms of zinc deficiency may help prevent health problems. Examples of thiazide diuretics include chlorthalidone and hydrochlorothiazide.

Sources

  1. Agren MS. Studies on zinc in wound healing. Acta Dermato-Venereologica. 1990;154:1-36.
  2. Dissanayake D, Wijesinghe P, Ratnasooriya W, Wimalasena S. Effects of zinc supplementation on sexual behavior of male rats. Journal of Human Reproductive Sciences. 2009;2(2):57. doi:10.4103/0974-1208.57223.
  3. Office of Dietary Supplements – Zinc. NIH Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/. Published July 10, 2019. Accessed July 17, 2019.
  4. Prasad AS. Zinc in Human Health: Effect of Zinc on Immune Cells. Molecular Medicine. 2008;14(5-6):353-357. doi:10.2119/2008-00033.prasad.
  5. Prasad A. Zinc Status and Serum Testosterone Levels of Healthy Adults. Nutrition. 1996;12(5):vi. doi:10.1016/s0899-9007(96)00064-0.
  6. Saeed HSM, El-Hadiyah TMH, Osman BI. Using Zinc in Management of Subfertile Male Patients: a Clinical Trial. Al-Kindy College Medical Journal. 2017;13(1):32-38.
  7. Wessells KR, Brown KH. Estimating the Global Prevalence of Zinc Deficiency: Results Based on Zinc Availability in National Food Supplies and the Prevalence of Stunting. PLoS ONE. 2012;7(11). doi:10.1371/journal.pone.0050568.

Genital Herpes Treatment Plan

Valacyclovir 500 mg

Daily therapy to suppress outbreaks and reduce risk of transmission to an uninfected partner

Be sure to take your time and read everything below. It is essential for you to understand the potential risks and benefits of treatment. Please do not hesitate to reach out to our medical support team if you have ANY questions.

Overview

Herpes is not simply an infection. Too many people suffer silently, fearing to even reach out to their healthcare providers. There are few conditions where a person’s care is so dependent on their participation. Time must be dedicated to education and to formulating a plan that is under your control.

Medication is available—and it works extremely well—but how it is used and when it is used can never be more precisely applied than when a person uses the guidance of experts to craft a personalized plan.

With the education we provide below, you will be able to decide how best to utilize all the tools at your disposal. The key is to learn as much as you can and make informed decisions. The information below will help you gain a level of independence you may not have realized is possible.

Read carefully your healthcare professional’s personalized treatment plan and all the material provided. It may well provide some new information that will be helpful to you. Nothing is sugar coated because we feel you deserve the information you need to live your life the way you want. Read it all along with the package insert and the information in the Prescribers’ Digital Reference (PDR).

One important point is that if the medicine prescribed does not improve your condition (now or at any time), or if your symptoms at any point in the future are not completely typical of your usual outbreak, then you must be seen by a physician in person and checked for other conditions.

Lastly, the plan your personal doctor or nurse practitioner has provided is just the initial plan.

You may well choose a different one after reading more about other options or, in 6 months, your life circumstances may have changed and a different plan may suit you better. Just reach out to us.  

We are here to make your life better, not to give you more challenges in finding the care you need. And don’t forget, contact us if you need us.


Your treatment plan

Your doctor or nurse practitioner has reviewed your medical information and has prescribed valacyclovir 500 mg to treat genital herpes. Valacyclovir has been approved to treat genital herpes in several ways. It can be taken to lessen the severity of an initial outbreak, to abort outbreaks when someone feels telltale signs (the prodrome) that tells them an outbreak is about to happen, or to prevent outbreaks and reduce the risk of transmitting herpes by taking one pill every day.

Your doctor or nurse practitioner has written a prescription for valacyclovir to be used to limit outbreaks and reduce the risk of transmitting herpes by taking one pill every day. One of the most important advances in herpes treatment came with the knowledge that transmission from an infected person to their uninfected partner could be reduced by the use of daily valacyclovir.

Valacyclovir not only reduces the number of outbreaks a person experiences when using the medication every day but it reduces the number of days that someone sheds the virus asymptomatically (shedding of the herpes virus from normal skin when a person feels completely well).

Asymptomatic shedding is how most transmissions occur. Reducing asymptomatic shedding results in fewer uninfected partners catching herpes. If a condom is worn and the medication used, the chances are cut in half compared to using a condom alone. Fewer outbreaks and fewer episodes of asymptomatic shedding means fewer people become infected.

In one study that followed the course of 144 couples in which one partner was infected and the other not infected, transmission occurred in 14 couples. In 9 of those cases, the person who transmitted the disease was completely free of symptoms—no outbreak, not even a prodrome (a warning that an attack was coming). The other 5 transmissions happened when the person who was infected had a prodrome or developed lesions near the time the infection was transmitted. As noted, the key to preventing transmission isn’t just limiting outbreaks but reducing asymptomatic shedding. Valacyclovir, taken daily, reduces the number of outbreaks a person experiences and the number of days that someone sheds the virus asymptomatically.

To reduce the number of outbreaks an infected person experiences and to reduce the risk of transmission to an uninfected partner (by up to 50%), the PDR recommends the infected partner take valacyclovir 500 mg/day.

The study measured results “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Also, the study ran only for 8 months.


Valacyclovir FAQs

An important point
Herpes can be transmitted to a partner despite best efforts like using a condom and using antiviral suppression therapy. Patients should never engage in sex without a condom or when they have an outbreak or a prodrome. Also, as asymptomatic shedding is more common in the seven days following an outbreak, it is prudent to avoid sex during that period, as well.

The following information (Preventing future outbreaks and Other ways to use the medication) is relevant if at some point you decide to go off suppression therapy and choose to try to abort outbreaks and use suppression therapy in some specific situations only.

Preventing Future Outbreaks

If you are just trying to abort outbreaks, make a note of everything you think may have made you more susceptible to an outbreak. Was there more irritation to the area? Did anything affect your immunity like another infection (e.g., a cold) or did you change something in your lifestyle that could have weakened your immune system (e.g., lack of sleep, stress, increased alcohol consumption)? No change is too small to note.

This is important because it will help you maintain the patterns that make herpes less likely to appear. For you, it may be a lack of sleep over a few consecutive nights that spurs most outbreaks. It might be excessive sun exposure or too much alcohol consumption. It could happen only when you are sick or just run down. Whatever it might be, over time you may come to recognize the issues and make changes that reduce the frequency of outbreaks.

Other ways to use the medication

Some patients ask if they can take the medication to prevent an outbreak when they least want to have one. The classic examples are a bride or groom on their wedding day, when first engaging in sex with a new partner, or going on that long planned and much-needed vacation with your partner or spouse. You don’t need to be getting married or about to rendezvous for a much-anticipated tryst to want to prevent a herpes outbreak at particular times. It could be that an outbreak would be uncomfortable during the holidays or at any time you determine.

That is what we mean when we say you have control. At one point in life, a person may choose to abort outbreaks when they feel them coming on, at another point they might choose suppression therapy, but that may change, too. Circumstances change; only you will be able to know how your circumstances affect which option you choose. That is why learning all you can is so important. It gives you independence. Things change and how you choose to use valacyclovir may change.

One other fact is worth noting. You have been prescribed 30 pills of valacyclovir 500 mg every month. You should always have medication on hand, so renew your prescription well before you run out. As long as valacyclovir proves effective and you are free of significant side effects, you should never have to worry about having access to what you need.

You can always drop a note to your doctor or nurse practitioner, the pharmacist, or the care team with any questions, issues, or changes you want to consider. There is no “extra” visit charge or cost if you just want to ask questions and learn more about how you can manage your condition.

Lastly, if you would like to switch to intermittent therapy, you can always hold back on getting more valacyclovir delivered.

This may be a new situation for you but as long as the medication works without causing you difficulties of any sort, you are in control.    


Herpes: condition overview

A wealth of herpes information (oral and genital)

In the United States, genital herpes caused by HSV-2 (Herpes Simplex Virus Type 2) is extremely common and the most frequent cause of genital ulcer disease. Yet, the people who have symptoms represent the smallest number of people infected. In fact, 80% of the people who have genital herpes do not know it. That means for every person with symptoms who takes the step to be treated as you have, there are 4 people who are infected but totally unaware. 

Much of what we know about herpes is different from what people learned during the height of the “fear” an infection caused when no treatment was available.

That is what we must change. We want you to learn the facts about herpes so you do not become a victim of the myths. Also, only by understanding the disease will you be able to work with your doctor or nurse practitioner to craft the right treatment plan for you as your life evolves. What suits you today may not in 6 months or in 5 years. If you understand herpes, and how medications can work in different circumstances, you will be able to take control of your life in ways you might not have known were possible.

Lastly, if you read the next few pages carefully (though seemingly simply) you probably will know more helpful facts about herpes than many doctors.

What is herpes?

Herpes is a virus. The herpes virus can barely be considered alive. It is little more than a strand of DNA (deoxyribonucleic acid), the code of life, safely hidden inside a shell of protein. On its own, a herpes virus cannot reproduce or do much of anything—until it infects us. When the herpes virus comes in contact with areas that are receptive, like the genitals or mouth, the virus invades the epithelial cells (skin cells) in that region.

Then, the DNA of the herpes virus is released into the skin cell. At that point, it quite literally takes over.

It directs the cell to make more herpes virus and, when they have made enough copies to damage the cell so severely that it bursts, millions of the newly formed viruses are released infecting more cells, eventually causing an ulcer.

That is what people can see and feel, but a good deal more than that happens. While it is infecting skin cells and causing pain and ulcers, it also begins to attack the nerve cells in the same area. When the virus enters the nerve cell, it not only reproduces but it moves up the nerve to a bundle of nerves in the back called the sacral plexus. Once it is in the nerves, it is essentially protected from being attacked by the body’s immune system. Nerve cells can never be replaced.

That is why when nerves in the spine are damaged people become paralyzed. Since nerves cannot reproduce themselves easily, the body is careful not to bombard them with all the weapons it has to clear infections. All the inflammation that is caused by the battle to eliminate infections elsewhere would be disastrous if that occurred with nerves.

There is no sense clearing an infection if nerve cells that could never be replaced are destroyed in the process.

The herpes virus is essentially protected from an attack by our immune system as long as it hides out in the nerves of the sacral plexus when it affects the genitals, or the “dorsal root ganglion” (a cluster of nerves in the neck region of the spine) when it infects the mouth.

Unfortunately, that leaves the virus in a perfect position to sneak back out when the immune system is suppressed in any way. That is how the virus is able to cause recurrent infections, especially during times of stress, illness, or any condition or circumstance that makes our immune system less vigilant. We will discuss that in detail later.

How common are HSV-1 and HSV-2?

Worldwide (in 2012) nearly one half billion people were infected with HSV-2 between the ages of 15 and 49—and the number rises with age and the number of life partners. More women than men have herpes (14.8% versus 8% global prevalence, respectively). In the US, the number of people infected has been dropping, but the news isn’t all good. The percentage of people with a positive blood test for HSV-2 has declined. In people age 14 to 49, 21% were positive in the early 90s. By 2010, that number dropped to about 16%. Unfortunately, the improvement has been seen mostly in the white population “with stable rates in black populations, resulting in worsening racial disparities such that for every one white man, four black men are infected, with similar ratios for women.”

The reasons for this might be that access to information, education—and the medication that can reduce the risk of transmission—has not been made available to all equally.

In the United States, the prevalence of HSV-1, which accounts for the vast majority of oral herpes, has dropped 29% among 14–19 year olds, from approximately 42% to 30%, over the past 30 years. As a result, adolescents and young adults may experience their first exposure to HSV-1 with the initiation of sexual activity, including oral sex.

How can it be that some people do not have symptoms of oral herpes and of genital herpes?

It is vital to understand that 80% of people with an infection have no symptoms they recognize. For those who experience severe or frequent outbreaks, that is difficult to understand. There are multiple explanations.

The first one is related to how we physicians first described the disease.

Before there were elegant tests to culture herpes, or to test lesions for signs of herpes DNA, and before accurate blood tests out of the University of Seattle, herpes was described by doctors by what they saw—and only by what they saw. This meant that only people who had visible lesions (sores) were diagnosed and doctors thought that all those who had herpes had symptoms. It turns out that patients with severe disease were just the tip of the iceberg, but doctors didn’t realize that. Unfortunately, too many myths and outright falsehoods became “common knowledge.”

The fact is most people have an immune response that holds the disease at bay—in terms of causing symptoms, that is. They are still infected and, as we will learn later, still able to transmit the disease, but the symptoms either do not occur or are so subtle that they go unnoticed or undiagnosed. Herpes can cause such minor complaints that they are ignored.

Herpes can appear as little more than an irritation or tiny erosion. A lesion tucked away in the genital region can be so small that it cannot be seen without doing some major stretching before trying or using a magnifying lens. Or the sore is in a place that is completely inaccessible to viewing (e.g., the anus, the groin, the vagina, or hidden within a small skin fold).

Also, the symptoms may disappear so quickly that they are dismissed, or never seen in time by a doctor, or a doctor does not recognize how minor herpes can be even when seen in time. This is true of oral and genital herpes.

Nevertheless, the people who have what we call asymptomatic herpes can still transmit the disease. They can do this because they can still “shed” the virus from the skin even without having a sore or a symptom that they recognize as herpes. Asymptomatic shedding occurs from the mouth in those with oral herpes, from the anal and genital region in those with genital herpes, and even from tears in people who have had herpes of the eye. The section on asymptomatic shedding explains this in detail.


Clinical manifestations of Herpes

Clinical manifestations of Oral HSV infection

Classically, the oral symptoms are familiar to most people who either have had an outbreak or seen them in others. The initial symptoms are a sense of tingling or itching that can occur 24 hours before any lesions appear.

The first visible symptoms are redness, followed by the forming of a papule or elevation of the skin affected (usually on the very edge of the lips where they transition to the skin of the face). Then, the small roundish elevations become filled with fluid (a vesicle), which can burst and reveal a small ulcer or divet in the skin. This will be painful and ooze fluid and within just a few days heal, usually without a scar. These lesions do not form solely on the edge of the lip. They can form anywhere on the face, particularly a region between the nose and lips and out to the first fold on the cheek called the “nasolabial fold.”

The virus hides in the nerves in the back of the neck called the dorsal root ganglion. When HSV-1 reactivates and comes out of that nerve it can take a route other than to the edge of the lip. It can even cause an outbreak on the back of the neck but, most often, it is the lips where outbreaks will recur.

Oral symptoms can be more easily seen but often are not understood to be related to herpes. Minor irritations that disappear quickly might easily be dismissed as a simple cut or reaction to spicy food.

Other people might mistakenly consider unrelated irritations to be herpes on the mouth when they are not. For example, canker sores that occur inside the mouth and can recur just like herpes are sometimes misdiagnosed by patients and doctors alike as being due to the HSV-1 virus when, in reality, it is possibly an immune reaction and not an infection. The same sometimes occurs with irritation on the corners of the mouth, called angular cheilitis or perleche. This can be idiopathic, meaning it has no known cause, or can be due to the buildup of fluid at the corners of the mouth. It is a perfect spot to nurture growths of yeast or fungus (think Candida) and the irritation can even lead to small cuts and sores.

We always advise patients to confirm their diagnosis if recurrent oral lesions are completely unresponsive to herpes antiviral therapy.  

Clinical manifestations of Genital HSV infection

HSV-2 is the leading cause of genital ulcers in the United States and throughout the world. We know that because a very accurate test called a PCR test, which is far more sensitive than a culture, has found herpes in 60% of genital ulcers. Remember that most people with herpes found by blood testing have had no symptoms of herpes. What follows is a description of herpes as it appears in those who experience symptoms, in people who are seen by doctors with lesions.

First outbreak or primary outbreak

For patients who have symptoms, the first outbreak can be the worst. During primary infection, patients may experience multiple genital ulcers that can cover larger areas of skin. It can be on both sides of the groin and be quite painful. They often experience burning during urination in addition to the local pain. They can have fever, headaches, muscle and joint pain, and their lymph nodes in the groin can be swollen and painful as well. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. Therapy can shorten that period significantly.

The reason an initial outbreak can be so severe is that there are no antibodies to herpes when the virus first enters the body, (though a prior history of herpes type 1 can give someone antibodies that work a little bit to fight herpes type 2 and may make an outbreak a bit less severe.)
An initial outbreak can be caused by Herpes 1 and in developed countries like the US, the most common cause of an initial attack of herpes is actually herpes 1. Most people do not realize that someone infected with oral herpes from type 1 can perform fellatio or cunnilingus on a partner and transmit herpes 1 from their mouth to their partner’s genitals. If you think about it, why not? The problem is that many people don’t know they have oral herpes. It may be easier to see but not many people remember the cold sore they had when they were 3. Also, while most people in the past acquired herpes on the mouth as a child when exchanging saliva with other children who were infected, that has not been happening with anywhere near the same frequency. The rate of infection with Herpes 1 is lower now than at any time in the past. In the United States, HSV-1 has dropped 29% among 14–19 year olds, from 42.6% to 30.1% over the last 3 decades.

That means that adolescents who engage in sex are more likely to be exposed to Herpes 1 for the first time when having oral or vaginal sex. Changes in sexual practices have also made the transmission more likely.

Fellatio (a “blow job”) and cunnilingus (“going down”) are much more frequently practiced at younger ages and with fewer restraints imposed by cultural or social forces. That has made herpes 1 the most common cause of first outbreaks in developed countries. Nevertheless, herpes 1 and herpes 2 on the genitals do not behave identically in terms of recurrences. Herpes 1 is more “at home” in the oral region and has developed ways to deal with that environment. When on the genitals, it can cause all the same symptoms and can still be transmitted, but it has a milder course than when herpes 2 infects the genitals. This is discussed more in the section on recurrences.

Understanding how herpes can remain in the body yet be kept at bay to some degree is pivotal. Herpes enters the sacral plexus of nerves during an initial infection. As discussed above, the virus remains safe from attack by antibodies and the immune system as long as it is tucked away in the nervous system. That little trick, entering the nervous system where it neither damages the nerves nor can be attacked, makes herpes a particularly stubborn infection. It can slide down the nerves that go from the sacral plexus to the skin and cause more outbreaks in the future. These are called recurrences.

Recurrences occur in a milder version than the initial outbreak because the body is not completely defenseless. It is the ongoing battle between the herpes virus’ ability to stay safe in the nervous system and the body’s ability to mount a defense with antibodies that determines if symptoms will appear or not. In most people, the battle is a stalemate in terms of symptoms. Most people never have an outbreak or, if they do, they are so mild they are not noticed. In terms of keeping herpes under such control that the virus never exits the nervous system and sheds from the skin, the battle definitely tilts in favor of the virus.

It is in the ways herpes remains active in those who are infected, and able to spread to those who are not, that makes herpes such a difficult infection to control in terms of preventing outbreaks and preventing transmission.

However, control is possible—and that is the key.

Recurrences

While the immune system for the vast majority of people makes recurrences far less severe than a primary outbreak, periodic recurrences occur in genital HSV infections. They are also quite different in character.

First, since herpes is in the nerves of the patient, as the virus becomes more active and begins to travel down the nerve to the skin, a person may get symptoms that tell them an outbreak on the skin is about to appear.

They may get leg pain, back pain, a tingling sensation, burning, or itching. They might notice less specific symptoms like increased urination, but symptoms like fever or muscle aches are much less common than with an initial outbreak. These symptoms collectively are known as a prodrome. It is very variable but patients begin to recognize their pattern, their unique prodrome.

The outbreaks themselves are much milder. They tend to occur on one side of the body, to cover a smaller area, and are less painful. Swelling of the lymph nodes is uncommon and all the symptoms resolve much more quickly, lasting just 3–5 days.

Because herpes lives in the sacral plexus and nerves from that accumulation of nerves can reach out not just to the skin where the infection first started but to any area the nerves can go, recurrent outbreaks are not limited to the initial region it entered the body. They can occur on the buttocks, the thigh, or anywhere in the anal and genital regions. Recurrences in areas other than the genitals (e.g., thigh) have a similar pattern to those that occur on the genitals.

Also, while herpes tends to improve over time, people can get outbreaks at any point that their immune system is challenged. This can happen when another illness occurs, with cancer or cancer treatments, or with such simple changes as life stress due to divorce, moving, changing jobs, or death of a family member as examples. Excessive friction, sunburns, exhaustion, poor sleep patterns can also deplete a person’s immune system. In fact, anything that makes you less healthy or is a challenge to the system can make an outbreak more likely to occur. Over time patients not only recognize their prodromes, but they also recognize the circumstances associated with an outbreak.

In terms of the frequency of recurrences, genital HSV-2 recurs far more often than genital HSV-1. In the first year after primary infection with genital HSV-2, patients average about 5 recurrences. That drops by approximately 2 outbreaks per year in the following year. In the first year after a genital HSV-1 infection, the recurrence rate is just 1.3 outbreaks/year. That drops to a mere .7 outbreaks/year in the second year.

Those statistics can be misleading, however. Some patients have no outbreaks and others can experience 9 or more outbreaks per year. It is incredibly variable.

Remember, these statistics are all about symptoms. People often wonder why someone who had symptoms or who knew they had herpes, and who had outbreaks, would have sex when they had an outbreak and could transmit the disease. The problem is that herpes is shed from the skin even when people who get outbreaks feel perfectly well. Also, even the people who have no history of herpes, but in whom we know herpes is present (by blood tests), shedding of the virus from the skin occurs silently and the potential to transmit the virus exists.

This is called asymptomatic shedding and occurs in anyone who has herpes—whether they have symptoms or not.

What is asymptomatic shedding?

When a genital herpes outbreak occurs, the virus can be cultured for about 11 days with an initial outbreak and for about 4 days with a recurrence. Yet, the question is whether the virus can be found on the skin even in between outbreaks.

As it turns out, the herpes virus becomes active and can be “shed” from the skin on days when patients who have recurrences of genital HSV-2 feel perfectly well and in people who have only a positive blood test for HSV-2 and have never had an outbreak. In a pivotal study, women with symptomatic genital herpes Type 2 collected cultures from the cervix, vulva, and the rectum every day for over 3 months. They kept track of their symptoms with a daily diary, as well.

Shedding occurred without symptoms on 2% of the days in women with HSV-2 genital herpes. They shed more frequently in the 7 days prior to or following an outbreak. Shedding lasted fewer days when they were free of an outbreak but still accounted for one-third of all the days they shed the virus.

But what is the case for the over 80% of HSV-2-seropositive persons in the United States who are not aware that they are infected with HSV-2? Using a very advanced test called PCR (Polymerase Chain Reaction), samples from patients who had herpes type 2 but who had never had symptoms were compared to patients with genital HSV-2 who had symptoms in terms of shedding the herpes virus. The patients who had a history of symptoms shed the virus when they had no symptoms on 13% of days while those who only had HSV-2 by blood testing shed on 9% of days.

What is interesting is that the amount of virus shed during when no symptoms were present was essentially the same in both groups.

The precise rate of genital HSV-1 shedding in between outbreaks is not known but it is suspected it is far less than genital HSV-2 herpes. One small study using cultures, and not the much more sensitive PCR test, found shedding on only 1 out of every 200 days. Unfortunately, we know that HSV-1 also sheds asymptomatically from the mouth and in developed countries like the US, it is responsible for most of the new infections of genital herpes.

Some things are associated with a risk for shedding and some things are not. With genital herpes, time of the month in relation to menstruation, sexual orientation, and sex were not. Having a history of prior outbreaks, especially a history of more than 8 outbreaks/year, and being Caucasian, are a risk for an increase in asymptomatic genital shedding, as well as an increase in overall shedding (symptomatic and asymptomatic shedding combined).

Duration of asymptomatic shedding

Another factor associated with asymptomatic shedding is how long a patient has had the infection. The first year after acquiring genital HSV is the most difficult symptomatically—and it makes sense that would be the year with the most shedding of the virus. In one study, the shedding rate declined from one-quarter of days in the first year to 13% in the years that followed; however, the rate never seems to drop to 0. Even in people with HSV-2 who had the disease for 20 years, shedding still occurred on more than 10% of days.  

Herpes transmission

It has become clear that people who have antibodies in their blood to Herpes Type 2 shed the virus from their skin whether they have a history of outbreaks or not. Basically, if someone has antibodies to herpes, they are capable of transmitting the disease. In one study that followed the course of 144 couples in which one partner was infected and the other not infected, transmission occurred in 14 couples. In 9 of those cases, the person who transmitted the disease was completely free of symptoms—no outbreak, not even a prodrome (a warning that an attack was coming).

The other 5 transmissions happened when the person who was infected had a prodrome or developed lesions near the time the infection was transmitted. This makes sense. Shedding of the virus frequently occurs within 7 days of an outbreak, either before or after.

In another study of a vaccine that was totally ineffective 155 people acquired herpes from their partner. Only 57 people who became infected had any symptoms of herpes. That means 99 people acquired the infection and only knew about it because they were in a study and had a very accurate blood test that confirmed the infection. This is consistent with what we know, which is that the disease is most often transmitted by asymptomatic shedding (when people have no symptoms) and that the people who become infected most will have no symptoms (yet will be capable of transmitting the disease).

Some Important Information about Safe Sex

Although genital herpes is not generally a dangerous disease, most people want to do what they can to decrease the risks of transmitting the virus to their partner(s). There are a few methods that can help.

Using condoms: Condoms decrease the risks of transmitting STDs and double as contraception.

Taking suppressive therapy: Using valacyclovir daily to manage genital herpes decreases both outbreaks and asymptomatic shedding.

Asymptomatic shedding is the cause of most transmissions of herpes.

Abstaining from sex around outbreaks: Shedding is more common 7 days before and 7 days after outbreaks. Abstaining from sex for 7 days after an outbreak can decrease the risk of transmitting the herpes virus. Of course, it’s also important to abstain during your prodrome and an outbreak.

Lastly, you and your partners should always inform each other about STDs. Honesty is an important part of any sexual relationship. With treatment and a few precautions, genital herpes is highly manageable and the risk of transmitting it to a partner can be reduced significantly.

Herpes and pregnancy

In terms of transmission, women with herpes are often concerned most about transmitting the infection to their child during childbirth. They wonder how they can protect their baby if they could be shedding the virus and not have any symptoms. They wonder if they should take medication to reduce shedding the herpes virus; they fear they might need a C-section or even ask for one “just to be safe.” It is true that subclinical genital HSV shedding at the time of labor and delivery can infect a neonate and cause neonatal herpes, or herpes of the newborn—but it is exceedingly rare.

In one study, only 202 women out of more than 40,000 women who had genital HSV cultures at delivery were shedding herpes. Only a quarter of them had lesions; the rest were shedding subclinically. Out of those 40,000 women, only 10 newborns became infected but they all acquired herpes from mothers who were shedding asymptomatically.

The worst cases of newborn herpes happen when a mother becomes infected at the end of pregnancy and has not yet developed antibodies to herpes, antibodies she can share with a baby while in the womb, antibodies that go a long way toward protecting the newborn as it travels the birth canal.  

Herpes on other parts of the body

Herpes Whitlow

Herpes can infect skin on other areas of the body other than the mouth and genitals. You have learned how once the virus enters the body through the genitals and finds a home in the sacral plexus, it can travel back down any nerve in that cluster of nerves and reach the skin on the buttock, thigh, anus, rectum, or anywhere in the region of the groin.

However, the virus can enter the body any place that it lands where the skin might be more receptive because of a cut or tiny opening. This has been seen on the fingers and when herpes occurs on the finger, it is called a whitlow. This was most often seen in the past in dentist and dental healthcare providers.   

Herpes of the eye

Herpes can infect the eye and is called Herpes Simplex Keratitis. It most often involves only one eye and affects the cornea. It can cause pain, redness of the eye, tearing, light sensitivity, and a feeling like there is grit in the eye. Unlike herpes elsewhere, topical antiviral therapy is the treatment that is most effective when an outbreak occurs. It is noteworthy that viral shedding occurs in tears even when patients have no symptoms and that treatment with valacyclovir decreases the number of recurrences just like it does for infections elsewhere.

Treatment

Treatments for herpes (oral and genital) have been available for decades. The first highly effective medication was acyclovir. It proved effective in shortening outbreaks and was a boon at a time when so little seemed to work. In those early days having anything that could shorten an outbreak and even prevent them changed how people saw the disease.
Acyclovir worked in a very targeted way against Herpes DNA. In reality, there isn’t much more to a virus than its DNA and the proteins that cover it. To affect the virus, it is nearly essential to attack its DNA and that is what acyclovir does. DNA is made up of four repeating chemicals called nucleosides. How they are put together in a sequence determines everything, and we mean everything. It is the code of life. So, anything that stops a virus from making more of its DNA stops the virus from making more of itself. Acyclovir is almost an identical copy of one of those nucleosides (Guanine) that makes the code of life—almost an identical copy. One small change to the part of DNA that makes a chain grow makes it so acyclovir can be placed in the growing line of code while lacking the small structure needed so the next piece of code can be added. The chain terminates. Acyclovir is known as a synthetic nucleoside analog.

One limitation was that acyclovir was limited in how much could be absorbed through the intestines. Only 20% of it was ever used by the body. This limitation was overcome by creating something called a prodrug of acyclovir. Since Acyclovir is so poorly absorbed through the gut a mechanism was sought that would allow acyclovir to cross the bowel and get into the bloodstream.

By adding the amino acid l-valine to acyclovir, valacyclovir is created. With that extra amino acid, valacyclovir can be absorbed much better than acyclovir. Once in the body, the amino acid, valine, is severed from the valacyclovir and acyclovir can do what it does but now much more effectively since so much more of it is in the bloodstream. Twice a day or even once a day valacyclovir works better than 3–5 times/day of acyclovir. Another drug, famciclovir, uses the same concept to help penciclovir enter the body.


Different ways to use the medicine

There are any number of conditions where doctors will assure patients that no one knows their disease as the patient does. That is never truer than with herpes. Recurrences can be so subtle that patients can detect them even when clinicians may glance over them without noticing a thing. Most importantly, however, many patients learn to recognize the unique prodrome that warns them an outbreak may be coming. Patients can identify specific shifts in senses and feelings that seem trivial but are consistent signals that the virus is about to make itself known. It can be a dull ache in the back of the thigh, a small increase in the frequency of urination, an odd discomfort in the groin, a sensitivity of a particular patch of skin; it can be anything, but it is specific. While patients may not have prodromes or outbreaks, those living with herpes recurrences often can predict an outbreak with uncanny accuracy.

What follows is a general discussion of the different ways medication can be used with more specific dosing guidelines following the discussion.

Genital herpes

To treat or abort an outbreak when there are early symptoms (prodrome)

That kind of knowledge can allow some patients to use the medication to abort an outbreak. Whether oral or genital, people can take medication when their specific prodrome tells them an outbreak is on the horizon. The medication will stop an outbreak cold (often) and when it does not, it can shorten a milder outbreak than they might have had otherwise.

To prevent outbreaks when there are no symptoms but outbreaks are more likely

Patients also learn the life circumstances or behaviors that lead to more outbreaks. For some, a lack of sleep, increased alcohol, another illness, stress, too much sunlight, irritation, or anything, in fact, that can affect one’s immunity can spur an outbreak. That means that some patients can know not just when they feel an outbreak coming on but can know when they are more likely to have an outbreak due to their circumstances. They might be under stress, having more sex so more irritated, drinking a bit more than they should or missing sleep over an extended period. They will know that they should avoid those triggers and do their best to do so, but they also might want to take medication preventatively knowing they are more vulnerable at that time. Essentially they might take the medication for a week or two until the stress that is making them more susceptible to an outbreak has resolved.

To suppress outbreaks for an extended period

Another way patients can take the medication is when they know they absolutely would like to do all they can to reduce their chance of having an outbreak at a pivotal time. The classic example would be during a honeymoon but taking medication to suppress outbreaks on a daily basis can be prudent when going on vacation, starting a new job, in a new relationship, or at any time a patient feels it is how they want to approach their condition. And that’s the key.

How medication is used is completely in your hands. Learn everything you can and do not worry about using the medication in the way that suits you best. That may change as your circumstances change, or as the condition changes, or even as your mind changes.

To prevent transmission to an uninfected partner

One of the most important advances in herpes treatment came with the knowledge that transmission from an infected person to their uninfected partner could be reduced by the use of valacyclovir. Valacyclovir not only reduces the number of outbreaks a person experiences when using the medication every day but it reduces the number of days that someone sheds the virus asymptomatically. That results in fewer uninfected partners catching herpes. If a condom is worn and the medication used, the chances are reduced at least in half compared to using a condom alone.

Fewer outbreaks and fewer episodes of shedding means fewer people become infected.

Oral herpes

Abort an outbreak at the earliest sign or symptom (prodrome)

At that earliest sign, two tablets of valacyclovir 1000 mg for a total of 2000 mg is taken by mouth as the first dose. Then, 12 hours later, 2 tablets of 1000 mg of valacyclovir, for a total of 2000 mg, is taken as the second and final dose. The second dose can be taken sooner than 12 hours but never before 6 hours have passed. Adequate hydration makes sure the medicine is cleared through the kidneys as it should be.
The medication is only approved for two doses and there is no evidence in studies to advise the use of medication once lesions have appeared.


Specific dosing recommendations for Herpes

Treatment of initial genital outbreak

In patients with a first outbreak, the symptoms can be very severe. Multiple painful, genital ulcers can cover large areas of skin on both sides of the groin. They can experience burning during urination, fever, headaches, muscle and joint pain, and swollen, painful lymph nodes in the groin. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. For such patients, treatment is vital and can shorten the outbreak and ease the symptoms significantly. For the treatment of an initial episode of herpes genitalis, the FDA recommends taking valacyclovir 1 gram (1000 mg) twice a day for 10 days starting at the first sign or symptom of lesions, preferably within 48 hours of onset. The “CDC recommends this same dose for 7 to 10 days; treatment may be extended if healing is not complete after 10 days.” For HIV-infected patients, they recommend 1 gram (1000 mg) every 12 hours for 5 to 14 days.

Treatment of herpes labialis (i.e., cold sores)

To abort an outbreak of herpes on the lips or mouth the recommendation is that the patient should take 2 grams (2000 mg) of valacyclovir at the first sign or symptom of lesions and a second dose 12 hours later. The second dose should not be taken within 6 hours of the first. Those are the only doses recommended but patients sometimes take another dose or two of just 1 gram if they continue to have symptoms, or if a mild outbreak follows.

The PDR states that for HIV-infected patients, 1 gram (1000 mg) be taken every 12 hours for 5 to 10 days. Despite what some patients do when having continued symptoms the PDR states, “there are no data supporting the effectiveness of beginning treatment after the development of clinical signs of a cold sore (e.g., papule, vesicle, or ulcer).”

Treatment of recurrent herpes genitalis, including HIV-infected patients

To treat a recurrent outbreak, the FDA recommends using 500 mg of valacyclovir twice daily for 3 days starting at the first sign or symptom of lesions—preferably within 24 hours of onset. The CDC recommendation is identical but adds in the choice of using valacyclovir 1 g (1000 mg) one time a day for 5 days. Valacyclovir 1 g taken every 12 hours for 5 to 14 days is recommended by the HIV guidelines. The PDR also states, “There are no data supporting the effectiveness of beginning treatment more than 24 hours after the onset of symptoms.”

Treatment with suppressive therapy

The PDR states that for suppressive therapy of recurrent herpes genitalis in all patients valacyclovir 1 gram (1000 mg) should be taken once daily.

However, “in patients with a history of fewer than 9 recurrences per year, 500 mg once daily may be given.” They note that “500 mg once daily regimen appears to be less effective than other regimens in patients with 10 or more episodes per year.”

The PDR continues, “Safety and efficacy of valacyclovir beyond 1 year have not been established. In HIV-infected patients, 500 mg by mouth twice daily. The safety and efficacy of therapy beyond 6 months have not been established.”

To prevent transmission to a partner

The PDR recommends the infected partner take valacyclovir 500 mg once a day to decrease the risk of transmission to the uninfected partner “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Studies also did not run for an extended period so the PDR also states, “The efficacy of reducing transmission beyond 8 months in discordant couples has not been established.” This means they can only vouch for the data for an 8 month period of time.

An important point

Being diagnosed with genital herpes means you have acquired a sexually transmitted infection. If you have been diagnosed with genital herpes, you should have been checked for other sexually transmitted infections when you were diagnosed, including but not limited to HIV and syphilis. If you have not been, you should be and this is highly recommended.

Herpes can be transmitted to a partner despite best efforts like using a condom and using antiviral suppression therapy. Patients should never engage in sex without a condom or when they have an outbreak or a prodrome. Also, as asymptomatic shedding is more common in the seven days following an outbreak it is prudent to avoid sex during that period, as well.

Herpes and the risk of HIV infection

HSV-2 infection puts a person at greater risk of acquiring HIV infection—as much as 2 to 3 times the risk of those without herpes. The reason is that herpes creates ulcers that can make it easier for HIV to enter the body but general inflammation of the genitals is also responsible for the increased vulnerability to the infection. In women and men with positive blood tests for herpes, specialized testing shows signs of inflammation on the cervixes of women and under the foreskin of men. The specialized test is the finding of CD4 T cells. This is probably the result of the body’s immune system constantly fighting the herpes virus and it is seen even when no outbreak is evident. Of note, some CD4 T cells have been shown in the lab to be more susceptible to HIV infection than skin samples tested under the same conditions. Moreover, CD4 T cells hang around in inflamed tissue long after outbreaks heal.

This is another reason why STD testing is always the rule when beginning a new sexual relationship and why, whether having an outbreak or not, a condom is essential.

HSV-2 infection in HIV-infected individuals

HIV infected persons who have genital ulcers due to herpes are more likely to transmit HIV, as HIV is shed from these ulcers. Herpes itself may behave identically in the HIV positive individual but they are more likely to develop acyclovir resistance and to have outbreaks that last longer and appear different from typical cases.

HIV positivity is a complex condition that requires careful evaluation by experts in the field.

HSV vaccines

After years of frustration, there are reasons to be optimistic that a vaccine to prevent, or even to treat, herpes may be achievable. The development of a vaccine has been spurred by the realization that controlling herpes would be a major step in controlling the spread of herpes around the world, especially in places where medication is unavailable.

Herpevac vaccine did not prevent the acquisition of genital herpes Type 2 but it did show moderate success against catching herpes Type 1 and in making the disease milder if someone caught it. The study included 8000 participants but they were all women so the data may not be consistent in men. Nevertheless, the fact that a vaccine worked for HSV-1 is encouraging, especially since so many new cases of genital herpes are due to HSV-1. A number of vaccines are being tested to see if they could reduce the number of outbreaks and, most importantly, the amount of asymptomatic shedding. One vaccine in early testing, GEN-003, reduced shedding by 55%.

The advances are being made that give hope to anyone who has the infection or is the partner of someone with the HSV virus.


Valacyclovir details: PDR information

Read full prescribing information Here  

How can Valtrex be used

Treatment of herpes labialis (i.e., cold sores)

To abort an outbreak of herpes on the lips or mouth the recommendation is that the patient should take 2 grams of Valacyclovir at the first sign or symptom of lesions and a second dose 12 hours later. The second dose should not be taken within 6 hours of the first. Those are the only doses recommended but patients sometimes take another dose or two of just 1 gram if they continue to have symptoms, or if a mild outbreak follows.

The PDR states that for HIV-infected patients, 1 gram (1000 mg) be taken every 12 hours for 5 to 10 days. Despite what some patients do when having continued symptoms the PDR states, “there are no data supporting the effectiveness of beginning treatment after the development of clinical signs of a cold sore (e.g., papule, vesicle, or ulcer).”

Treatment of Initial genital outbreak

In patients with a first outbreak, the symptoms can be very severe.

Multiple painful, genital ulcers can cover large areas of skin on both sides of the groin. They can experience burning during urination, fever, headaches, muscle and joint pain, and swollen, painful lymph nodes in the groin. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. For such patients, treatment is vital and can shorten the outbreak and ease the symptoms significantly.

For the treatment of an initial episode of herpes genitalis, the FDA recommends taking valacyclovir 1 gram (1000 mg) twice a day for 10 days starting at the first sign or symptom of lesions, preferably within 48 hours of onset. The “CDC recommends this same dose for 7 to 10 days; treatment may be extended if healing is not complete after 10 days.”

For HIV-infected patients, they recommend 1 gram (1000 mg) every 12 hours for 5 to 14 days. The PDR also notes, “The efficacy of treatment with VALTREX, when initiated more than 72 hours after the onset of signs and symptoms, has not been established.”

Treatment of Recurrent Herpes Genitalis, Including HIV-infected Patients

To treat a recurrent outbreak, the FDA recommends using 500 mg of Valacyclovir twice daily for 3 days starting at the first sign or symptom of lesions—preferably within 24 hours of onset. The CDC recommendation is identical but adds in the choice of using Valacyclovir 1 gram (1000 mg) one time a day for 5 days. Valacyclovir 1 gram taken every 12 hours for 5 to 14 days is recommended by the HIV guidelines. The PDR also states, “There are no data supporting the effectiveness of beginning treatment more than 24 hours after the onset of symptoms.”

Treatment with Suppressive Therapy

The PDR states that for suppressive therapy of recurrent herpes genitalis in all patients Valacyclovir 1 gram (1000 mg) should be taken once daily.

However, “in patients with a history of fewer than 9 recurrences per year, 500 mg once daily may be given.” They note that “500 mg once daily regimen appears to be less effective than other regimens in patients with 10 or more episodes per year.”

The PDR continues, “Safety and efficacy of valacyclovir beyond 1 year have not been established. In HIV-infected patients, 500 mg PO twice daily. The safety and efficacy of therapy beyond 6 months have not been established.”

To Prevent Transmission to a Partner

The PDR recommends the infected partner take Valacyclovir 500 mg once a day to decrease the risk of transmission to the uninfected partner “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Studies also did not run for an extended period so the PDR also states, “The efficacy of reducing transmission beyond 8 months in discordant couples has not been established.” This means they can only vouch for the data for an 8 month period of time. The PDR also states, “The efficacy of VALTREX for the reduction of transmission of genital herpes in individuals with multiple partners and non-heterosexual couples has not been established. Safer sex practices should be used with suppressive therapy.” Centers for Disease Control 26 and Prevention [CDC] Sexually Transmitted Diseases Treatment Guidelines

Maximum Dose

In children 12 years and older, adolescents, adults, and the elderly, the maximum daily dose is 4 grams if given for just 1 day and 3 grams/day if given for more than 1 day.

In children 2 years to 11 years, 3 grams/day is the maximum dose.
Safety has not been established in neonates, infants, and children less than 2 years.

Dose adjustments should be made for those with kidney impairment or issues. Decreased doses are needed as kidney impairment slows the clearing from the body of valacyclovir. The degree of impairment determines the decrease in the dosage. The elderly may have decreased kidney function and adjustments should be considered in such cases.

No adjustment is needed, generally, in patients with liver impairment.

However, if you have a liver condition or impairment, inform your doctor.

Overdose: Valtrex is not usually harmful unless you take too much for several days. An excess of Valtrex can cause vomiting, kidney problems, confusion, agitation, feeling less aware, seeing things that aren’t there, or loss of consciousness. For severe symptoms, go direction to an emergency room. Otherwise, talk to your doctor or pharmacist if you take too much Valtrex. Take the medicine pack with you.


Contraindications and Precautions

Sensitivity or Allergies: Patients with sensitivity or an allergy to any of the following medications should not use Valacyclovir: Acyclovir, Famciclovir, ganciclovir, penciclovir, valacyclovir, or valganciclovir.

Kidney Issues: Dose adjustments should be made for those with kidney impairment or issues. Decreased doses are needed as kidney impairment slows the clearing from the body of valacyclovir. The degree of impairment determines the decrease in the dosage. The PDR states, “Acute renal failure and CNS (Nervous System) toxicity have been reported in patients with underlying renal (Kidney) dysfunction who have received inappropriately high doses of valacyclovir for their level of renal (Kidney) function. Patients receiving potentially nephrotoxic(Toxic to the Kidney) drugs together with valacyclovir may have an increased risk of renal dysfunction (impairment).”

The Elderly: The elderly are more likely to have impaired kidneys so they might not clear valacyclovir from their system as efficiently as they should. This can lead to inappropriately high levels of valacyclovir, which means the elderly may need lower doses of valacyclovir. The elderly are also more likely to experience neurological side effects, including: agitation, hallucinations, confusion, delirium, and other abnormalities of brain function termed encephalopathy.

Dehydration: When patients are dehydrated acyclovir can reform as a solid in the kidney leading to kidney damage. Patients should all remain well hydrated when taking valacyclovir.

Newborns, Infants, and children: Safety has not been established in neonates, infants, and children less than 2 years.

Pregnancy: While a registry that collected data on the 756 pregnancies of women exposed to acyclovir in the first trimester showed no greater occurrence of birth defects than occurs in the general population, the study size was too small to guarantee safety during pregnancy.

You should not take valacyclovir if you are pregnant or trying to become pregnant, unless recommended by your obstetrician/gynecologist or other healthcare provider.

Breastfeeding: The PDR states, “According to the manufacturer, valacyclovir should be administered to a nursing mother with caution and only when indicated. Although the American Academy of Pediatrics (AAP) has not specifically evaluated valacyclovir, systemic maternal acyclovir is considered to be usually compatible with breastfeeding…Consider the benefits of breastfeeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition.”

Driving or Using Machines: Valtrex can cause side effects that affect your ability to drive. Don’t drive or use machines unless you are sure you’re not affected.

Thrombotic Thrombocytopenic Purpura/Hemolytic Uremic Syndrome (TTP/HUS): TTP/HUS is a rare condition but has occurred in patients with advanced HIV disease and also in allogeneic bone marrow transplant and renal transplant recipients participating in clinical trials of VALTREX at doses of 8 grams per day. If any of these conditions apply to you, please inform your doctor and pharmacist.


Side Effects (Overview)

What follows is a summary and does not include every side effect possible. Please, read the package insert and report any side effects you experience whether on the list below or not.

Very Common (may affect more than 1 in 10 people): headache

Common (may affect up to 1 in 10 people): feeling sick, dizziness, vomiting, diarrhea, skin reaction after exposure to sunlight (photosensitivity), rash, itching (pruritus)

Uncommon (may affect up to 1 in 100 people), feeling confused, seeing or hearing things that aren’t there (hallucinations), feeling very drowsy, tremors, feeling agitated

These nervous system side effects usually occur in people with kidney problems, the elderly or in organ transplant patients taking high doses of 8 grams or more of Valtrex a day. They usually get better when Valtrex is stopped or the dose reduced.

Other Uncommon Side Effects: shortness of breath (dyspnea), stomach discomfort, rash, sometimes itchy, hive-like rash (urticaria), low back pain (kidney pain), blood in the urine (hematuria)

Uncommon Side Effects That May Show Up In Blood Tests: reduction in the number of blood platelets which are cells that help blood to clot (thrombocytopenia), reduction in the number of white blood cells (leukopenia), increase in substances produced by the liver  

Rare (may affect up to 1 in 1,000 people): unsteadiness when walking and lack of coordination (ataxia), slow, slurred speech (dysarthria), fits (convulsions), altered brain function (encephalopathy), unconsciousness (coma), confused or disturbed thoughts (delirium)

These nervous system side effects usually occur in people with kidney problems, the elderly or in organ transplant patients taking high doses of 8 grams or more of Valtrex a day. They usually get better when Valtrex is stopped or the dose reduced.

Other Rare Side Effects: kidney problems where you pass little or no urine.

Lastly, watch out for a severe allergy. It may be rare but it can be life-threatening so being aware of the symptoms is vital.

Severe allergic reactions (anaphylaxis): These are rare in people taking Valtrex. Anaphylaxis is marked by the rapid development of flushing, itchy skin rash, swelling of the lips, face, neck, and throat—causing difficulty in breathing (angioedema), fall in blood pressure leading to collapse. If any of these occur, get emergency treatment immediately


Drug interactions

Of Note: “When Valtrex is coadministered with antacids, cimetidine and/or probenecid, digoxin, or thiazide diuretics in patients with normal renal function, the effects are not considered to be of clinical significance. Therefore, when VALTREX is coadministered with these drugs in patients with normal renal function, no dosage adjustment is recommended.” (PDR)

Aprotinin: Aprotinin is cleared in the kidney as is Valacyclovir. Together, the risk to the kidney is increased.

Bictegravir; Emtricitabine; Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.  

Cimetidine: Cimetidine may slow how quickly valacyclovir is cleared out of the body through the kidney but no dosage adjustments are recommended for patients with normal renal function.

Cobicistat; Elvitegravir; Emtricitabine; Tenofovir
Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Cobicistat; Elvitegravir; Emtricitabine; Tenofovir Disoproxil Fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Efavirenz; Emtricitabine; Tenofovir: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Rilpivirine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Rilpivirine; Tenofovir disoproxil fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Tenofovir disoproxil fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Entecavir: Entecavir can affect kidney function and should be used cautiously with valacyclovir.

Fosphenytoin: Phenytoin and fosphenytoin are anti-seizure medications. The addition of valacyclovir to phenytoin may lead to a clinically significant decrease in phenytoin serum concentrations and loss of seizure control. Adjustments in phenytoin or fosphenytoin dosing should be considered if Valacyclovir is added or stopped when a patient is on either phenytoin and fosphenytoin.

Hyaluronidase, Recombinant; Immune Globulin: Immune Globulin (IG) products can damage the kidney. If they take any other drug that can affect the kidney, including valacyclovir, the dose of IG may need to be lowered and the infusion rate slowed.

Immune Globulin IV, IVIG, IGIV: Immune Globulin (IG) products can damage the kidney. If they take any other drug that can affect the kidney, including valacyclovir, the dose of IG may need to be lowered and the infusion rate slowed.

Lamivudine; Tenofovir Disoproxil Fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Measles Virus; Mumps Virus; Rubella Virus; Varicella Virus Vaccine, Live: (Major) If possible, discontinue valacyclovir at least 24 hours before administration of the varicella-zoster virus vaccine, live. Also, do not administer valacyclovir for at least 14 days after vaccination. The medication might have the unintended effect of diminishing the protective benefit of the vaccine.

Mycophenolate: (Moderate) Valacyclovir, when added to MMF, cyclosporine, and prednisolone caused a decrease in White Blood Cells, called neutropenia. When this combination must be used careful blood monitoring is recommended.

Phenytoin: Phenytoin is an anti-seizure medication. The addition of valacyclovir to phenytoin may lead to a clinically significant decrease in phenytoin levels and loss of seizure control. Adjustments in phenytoin dosing should be considered if valacyclovir therapy is added or discontinued.

Probenecid: Probenecid can reduce the kidney’s clearance of valacyclovir causing an increase in the blood level of valacyclovir. In the absence of a decrease in renal function, no dose adjustment is needed.

Talimogene Laherparepvec: “Consider the risks and benefits of treatment with talimogene laherparepvec before administering acyclovir or other antivirals to prevent or manage herpetic infection. Talimogene laherparepvec is a live, attenuated (lessened capacity to cause disease) herpes simplex virus that is sensitive to acyclovir; coadministration with antiviral agents may cause a decrease in efficacy.”

Telbivudine: Valacyclovir can affect kidney function. Since telbivudine is also cleared by the kidney, monitoring kidney function before and during telbivudine treatment is recommended.

Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Tenofovir, PMPA: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Varicella-Zoster Virus Vaccine, Live: (Major) If possible, discontinue valacyclovir at least 24 hours before administration of the varicella-zoster virus vaccine, live. Also, do not administer valacyclovir for at least 14 days after vaccination. The medication might have the unintended effect of diminishing the protective benefit of the vaccine.


Genital Herpes Treatment Plan

Valacyclovir 1000 mg

Daily therapy to suppress outbreaks and reduce risk of transmission to an uninfected partner

Be sure to take your time and read everything below. It is essential for you to understand the potential risks and benefits of treatment. Please do not hesitate to reach out to our medical support team if you have ANY questions.

Overview

Herpes is not simply an infection. Too many people suffer silently, fearing to even reach out to their healthcare providers. There are few conditions where a person’s care is so dependent on their participation. Time must be dedicated to education and to formulating a plan that is under your control.

Medication is available—and it works extremely well—but how it is used and when it is used can never be more precisely applied than when a person uses the guidance of experts to craft a personalized plan.

With the education we provide below, you will be able to decide how best to utilize all the tools at your disposal. The key is to learn as much as you can and make informed decisions. The information below will help you gain a level of independence you may not have realized is possible.

Read carefully your healthcare professional’s personalized treatment plan and all the material provided. It may well provide some new information that will be helpful to you. Nothing is sugar coated because we feel you deserve the information you need to live your life the way you want. Read it all along with the package insert and the information in the Prescribers’ Digital Reference (PDR).

One important point is that if the medicine prescribed does not improve your condition (now or at any time), or if your symptoms at any point in the future are not completely typical of your usual outbreak, then you must be seen by a physician in person and checked for other conditions.

Lastly, the plan your personal doctor or nurse practitioner has provided is just the initial plan.

You may well choose a different one after reading more about other options or, in 6 months, your life circumstances may have changed and a different plan may suit you better. Just reach out to us.  

We are here to make your life better, not to give you more challenges in finding the care you need. And don’t forget, contact us if you need us.


Your treatment plan

Your doctor or nurse practitioner has reviewed your medical information and has prescribed valacyclovir 1000 mg to treat genital herpes. Valacyclovir has been approved to treat genital herpes in several ways. It can be taken to lessen the severity of an initial outbreak, to abort outbreaks when someone feels telltale signs (the prodrome) that tells them an outbreak is about to happen, or to prevent outbreaks and reduce the risk of transmitting herpes by taking one pill every day.

Your doctor or nurse practitioner has written a prescription for valacyclovir to be used to limit outbreaks and reduce the risk of transmitting herpes by taking one pill every day. One of the most important advances in herpes treatment came with the knowledge that transmission from an infected person to their uninfected partner could be reduced by the use of daily valacyclovir.

Valacyclovir not only reduces the number of outbreaks a person experiences when using the medication every day but it reduces the number of days that someone sheds the virus asymptomatically (shedding of the herpes virus from normal skin when a person feels completely well).

Asymptomatic shedding is how most transmissions occur. Reducing asymptomatic shedding results in fewer uninfected partners catching herpes. If a condom is worn and the medication used, the chances are cut in half compared to using a condom alone. Fewer outbreaks and fewer episodes of asymptomatic shedding means fewer people become infected.

In one study that followed the course of 144 couples in which one partner was infected and the other not infected, transmission occurred in 14 couples. In 9 of those cases, the person who transmitted the disease was completely free of symptoms—no outbreak, not even a prodrome (a warning that an attack was coming). The other 5 transmissions happened when the person who was infected had a prodrome or developed lesions near the time the infection was transmitted. As noted, the key to preventing transmission isn’t just limiting outbreaks but reducing asymptomatic shedding. Valacyclovir, taken daily, reduces the number of outbreaks a person experiences and the number of days that someone sheds the virus asymptomatically.

To reduce the number of outbreaks an infected person experiences and to reduce the risk of transmission to an uninfected partner (by up to 50%), the PDR recommends the infected partner take valacyclovir 500 mg/day. The study measured results “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Also, the study ran only for 8 months.


Valacyclovir FAQs

An important point

Herpes can be transmitted to a partner despite best efforts like using a condom and using antiviral suppression therapy. Patients should never engage in sex without a condom or when they have an outbreak or a prodrome. Also, as asymptomatic shedding is more common in the seven days following an outbreak, it is prudent to avoid sex during that period, as well.

The following information (Preventing future outbreaks and Other ways to use the medication) is relevant if at some point you decide to go off suppression therapy and choose to try to abort outbreaks and use suppression therapy in some specific situations only.

Preventing Future Outbreaks

If you are just trying to abort outbreaks, make a note of everything you think may have made you more susceptible to an outbreak. Was there more irritation to the area? Did anything affect your immunity like another infection (e.g., a cold) or did you change something in your lifestyle that could have weakened your immune system (e.g., lack of sleep, stress, increased alcohol consumption)? No change is too small to note.

This is important because it will help you maintain the patterns that make herpes less likely to appear. For you, it may be a lack of sleep over a few consecutive nights that spurs most outbreaks. It might be excessive sun exposure or too much alcohol consumption. It could happen only when you are sick or just run down. Whatever it might be, over time you may come to recognize the issues and make changes that reduce the frequency of outbreaks.

Other ways to use the medication

Some patients ask if they can take the medication to prevent an outbreak when they least want to have one. The classic examples are a bride or groom on their wedding day, when first engaging in sex with a new partner, or going on that long planned and much-needed vacation with your partner or spouse. You don’t need to be getting married or about to rendezvous for a much-anticipated tryst to want to prevent a herpes outbreak at particular times. It could be that an outbreak would be uncomfortable during the holidays or at any time you determine.

That is what we mean when we say you have control. At one point in life, a person may choose to abort outbreaks when they feel them coming on, at another point they might choose suppression therapy, but that may change, too. Circumstances change; only you will be able to know how your circumstances affect which option you choose. That is why learning all you can is so important. It gives you independence. Things change and how you choose to use valacyclovir may change.

One other fact is worth noting. You have been prescribed 30 pills of valacyclovir 1000 mg every month. You should always have medication on hand, so renew your prescription well before you run out. As long as valacyclovir proves effective and you are free of significant side effects, you should never have to worry about having access to what you need.

You can always drop a note to your doctor or nurse practitioner, the pharmacist, or the care team with any questions, issues, or changes you want to consider. There is no “extra” visit charge or cost if you just want to ask questions and learn more about how you can manage your condition.

Lastly, if you would like to switch to intermittent therapy, you can always hold back on getting more valacyclovir delivered.

This may be a new situation for you but as long as the medication works without causing you difficulties of any sort, you are in control.    


Herpes: condition overview

A wealth of herpes information (oral and genital)

In the United States, genital herpes caused by HSV-2 (Herpes Simplex Virus Type 2) is extremely common and the most frequent cause of genital ulcer disease. Yet, the people who have symptoms represent the smallest number of people infected. In fact, 80% of the people who have genital herpes do not know it. That means for every person with symptoms who takes the step to be treated as you have, there are 4 people who are infected but totally unaware. 

Much of what we know about herpes is different from what people learned during the height of the “fear” an infection caused when no treatment was available.

That is what we must change. We want you to learn the facts about herpes so you do not become a victim of the myths. Also, only by understanding the disease will you be able to work with your doctor or nurse practitioner to craft the right treatment plan for you as your life evolves. What suits you today may not in 6 months or in 5 years. If you understand herpes, and how medications can work in different circumstances, you will be able to take control of your life in ways you might not have known were possible.

Lastly, if you read the next few pages carefully (though seemingly simply) you probably will know more helpful facts about herpes than many doctors.

What is herpes?

Herpes is a virus. The herpes virus can barely be considered alive. It is little more than a strand of DNA (deoxyribonucleic acid), the code of life, safely hidden inside a shell of protein. On its own, a herpes virus cannot reproduce or do much of anything—until it infects us. When the herpes virus comes in contact with areas that are receptive, like the genitals or mouth, the virus invades the epithelial cells (skin cells) in that region.

Then, the DNA of the herpes virus is released into the skin cell. At that point, it quite literally takes over.

It directs the cell to make more herpes virus and, when they have made enough copies to damage the cell so severely that it bursts, millions of the newly formed viruses are released infecting more cells, eventually causing an ulcer.

That is what people can see and feel, but a good deal more than that happens. While it is infecting skin cells and causing pain and ulcers, it also begins to attack the nerve cells in the same area. When the virus enters the nerve cell, it not only reproduces but it moves up the nerve to a bundle of nerves in the back called the sacral plexus. Once it is in the nerves, it is essentially protected from being attacked by the body’s immune system. Nerve cells can never be replaced.

That is why when nerves in the spine are damaged people become paralyzed. Since nerves cannot reproduce themselves easily, the body is careful not to bombard them with all the weapons it has to clear infections. All the inflammation that is caused by the battle to eliminate infections elsewhere would be disastrous if that occurred with nerves.

There is no sense clearing an infection if nerve cells that could never be replaced are destroyed in the process.

The herpes virus is essentially protected from an attack by our immune system as long as it hides out in the nerves of the sacral plexus when it affects the genitals, or the “dorsal root ganglion” (a cluster of nerves in the neck region of the spine) when it infects the mouth.

Unfortunately, that leaves the virus in a perfect position to sneak back out when the immune system is suppressed in any way. That is how the virus is able to cause recurrent infections, especially during times of stress, illness, or any condition or circumstance that makes our immune system less vigilant. We will discuss that in detail later.

How common are HSV-1 and HSV-2?

Worldwide (in 2012) nearly one half billion people were infected with HSV-2 between the ages of 15 and 49—and the number rises with age and the number of life partners. More women than men have herpes (14.8% versus 8% global prevalence, respectively). In the US, the number of people infected has been dropping, but the news isn’t all good. The percentage of people with a positive blood test for HSV-2 has declined. In people age 14 to 49, 21% were positive in the early 90s. By 2010, that number dropped to about 16%. Unfortunately, the improvement has been seen mostly in the white population “with stable rates in black populations, resulting in worsening racial disparities such that for every one white man, four black men are infected, with similar ratios for women.”

The reasons for this might be that access to information, education—and the medication that can reduce the risk of transmission—has not been made available to all equally.

In the United States, the prevalence of HSV-1, which accounts for the vast majority of oral herpes, has dropped 29% among 14–19 year olds, from approximately 42% to 30%, over the past 30 years. As a result, adolescents and young adults may experience their first exposure to HSV-1 with the initiation of sexual activity, including oral sex.

How can it be that some people do not have symptoms of oral herpes and of genital herpes?

It is vital to understand that 80% of people with an infection have no symptoms they recognize. For those who experience severe or frequent outbreaks, that is difficult to understand. There are multiple explanations.

The first one is related to how we physicians first described the disease.

Before there were elegant tests to culture herpes, or to test lesions for signs of herpes DNA, and before accurate blood tests out of the University of Seattle, herpes was described by doctors by what they saw—and only by what they saw. This meant that only people who had visible lesions (sores) were diagnosed and doctors thought that all those who had herpes had symptoms. It turns out that patients with severe disease were just the tip of the iceberg, but doctors didn’t realize that. Unfortunately, too many myths and outright falsehoods became “common knowledge.”

The fact is most people have an immune response that holds the disease at bay—in terms of causing symptoms, that is. They are still infected and, as we will learn later, still able to transmit the disease, but the symptoms either do not occur or are so subtle that they go unnoticed or undiagnosed. Herpes can cause such minor complaints that they are ignored.

Herpes can appear as little more than an irritation or tiny erosion. A lesion tucked away in the genital region can be so small that it cannot be seen without doing some major stretching before trying or using a magnifying lens. Or the sore is in a place that is completely inaccessible to viewing (e.g., the anus, the groin, the vagina, or hidden within a small skin fold).

Also, the symptoms may disappear so quickly that they are dismissed, or never seen in time by a doctor, or a doctor does not recognize how minor herpes can be even when seen in time. This is true of oral and genital herpes.

Nevertheless, the people who have what we call asymptomatic herpes can still transmit the disease. They can do this because they can still “shed” the virus from the skin even without having a sore or a symptom that they recognize as herpes. Asymptomatic shedding occurs from the mouth in those with oral herpes, from the anal and genital region in those with genital herpes, and even from tears in people who have had herpes of the eye. The section on asymptomatic shedding explains this in detail.


Clinical manifestations of Herpes

Clinical manifestations of Oral HSV infection

Classically, the oral symptoms are familiar to most people who either have had an outbreak or seen them in others. The initial symptoms are a sense of tingling or itching that can occur 24 hours before any lesions appear.

The first visible symptoms are redness, followed by the forming of a papule or elevation of the skin affected (usually on the very edge of the lips where they transition to the skin of the face). Then, the small roundish elevations become filled with fluid (a vesicle), which can burst and reveal a small ulcer or divet in the skin. This will be painful and ooze fluid and within just a few days heal, usually without a scar. These lesions do not form solely on the edge of the lip. They can form anywhere on the face, particularly a region between the nose and lips and out to the first fold on the cheek called the “nasolabial fold.”

The virus hides in the nerves in the back of the neck called the dorsal root ganglion. When HSV-1 reactivates and comes out of that nerve it can take a route other than to the edge of the lip. It can even cause an outbreak on the back of the neck but, most often, it is the lips where outbreaks will recur.

Oral symptoms can be more easily seen but often are not understood to be related to herpes. Minor irritations that disappear quickly might easily be dismissed as a simple cut or reaction to spicy food.

Other people might mistakenly consider unrelated irritations to be herpes on the mouth when they are not. For example, canker sores that occur inside the mouth and can recur just like herpes are sometimes misdiagnosed by patients and doctors alike as being due to the HSV-1 virus when, in reality, it is possibly an immune reaction and not an infection. The same sometimes occurs with irritation on the corners of the mouth, called angular cheilitis or perleche. This can be idiopathic, meaning it has no known cause, or can be due to the buildup of fluid at the corners of the mouth. It is a perfect spot to nurture growths of yeast or fungus (think Candida) and the irritation can even lead to small cuts and sores.

We always advise patients to confirm their diagnosis if recurrent oral lesions are completely unresponsive to herpes antiviral therapy.  

Clinical manifestations of Genital HSV infection

HSV-2 is the leading cause of genital ulcers in the United States and throughout the world. We know that because a very accurate test called a PCR test, which is far more sensitive than a culture, has found herpes in 60% of genital ulcers. Remember that most people with herpes found by blood testing have had no symptoms of herpes. What follows is a description of herpes as it appears in those who experience symptoms, in people who are seen by doctors with lesions.

First outbreak or primary outbreak

For patients who have symptoms, the first outbreak can be the worst. During primary infection, patients may experience multiple genital ulcers that can cover larger areas of skin. It can be on both sides of the groin and be quite painful. They often experience burning during urination in addition to the local pain. They can have fever, headaches, muscle and joint pain, and their lymph nodes in the groin can be swollen and painful as well. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. Therapy can shorten that period significantly.

The reason an initial outbreak can be so severe is that there are no antibodies to herpes when the virus first enters the body, (though a prior history of herpes type 1 can give someone antibodies that work a little bit to fight herpes type 2 and may make an outbreak a bit less severe.)
An initial outbreak can be caused by Herpes 1 and in developed countries like the US, the most common cause of an initial attack of herpes is actually herpes 1. Most people do not realize that someone infected with oral herpes from type 1 can perform fellatio or cunnilingus on a partner and transmit herpes 1 from their mouth to their partner’s genitals. If you think about it, why not? The problem is that many people don’t know they have oral herpes. It may be easier to see but not many people remember the cold sore they had when they were 3. Also, while most people in the past acquired herpes on the mouth as a child when exchanging saliva with other children who were infected, that has not been happening with anywhere near the same frequency. The rate of infection with Herpes 1 is lower now than at any time in the past. In the United States, HSV-1 has dropped 29% among 14–19 year olds, from 42.6% to 30.1% over the last 3 decades.

That means that adolescents who engage in sex are more likely to be exposed to Herpes 1 for the first time when having oral or vaginal sex. Changes in sexual practices have also made the transmission more likely.

Fellatio (a “blow job”) and cunnilingus (“going down”) are much more frequently practiced at younger ages and with fewer restraints imposed by cultural or social forces. That has made herpes 1 the most common cause of first outbreaks in developed countries. Nevertheless, herpes 1 and herpes 2 on the genitals do not behave identically in terms of recurrences. Herpes 1 is more “at home” in the oral region and has developed ways to deal with that environment. When on the genitals, it can cause all the same symptoms and can still be transmitted, but it has a milder course than when herpes 2 infects the genitals. This is discussed more in the section on recurrences.

Understanding how herpes can remain in the body yet be kept at bay to some degree is pivotal. Herpes enters the sacral plexus of nerves during an initial infection. As discussed above, the virus remains safe from attack by antibodies and the immune system as long as it is tucked away in the nervous system. That little trick, entering the nervous system where it neither damages the nerves nor can be attacked, makes herpes a particularly stubborn infection. It can slide down the nerves that go from the sacral plexus to the skin and cause more outbreaks in the future. These are called recurrences.

Recurrences occur in a milder version than the initial outbreak because the body is not completely defenseless. It is the ongoing battle between the herpes virus’ ability to stay safe in the nervous system and the body’s ability to mount a defense with antibodies that determines if symptoms will appear or not. In most people, the battle is a stalemate in terms of symptoms. Most people never have an outbreak or, if they do, they are so mild they are not noticed. In terms of keeping herpes under such control that the virus never exits the nervous system and sheds from the skin, the battle definitely tilts in favor of the virus.

It is in the ways herpes remains active in those who are infected, and able to spread to those who are not, that makes herpes such a difficult infection to control in terms of preventing outbreaks and preventing transmission.

However, control is possible—and that is the key.

Recurrences

While the immune system for the vast majority of people makes recurrences far less severe than a primary outbreak, periodic recurrences occur in genital HSV infections. They are also quite different in character.

First, since herpes is in the nerves of the patient, as the virus becomes more active and begins to travel down the nerve to the skin, a person may get symptoms that tell them an outbreak on the skin is about to appear.

They may get leg pain, back pain, a tingling sensation, burning, or itching. They might notice less specific symptoms like increased urination, but symptoms like fever or muscle aches are much less common than with an initial outbreak. These symptoms collectively are known as a prodrome. It is very variable but patients begin to recognize their pattern, their unique prodrome.

The outbreaks themselves are much milder. They tend to occur on one side of the body, to cover a smaller area, and are less painful. Swelling of the lymph nodes is uncommon and all the symptoms resolve much more quickly, lasting just 3–5 days.

Because herpes lives in the sacral plexus and nerves from that accumulation of nerves can reach out not just to the skin where the infection first started but to any area the nerves can go, recurrent outbreaks are not limited to the initial region it entered the body. They can occur on the buttocks, the thigh, or anywhere in the anal and genital regions. Recurrences in areas other than the genitals (e.g., thigh) have a similar pattern to those that occur on the genitals.

Also, while herpes tends to improve over time, people can get outbreaks at any point that their immune system is challenged. This can happen when another illness occurs, with cancer or cancer treatments, or with such simple changes as life stress due to divorce, moving, changing jobs, or death of a family member as examples. Excessive friction, sunburns, exhaustion, poor sleep patterns can also deplete a person’s immune system. In fact, anything that makes you less healthy or is a challenge to the system can make an outbreak more likely to occur. Over time patients not only recognize their prodromes, but they also recognize the circumstances associated with an outbreak.

In terms of the frequency of recurrences, genital HSV-2 recurs far more often than genital HSV-1. In the first year after primary infection with genital HSV-2, patients average about 5 recurrences. That drops by approximately 2 outbreaks per year in the following year. In the first year after a genital HSV-1 infection, the recurrence rate is just 1.3 outbreaks/year. That drops to a mere .7 outbreaks/year in the second year.

Those statistics can be misleading, however. Some patients have no outbreaks and others can experience 9 or more outbreaks per year. It is incredibly variable.

Remember, these statistics are all about symptoms. People often wonder why someone who had symptoms or who knew they had herpes, and who had outbreaks, would have sex when they had an outbreak and could transmit the disease. The problem is that herpes is shed from the skin even when people who get outbreaks feel perfectly well. Also, even the people who have no history of herpes, but in whom we know herpes is present (by blood tests), shedding of the virus from the skin occurs silently and the potential to transmit the virus exists.

This is called asymptomatic shedding and occurs in anyone who has herpes—whether they have symptoms or not.

What is asymptomatic shedding?

When a genital herpes outbreak occurs, the virus can be cultured for about 11 days with an initial outbreak and for about 4 days with a recurrence. Yet, the question is whether the virus can be found on the skin even in between outbreaks.

As it turns out, the herpes virus becomes active and can be “shed” from the skin on days when patients who have recurrences of genital HSV-2 feel perfectly well and in people who have only a positive blood test for HSV-2 and have never had an outbreak. In a pivotal study, women with symptomatic genital herpes Type 2 collected cultures from the cervix, vulva, and the rectum every day for over 3 months. They kept track of their symptoms with a daily diary, as well.

Shedding occurred without symptoms on 2% of the days in women with HSV-2 genital herpes. They shed more frequently in the 7 days prior to or following an outbreak. Shedding lasted fewer days when they were free of an outbreak but still accounted for one-third of all the days they shed the virus.

But what is the case for the over 80% of HSV-2-seropositive persons in the United States who are not aware that they are infected with HSV-2? Using a very advanced test called PCR (Polymerase Chain Reaction), samples from patients who had herpes type 2 but who had never had symptoms were compared to patients with genital HSV-2 who had symptoms in terms of shedding the herpes virus. The patients who had a history of symptoms shed the virus when they had no symptoms on 13% of days while those who only had HSV-2 by blood testing shed on 9% of days.

What is interesting is that the amount of virus shed during when no symptoms were present was essentially the same in both groups.

The precise rate of genital HSV-1 shedding in between outbreaks is not known but it is suspected it is far less than genital HSV-2 herpes. One small study using cultures, and not the much more sensitive PCR test, found shedding on only 1 out of every 200 days. Unfortunately, we know that HSV-1 also sheds asymptomatically from the mouth and in developed countries like the US, it is responsible for most of the new infections of genital herpes.

Some things are associated with a risk for shedding and some things are not. With genital herpes, time of the month in relation to menstruation, sexual orientation, and sex were not. Having a history of prior outbreaks, especially a history of more than 8 outbreaks/year, and being Caucasian, are a risk for an increase in asymptomatic genital shedding, as well as an increase in overall shedding (symptomatic and asymptomatic shedding combined).

Duration of asymptomatic shedding

Another factor associated with asymptomatic shedding is how long a patient has had the infection. The first year after acquiring genital HSV is the most difficult symptomatically—and it makes sense that would be the year with the most shedding of the virus. In one study, the shedding rate declined from one-quarter of days in the first year to 13% in the years that followed; however, the rate never seems to drop to 0. Even in people with HSV-2 who had the disease for 20 years, shedding still occurred on more than 10% of days.  

Herpes transmission

It has become clear that people who have antibodies in their blood to Herpes Type 2 shed the virus from their skin whether they have a history of outbreaks or not. Basically, if someone has antibodies to herpes, they are capable of transmitting the disease. In one study that followed the course of 144 couples in which one partner was infected and the other not infected, transmission occurred in 14 couples. In 9 of those cases, the person who transmitted the disease was completely free of symptoms—no outbreak, not even a prodrome (a warning that an attack was coming).

The other 5 transmissions happened when the person who was infected had a prodrome or developed lesions near the time the infection was transmitted. This makes sense. Shedding of the virus frequently occurs within 7 days of an outbreak, either before or after.

In another study of a vaccine that was totally ineffective 155 people acquired herpes from their partner. Only 57 people who became infected had any symptoms of herpes. That means 99 people acquired the infection and only knew about it because they were in a study and had a very accurate blood test that confirmed the infection. This is consistent with what we know, which is that the disease is most often transmitted by asymptomatic shedding (when people have no symptoms) and that the people who become infected most will have no symptoms (yet will be capable of transmitting the disease).

Some Important Information about Safe Sex

Although genital herpes is not generally a dangerous disease, most people want to do what they can to decrease the risks of transmitting the virus to their partner(s). There are a few methods that can help.

Using condoms: Condoms decrease the risks of transmitting STDs and double as contraception.

Taking suppressive therapy: Using valacyclovir daily to manage genital herpes decreases both outbreaks and asymptomatic shedding.

Asymptomatic shedding is the cause of most transmissions of herpes.

Abstaining from sex around outbreaks: Shedding is more common 7 days before and 7 days after outbreaks. Abstaining from sex for 7 days after an outbreak can decrease the risk of transmitting the herpes virus. Of course, it’s also important to abstain during your prodrome and an outbreak.

Lastly, you and your partners should always inform each other about STDs. Honesty is an important part of any sexual relationship. With treatment and a few precautions, genital herpes is highly manageable and the risk of transmitting it to a partner can be reduced significantly.

Herpes and pregnancy

In terms of transmission, women with herpes are often concerned most about transmitting the infection to their child during childbirth. They wonder how they can protect their baby if they could be shedding the virus and not have any symptoms. They wonder if they should take medication to reduce shedding the herpes virus; they fear they might need a C-section or even ask for one “just to be safe.” It is true that subclinical genital HSV shedding at the time of labor and delivery can infect a neonate and cause neonatal herpes, or herpes of the newborn—but it is exceedingly rare.

In one study, only 202 women out of more than 40,000 women who had genital HSV cultures at delivery were shedding herpes. Only a quarter of them had lesions; the rest were shedding subclinically. Out of those 40,000 women, only 10 newborns became infected but they all acquired herpes from mothers who were shedding asymptomatically.

The worst cases of newborn herpes happen when a mother becomes infected at the end of pregnancy and has not yet developed antibodies to herpes, antibodies she can share with a baby while in the womb, antibodies that go a long way toward protecting the newborn as it travels the birth canal.  

Herpes on other parts of the body

Herpes Whitlow

Herpes can infect skin on other areas of the body other than the mouth and genitals. You have learned how once the virus enters the body through the genitals and finds a home in the sacral plexus, it can travel back down any nerve in that cluster of nerves and reach the skin on the buttock, thigh, anus, rectum, or anywhere in the region of the groin.

However, the virus can enter the body any place that it lands where the skin might be more receptive because of a cut or tiny opening. This has been seen on the fingers and when herpes occurs on the finger, it is called a whitlow. This was most often seen in the past in dentist and dental healthcare providers.   

Herpes of the eye

Herpes can infect the eye and is called Herpes Simplex Keratitis. It most often involves only one eye and affects the cornea. It can cause pain, redness of the eye, tearing, light sensitivity, and a feeling like there is grit in the eye. Unlike herpes elsewhere, topical antiviral therapy is the treatment that is most effective when an outbreak occurs. It is noteworthy that viral shedding occurs in tears even when patients have no symptoms and that treatment with valacyclovir decreases the number of recurrences just like it does for infections elsewhere.

Treatment

Treatments for herpes (oral and genital) have been available for decades. The first highly effective medication was acyclovir. It proved effective in shortening outbreaks and was a boon at a time when so little seemed to work. In those early days having anything that could shorten an outbreak and even prevent them changed how people saw the disease.
Acyclovir worked in a very targeted way against Herpes DNA. In reality, there isn’t much more to a virus than its DNA and the proteins that cover it. To affect the virus, it is nearly essential to attack its DNA and that is what acyclovir does. DNA is made up of four repeating chemicals called nucleosides. How they are put together in a sequence determines everything, and we mean everything. It is the code of life. So, anything that stops a virus from making more of its DNA stops the virus from making more of itself. Acyclovir is almost an identical copy of one of those nucleosides (Guanine) that makes the code of life—almost an identical copy. One small change to the part of DNA that makes a chain grow makes it so acyclovir can be placed in the growing line of code while lacking the small structure needed so the next piece of code can be added. The chain terminates. Acyclovir is known as a synthetic nucleoside analog.


One limitation was that acyclovir was limited in how much could be absorbed through the intestines. Only 20% of it was ever used by the body. This limitation was overcome by creating something called a prodrug of acyclovir. Since Acyclovir is so poorly absorbed through the gut a mechanism was sought that would allow acyclovir to cross the bowel and get into the bloodstream.

By adding the amino acid l-valine to acyclovir, valacyclovir is created. With that extra amino acid, valacyclovir can be absorbed much better than acyclovir. Once in the body, the amino acid, valine, is severed from the valacyclovir and acyclovir can do what it does but now much more effectively since so much more of it is in the bloodstream. Twice a day or even once a day valacyclovir works better than 3–5 times/day of acyclovir. Another drug, famciclovir, uses the same concept to help penciclovir enter the body.


Different ways to use the medicine

There are any number of conditions where doctors will assure patients that no one knows their disease as the patient does. That is never truer than with herpes. Recurrences can be so subtle that patients can detect them even when clinicians may glance over them without noticing a thing. Most importantly, however, many patients learn to recognize the unique prodrome that warns them an outbreak may be coming. Patients can identify specific shifts in senses and feelings that seem trivial but are consistent signals that the virus is about to make itself known. It can be a dull ache in the back of the thigh, a small increase in the frequency of urination, an odd discomfort in the groin, a sensitivity of a particular patch of skin; it can be anything, but it is specific. While patients may not have prodromes or outbreaks, those living with herpes recurrences often can predict an outbreak with uncanny accuracy.

What follows is a general discussion of the different ways medication can be used with more specific dosing guidelines following the discussion.

Genital herpes

To treat or abort an outbreak when there are early symptoms (prodrome)

That kind of knowledge can allow some patients to use the medication to abort an outbreak. Whether oral or genital, people can take medication when their specific prodrome tells them an outbreak is on the horizon. The medication will stop an outbreak cold (often) and when it does not, it can shorten a milder outbreak than they might have had otherwise.

To prevent outbreaks when there are no symptoms but outbreaks are more likely

Patients also learn the life circumstances or behaviors that lead to more outbreaks. For some, a lack of sleep, increased alcohol, another illness, stress, too much sunlight, irritation, or anything, in fact, that can affect one’s immunity can spur an outbreak. That means that some patients can know not just when they feel an outbreak coming on but can know when they are more likely to have an outbreak due to their circumstances. They might be under stress, having more sex so more irritated, drinking a bit more than they should or missing sleep over an extended period. They will know that they should avoid those triggers and do their best to do so, but they also might want to take medication preventatively knowing they are more vulnerable at that time. Essentially they might take the medication for a week or two until the stress that is making them more susceptible to an outbreak has resolved.

To suppress outbreaks for an extended period

Another way patients can take the medication is when they know they absolutely would like to do all they can to reduce their chance of having an outbreak at a pivotal time. The classic example would be during a honeymoon but taking medication to suppress outbreaks on a daily basis can be prudent when going on vacation, starting a new job, in a new relationship, or at any time a patient feels it is how they want to approach their condition. And that’s the key.

How medication is used is completely in your hands. Learn everything you can and do not worry about using the medication in the way that suits you best. That may change as your circumstances change, or as the condition changes, or even as your mind changes.

To prevent transmission to an uninfected partner

One of the most important advances in herpes treatment came with the knowledge that transmission from an infected person to their uninfected partner could be reduced by the use of valacyclovir. Valacyclovir not only reduces the number of outbreaks a person experiences when using the medication every day but it reduces the number of days that someone sheds the virus asymptomatically. That results in fewer uninfected partners catching herpes. If a condom is worn and the medication used, the chances are reduced at least in half compared to using a condom alone.

Fewer outbreaks and fewer episodes of shedding means fewer people become infected.

Oral herpes

Abort an outbreak at the earliest sign or symptom (prodrome)

At that earliest sign, two tablets of valacyclovir 1000 mg for a total of 2000 mg is taken by mouth as the first dose. Then, 12 hours later, 2 tablets of 1000 mg of valacyclovir, for a total of 2000 mg, is taken as the second and final dose. The second dose can be taken sooner than 12 hours but never before 6 hours have passed. Adequate hydration makes sure the medicine is cleared through the kidneys as it should be.
The medication is only approved for two doses and there is no evidence in studies to advise the use of medication once lesions have appeared.


Specific dosing recommendations for Herpes

Treatment of initial genital outbreak

In patients with a first outbreak, the symptoms can be very severe. Multiple painful, genital ulcers can cover large areas of skin on both sides of the groin. They can experience burning during urination, fever, headaches, muscle and joint pain, and swollen, painful lymph nodes in the groin. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. For such patients, treatment is vital and can shorten the outbreak and ease the symptoms significantly. For the treatment of an initial episode of herpes genitalis, the FDA recommends taking valacyclovir 1 gram (1000 mg) twice a day for 10 days starting at the first sign or symptom of lesions, preferably within 48 hours of onset. The “CDC recommends this same dose for 7 to 10 days; treatment may be extended if healing is not complete after 10 days.” For HIV-infected patients, they recommend 1 gram (1000 mg) every 12 hours for 5 to 14 days.

Treatment of herpes labialis (i.e., cold sores)

To abort an outbreak of herpes on the lips or mouth the recommendation is that the patient should take 2 grams (2000 mg) of valacyclovir at the first sign or symptom of lesions and a second dose 12 hours later. The second dose should not be taken within 6 hours of the first. Those are the only doses recommended but patients sometimes take another dose or two of just 1 gram if they continue to have symptoms, or if a mild outbreak follows.

The PDR states that for HIV-infected patients, 1 gram (1000 mg) be taken every 12 hours for 5 to 10 days. Despite what some patients do when having continued symptoms the PDR states, “there are no data supporting the effectiveness of beginning treatment after the development of clinical signs of a cold sore (e.g., papule, vesicle, or ulcer).”

Treatment of recurrent herpes genitalis, including HIV-infected patients

To treat a recurrent outbreak, the FDA recommends using 500 mg of valacyclovir twice daily for 3 days starting at the first sign or symptom of lesions—preferably within 24 hours of onset. The CDC recommendation is identical but adds in the choice of using valacyclovir 1 g (1000 mg) one time a day for 5 days. Valacyclovir 1 g taken every 12 hours for 5 to 14 days is recommended by the HIV guidelines. The PDR also states, “There are no data supporting the effectiveness of beginning treatment more than 24 hours after the onset of symptoms.”

Treatment with suppressive therapy

The PDR states that for suppressive therapy of recurrent herpes genitalis in all patients valacyclovir 1 gram (1000 mg) should be taken once daily.

However, “in patients with a history of fewer than 9 recurrences per year, 500 mg once daily may be given.” They note that “500 mg once daily regimen appears to be less effective than other regimens in patients with 10 or more episodes per year.”

The PDR continues, “Safety and efficacy of valacyclovir beyond 1 year have not been established. In HIV-infected patients, 500 mg by mouth twice daily. The safety and efficacy of therapy beyond 6 months have not been established.”

To prevent transmission to a partner

The PDR recommends the infected partner take valacyclovir 500 mg once a day to decrease the risk of transmission to the uninfected partner “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Studies also did not run for an extended period so the PDR also states, “The efficacy of reducing transmission beyond 8 months in discordant couples has not been established.” This means they can only vouch for the data for an 8 month period of time.

An important point

Being diagnosed with genital herpes means you have acquired a sexually transmitted infection. If you have been diagnosed with genital herpes, you should have been checked for other sexually transmitted infections when you were diagnosed, including but not limited to HIV and syphilis. If you have not been, you should be and this is highly recommended.

Herpes can be transmitted to a partner despite best efforts like using a condom and using antiviral suppression therapy. Patients should never engage in sex without a condom or when they have an outbreak or a prodrome. Also, as asymptomatic shedding is more common in the seven days following an outbreak it is prudent to avoid sex during that period, as well.

Herpes and the risk of HIV infection

HSV-2 infection puts a person at greater risk of acquiring HIV infection—as much as 2 to 3 times the risk of those without herpes. The reason is that herpes creates ulcers that can make it easier for HIV to enter the body but general inflammation of the genitals is also responsible for the increased vulnerability to the infection. In women and men with positive blood tests for herpes, specialized testing shows signs of inflammation on the cervixes of women and under the foreskin of men. The specialized test is the finding of CD4 T cells. This is probably the result of the body’s immune system constantly fighting the herpes virus and it is seen even when no outbreak is evident. Of note, some CD4 T cells have been shown in the lab to be more susceptible to HIV infection than skin samples tested under the same conditions. Moreover, CD4 T cells hang around in inflamed tissue long after outbreaks heal.

This is another reason why STD testing is always the rule when beginning a new sexual relationship and why, whether having an outbreak or not, a condom is essential.

HSV-2 infection in HIV-infected individuals

HIV infected persons who have genital ulcers due to herpes are more likely to transmit HIV, as HIV is shed from these ulcers. Herpes itself may behave identically in the HIV positive individual but they are more likely to develop acyclovir resistance and to have outbreaks that last longer and appear different from typical cases.

HIV positivity is a complex condition that requires careful evaluation by experts in the field.

HSV vaccines

After years of frustration, there are reasons to be optimistic that a vaccine to prevent, or even to treat, herpes may be achievable. The development of a vaccine has been spurred by the realization that controlling herpes would be a major step in controlling the spread of herpes around the world, especially in places where medication is unavailable.

Herpevac vaccine did not prevent the acquisition of genital herpes Type 2 but it did show moderate success against catching herpes Type 1 and in making the disease milder if someone caught it. The study included 8000 participants but they were all women so the data may not be consistent in men. Nevertheless, the fact that a vaccine worked for HSV-1 is encouraging, especially since so many new cases of genital herpes are due to HSV-1. A number of vaccines are being tested to see if they could reduce the number of outbreaks and, most importantly, the amount of asymptomatic shedding. One vaccine in early testing, GEN-003, reduced shedding by 55%.

The advances are being made that give hope to anyone who has the infection or is the partner of someone with the HSV virus.


Valacyclovir details: PDR information

Read full prescribing information Here  

How can Valtrex be used

Treatment of herpes labialis (i.e., cold sores)

To abort an outbreak of herpes on the lips or mouth the recommendation is that the patient should take 2 grams of Valacyclovir at the first sign or symptom of lesions and a second dose 12 hours later. The second dose should not be taken within 6 hours of the first. Those are the only doses recommended but patients sometimes take another dose or two of just 1 gram if they continue to have symptoms, or if a mild outbreak follows.

The PDR states that for HIV-infected patients, 1 gram (1000 mg) be taken every 12 hours for 5 to 10 days. Despite what some patients do when having continued symptoms the PDR states, “there are no data supporting the effectiveness of beginning treatment after the development of clinical signs of a cold sore (e.g., papule, vesicle, or ulcer).”

Treatment of Initial genital outbreak

In patients with a first outbreak, the symptoms can be very severe.

Multiple painful, genital ulcers can cover large areas of skin on both sides of the groin. They can experience burning during urination, fever, headaches, muscle and joint pain, and swollen, painful lymph nodes in the groin. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. For such patients, treatment is vital and can shorten the outbreak and ease the symptoms significantly.

For the treatment of an initial episode of herpes genitalis, the FDA recommends taking valacyclovir 1 gram (1000 mg) twice a day for 10 days starting at the first sign or symptom of lesions, preferably within 48 hours of onset. The “CDC recommends this same dose for 7 to 10 days; treatment may be extended if healing is not complete after 10 days.”

For HIV-infected patients, they recommend 1 gram (1000 mg) every 12 hours for 5 to 14 days. The PDR also notes, “The efficacy of treatment with VALTREX, when initiated more than 72 hours after the onset of signs and symptoms, has not been established.”

Treatment of Recurrent Herpes Genitalis, Including HIV-infected Patients

To treat a recurrent outbreak, the FDA recommends using 500 mg of Valacyclovir twice daily for 3 days starting at the first sign or symptom of lesions—preferably within 24 hours of onset. The CDC recommendation is identical but adds in the choice of using Valacyclovir 1 gram (1000 mg) one time a day for 5 days. Valacyclovir 1 gram taken every 12 hours for 5 to 14 days is recommended by the HIV guidelines. The PDR also states, “There are no data supporting the effectiveness of beginning treatment more than 24 hours after the onset of symptoms.”

Treatment with Suppressive Therapy

The PDR states that for suppressive therapy of recurrent herpes genitalis in all patients Valacyclovir 1 gram (1000 mg) should be taken once daily.

However, “in patients with a history of fewer than 9 recurrences per year, 500 mg once daily may be given.” They note that “500 mg once daily regimen appears to be less effective than other regimens in patients with 10 or more episodes per year.”

The PDR continues, “Safety and efficacy of valacyclovir beyond 1 year have not been established. In HIV-infected patients, 500 mg PO twice daily. The safety and efficacy of therapy beyond 6 months have not been established.”

To Prevent Transmission to a Partner

The PDR recommends the infected partner take Valacyclovir 500 mg once a day to decrease the risk of transmission to the uninfected partner “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Studies also did not run for an extended period so the PDR also states, “The efficacy of reducing transmission beyond 8 months in discordant couples has not been established.” This means they can only vouch for the data for an 8 month period of time. The PDR also states, “The efficacy of VALTREX for the reduction of transmission of genital herpes in individuals with multiple partners and non-heterosexual couples has not been established. Safer sex practices should be used with suppressive therapy.” Centers for Disease Control 26 and Prevention [CDC] Sexually Transmitted Diseases Treatment Guidelines

Maximum Dose

In children 12 years and older, adolescents, adults, and the elderly, the maximum daily dose is 4 grams if given for just 1 day and 3 grams/day if given for more than 1 day.

In children 2 years to 11 years, 3 grams/day is the maximum dose.
Safety has not been established in neonates, infants, and children less than 2 years.

Dose adjustments should be made for those with kidney impairment or issues. Decreased doses are needed as kidney impairment slows the clearing from the body of valacyclovir. The degree of impairment determines the decrease in the dosage. The elderly may have decreased kidney function and adjustments should be considered in such cases.

No adjustment is needed, generally, in patients with liver impairment.

However, if you have a liver condition or impairment, inform your doctor.

Overdose: Valtrex is not usually harmful unless you take too much for several days. An excess of Valtrex can cause vomiting, kidney problems, confusion, agitation, feeling less aware, seeing things that aren’t there, or loss of consciousness. For severe symptoms, go direction to an emergency room. Otherwise, talk to your doctor or pharmacist if you take too much Valtrex. Take the medicine pack with you.


Contraindications and Precautions

Sensitivity or Allergies: Patients with sensitivity or an allergy to any of the following medications should not use Valacyclovir: Acyclovir, Famciclovir, ganciclovir, penciclovir, valacyclovir, or valganciclovir.

Kidney Issues: Dose adjustments should be made for those with kidney impairment or issues. Decreased doses are needed as kidney impairment slows the clearing from the body of valacyclovir. The degree of impairment determines the decrease in the dosage. The PDR states, “Acute renal failure and CNS (Nervous System) toxicity have been reported in patients with underlying renal (Kidney) dysfunction who have received inappropriately high doses of valacyclovir for their level of renal (Kidney) function. Patients receiving potentially nephrotoxic(Toxic to the Kidney) drugs together with valacyclovir may have an increased risk of renal dysfunction (impairment).”

The Elderly: The elderly are more likely to have impaired kidneys so they might not clear valacyclovir from their system as efficiently as they should. This can lead to inappropriately high levels of valacyclovir, which means the elderly may need lower doses of valacyclovir. The elderly are also more likely to experience neurological side effects, including: agitation, hallucinations, confusion, delirium, and other abnormalities of brain function termed encephalopathy.

Dehydration: When patients are dehydrated acyclovir can reform as a solid in the kidney leading to kidney damage. Patients should all remain well hydrated when taking valacyclovir.

Newborns, Infants, and children: Safety has not been established in neonates, infants, and children less than 2 years.

Pregnancy: While a registry that collected data on the 756 pregnancies of women exposed to acyclovir in the first trimester showed no greater occurrence of birth defects than occurs in the general population, the study size was too small to guarantee safety during pregnancy.

You should not take valacyclovir if you are pregnant or trying to become pregnant, unless recommended by your obstetrician/gynecologist or other healthcare provider.

Breastfeeding: The PDR states, “According to the manufacturer, valacyclovir should be administered to a nursing mother with caution and only when indicated. Although the American Academy of Pediatrics (AAP) has not specifically evaluated valacyclovir, systemic maternal acyclovir is considered to be usually compatible with breastfeeding…Consider the benefits of breastfeeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition.”

Driving or Using Machines: Valtrex can cause side effects that affect your ability to drive. Don’t drive or use machines unless you are sure you’re not affected.

Thrombotic Thrombocytopenic Purpura/Hemolytic Uremic Syndrome (TTP/HUS): TTP/HUS is a rare condition but has occurred in patients with advanced HIV disease and also in allogeneic bone marrow transplant and renal transplant recipients participating in clinical trials of VALTREX at doses of 8 grams per day. If any of these conditions apply to you, please inform your doctor and pharmacist.


Side Effects (Overview)

What follows is a summary and does not include every side effect possible. Please, read the package insert and report any side effects you experience whether on the list below or not.

Very Common (may affect more than 1 in 10 people): headache

Common (may affect up to 1 in 10 people): feeling sick, dizziness, vomiting, diarrhea, skin reaction after exposure to sunlight (photosensitivity), rash, itching (pruritus)

Uncommon (may affect up to 1 in 100 people), feeling confused, seeing or hearing things that aren’t there (hallucinations), feeling very drowsy, tremors, feeling agitated

These nervous system side effects usually occur in people with kidney problems, the elderly or in organ transplant patients taking high doses of 8 grams or more of Valtrex a day. They usually get better when Valtrex is stopped or the dose reduced.

Other Uncommon Side Effects: shortness of breath (dyspnea), stomach discomfort, rash, sometimes itchy, hive-like rash (urticaria), low back pain (kidney pain), blood in the urine (hematuria)

Uncommon Side Effects That May Show Up In Blood Tests: reduction in the number of blood platelets which are cells that help blood to clot (thrombocytopenia), reduction in the number of white blood cells (leukopenia), increase in substances produced by the liver  

Rare (may affect up to 1 in 1,000 people): unsteadiness when walking and lack of coordination (ataxia), slow, slurred speech (dysarthria), fits (convulsions), altered brain function (encephalopathy), unconsciousness (coma), confused or disturbed thoughts (delirium)

These nervous system side effects usually occur in people with kidney problems, the elderly or in organ transplant patients taking high doses of 8 grams or more of Valtrex a day. They usually get better when Valtrex is stopped or the dose reduced.

Other Rare Side Effects: kidney problems where you pass little or no urine.

Lastly, watch out for a severe allergy. It may be rare but it can be life-threatening so being aware of the symptoms is vital.

Severe allergic reactions (anaphylaxis): These are rare in people taking Valtrex. Anaphylaxis is marked by the rapid development of flushing, itchy skin rash, swelling of the lips, face, neck, and throat—causing difficulty in breathing (angioedema), fall in blood pressure leading to collapse. If any of these occur, get emergency treatment immediately


Drug Interactions

Of Note: “When VALTREX is coadministered with antacids, cimetidine and/or probenecid, digoxin, or thiazide diuretics in patients with normal renal function, the effects are not considered to be of clinical significance. Therefore, when VALTREX is coadministered with these drugs in patients with normal renal function, no dosage adjustment is recommended.” (PDR)

Aprotinin: Aprotinin is cleared in the kidney as is Valacyclovir. Together, the risk to the kidney is increased.

Bictegravir; Emtricitabine; Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.  

Cimetidine: Cimetidine may slow how quickly valacyclovir is cleared out of the body through the kidney but no dosage adjustments are recommended for patients with normal renal function.

Cobicistat; Elvitegravir; Emtricitabine; Tenofovir
Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Cobicistat; Elvitegravir; Emtricitabine; Tenofovir Disoproxil Fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Efavirenz; Emtricitabine; Tenofovir: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Rilpivirine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Rilpivirine; Tenofovir disoproxil fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Tenofovir disoproxil fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Entecavir: Entecavir can affect kidney function and should be used cautiously with valacyclovir.

Fosphenytoin: Phenytoin and fosphenytoin are anti-seizure medications. The addition of valacyclovir to phenytoin may lead to a clinically significant decrease in phenytoin serum concentrations and loss of seizure control. Adjustments in phenytoin or fosphenytoin dosing should be considered if Valacyclovir is added or stopped when a patient is on either phenytoin and fosphenytoin.

Hyaluronidase, Recombinant; Immune Globulin: Immune Globulin (IG) products can damage the kidney. If they take any other drug that can affect the kidney, including valacyclovir, the dose of IG may need to be lowered and the infusion rate slowed.

Immune Globulin IV, IVIG, IGIV: Immune Globulin (IG) products can damage the kidney. If they take any other drug that can affect the kidney, including valacyclovir, the dose of IG may need to be lowered and the infusion rate slowed.

Lamivudine; Tenofovir Disoproxil Fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Measles Virus; Mumps Virus; Rubella Virus; Varicella Virus Vaccine, Live: (Major) If possible, discontinue valacyclovir at least 24 hours before administration of the varicella-zoster virus vaccine, live. Also, do not administer valacyclovir for at least 14 days after vaccination. The medication might have the unintended effect of diminishing the protective benefit of the vaccine.

Mycophenolate: (Moderate) Valacyclovir, when added to MMF, cyclosporine, and prednisolone caused a decrease in White Blood Cells, called neutropenia. When this combination must be used careful blood monitoring is recommended.

Phenytoin: Phenytoin is an anti-seizure medication. The addition of valacyclovir to phenytoin may lead to a clinically significant decrease in phenytoin levels and loss of seizure control. Adjustments in phenytoin dosing should be considered if valacyclovir therapy is added or discontinued.

Probenecid: Probenecid can reduce the kidney’s clearance of valacyclovir causing an increase in the blood level of valacyclovir. In the absence of a decrease in renal function, no dose adjustment is needed.

Talimogene Laherparepvec: “Consider the risks and benefits of treatment with talimogene laherparepvec before administering acyclovir or other antivirals to prevent or manage herpetic infection. Talimogene laherparepvec is a live, attenuated (lessened capacity to cause disease) herpes simplex virus that is sensitive to acyclovir; coadministration with antiviral agents may cause a decrease in efficacy.”

Telbivudine: Valacyclovir can affect kidney function. Since telbivudine is also cleared by the kidney, monitoring kidney function before and during telbivudine treatment is recommended.

Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Tenofovir, PMPA: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Varicella-Zoster Virus Vaccine, Live: (Major) If possible, discontinue valacyclovir at least 24 hours before administration of the varicella-zoster virus vaccine, live. Also, do not administer valacyclovir for at least 14 days after vaccination. The medication might have the unintended effect of diminishing the protective benefit of the vaccine.


Genital Herpes Treatment Plan

Be sure to take your time and read everything below. It is essential for you to understand the potential risks and benefits of treatment. Please do not hesitate to reach out to our medical support team if you have ANY questions.

Overview

Herpes is not simply an infection. Too many people suffer silently, fearing to even reach out to their healthcare providers. There are few conditions where a person’s care is so dependent on their participation. Time must be dedicated to education and to formulating a plan that is under your control.

Medication is available—and it works extremely well—but how it is used and when it is used can never be more precisely applied than when a person uses the guidance of experts to craft a personalized plan.

With the education we provide below, you will be able to decide how best to utilize all the tools at your disposal. The key is to learn as much as you can and make informed decisions. The information below will help you gain a level of independence you may not have realized is possible.

Read carefully your doctor’s personalized treatment plan and all the material provided. It may well provide some new information that will be helpful to you. Nothing is sugar coated because we feel you deserve the information you need to live your life the way you want. Read it all along with the package insert and the information in the Prescribers’ Digital Reference (PDR).

One important point is that if the medicine prescribed does not improve your condition (now or at any time), or if your symptoms at any point in the future are not completely typical of your usual outbreak, then you must be seen by a physician in person and checked for other conditions.

Lastly, the plan your personal doctor has provided is just the initial plan.

You may well choose a different one after reading more about other options or, in 6 months, your life circumstances may have changed and a different plan may suit you better. Just reach out to us.  

We are here to make your life better, not to give you more challenges in finding the care you need. And don’t forget, contact us if you need us.


Your treatment plan

Your doctor has written a prescription for valacyclovir. It can be used to stop an outbreak when you feel one is coming on (“aborting an outbreak”). Valacyclovir can also prevent an outbreak when it is important to you do so or when you know (from your personal experience) that you are more likely to have outbreaks (e.g., summer). When to use the medicine is completely up to you. You have expressed a desire to use the medication to abort an outbreak.

The best way to stop an outbreak is to start the medication the moment you sense one is coming on. The symptoms you feel are called a prodrome and is unique to you. No one will recognize them as quickly as you can. Whether it is a vague achiness in the low back, or a difficult-to-describe pain running down your thigh, or a dull throb in the groin, you recognize it.

The plan recommended by the CDC was chosen as the best therapy given your history. Valacyclovir 1 gram (1000 mg) should be taken as soon as possible when you feel your first symptom. The same dose, 1 gram (1000 mg), should then be taken once a day for a total of 5 days. The PDR allows for a regimen of valacyclovir 500 mg to be taken twice a day for just 3 days and for many patients the use of medication for just three days wipes out the advantage of one a day medication that is used for 5 days. Your physician has chosen the longer period as studies show an increased likelihood to shed virus within 7 days of the last outbreak. The convenience of the higher dose, once a day therapy, and the reliability that happens when such a regimen is used, makes it the preferred treatment.

The PDR states, “There are no data supporting the effectiveness of beginning treatment more than 24 hours after the onset of symptoms.” That is why it is so important to identify your prodrome and to react to it quickly. Your best chance of aborting an outbreak happens when you can reliably identify your prodrome and react quickly. You may treat a few false alarms but with time you will be able to distinguish those symptoms that mean an outbreak is about to appear from those minor irritations that are unrelated to herpes.


Valacyclovir FAQs

Preventing future outbreaks

Make a note of everything you think may have made you more susceptible to an outbreak. Was there more irritation to the area? Did anything affect your immunity like another infection (e.g., a cold) or did you change something in your lifestyle that could have weakened your immune system (e.g., lack of sleep, stress, increased alcohol consumption)? No change is too small to note.

This is important because it will help you maintain the patterns that make herpes less likely to appear. For you, it may be a lack of sleep over a few consecutive nights that spurs most outbreaks. It might be excessive sun exposure or too much alcohol consumption. It could happen only when you are sick or just run down. Whatever it might be, over time you may come to recognize the issues and make changes that reduce the frequency of outbreaks simply by maintaining a healthful lifestyle.

Other ways to use the medication

Some patients ask if they can take the medication on a daily basis (for short periods) to prevent an outbreak when they least want to have one. The classic examples are a bride or groom on their wedding day, when first engaging in sex with a new partner, or going on that long planned and much-needed vacation with your partner or spouse. You don’t need to be getting married or about to rendezvous for a much-anticipated tryst to want to prevent a herpes outbreak at particular times. It could be that an outbreak would be uncomfortable during the holidays or at any time you determine.

That is what we mean when we say you have control. Today, you have chosen to abort outbreaks when you feel them coming on but that may change. You may enter a relationship and want to do all you can to reduce the number of outbreaks you experience and limit the risk of your partner catching the disease by taking suppressive therapy (meaning taking medicine every day) all the time. This can reduce transmission to an uninfected partner by 50%.

Circumstances change; only you will be able to know how your circumstances affect which option you choose. That is why learning all you can is so important. It gives you independence.

One other fact is worth noting. You have been prescribed 15 pills of the 1 gram size of valacyclovir. Each outbreak would require the use of just 5 tablets so you have enough medication to treat 3 outbreaks. You should always have medication on hand, so renew your prescription as frequently as you feel you need to.

As long as the medicine proves effective and you are free of significant side effects, you should never have to worry about having access to what you need. You may treat a few false alarms at first. That’s OK. You will get better at recognizing your prodrome reliably over time.

You can always drop a note to your doctor, the pharmacist, or the care team with any questions, issues, or changes you want to consider. There is no “extra” visit charge or cost if you just want to ask questions and learn more about how you can manage your condition.

Lastly, if you would like to switch to suppression therapy, you can request a prescription for 30 pills so you can have the option of going on suppression therapy for an extended period should you choose. You can always hold back on getting more delivered when you no longer need it.

It may be a new situation for you but as long as the medication works without causing you difficulties of any sort, you are in control.  


Herpes: condition overview

A wealth of herpes information (oral and genital)

In the United States, genital herpes caused by HSV-2 (Herpes Simplex Virus Type 2) is extremely common and the most frequent cause of genital ulcer disease. Yet, the people who have symptoms represent the smallest number of people infected. In fact, 80% of the people who have genital herpes do not know it. That means for every person with symptoms who takes the step to be treated as you have, there are 4 people who are infected but totally unaware. 

Much of what we know about herpes is different from what people learned during the height of the “fear” an infection caused when no treatment was available.

That is what we must change. We want you to learn the facts about herpes so you do not become a victim of the myths. Also, only by understanding the disease will you be able to work with your doctor to craft the right treatment plan for you as your life evolves. What suits you today may not in 6 months or in 5 years. If you understand herpes, and how medications can work in different circumstances, you will be able to take control of your life in ways you might not have known were possible.

Lastly, if you read the next few pages carefully (though seemingly simply) you probably will know more helpful facts about herpes than many doctors.

What is herpes?

Herpes is a virus. The herpes virus can barely be considered alive. It is little more than a strand of DNA (deoxyribonucleic acid), the code of life, safely hidden inside a shell of protein. On its own, a herpes virus cannot reproduce or do much of anything—until it infects us. When the herpes virus comes in contact with areas that are receptive, like the genitals or mouth, the virus invades the epithelial cells (skin cells) in that region.

Then, the DNA of the herpes virus is released into the skin cell. At that point, it quite literally takes over.

It directs the cell to make more herpes virus and, when they have made enough copies to damage the cell so severely that it bursts, millions of the newly formed viruses are released infecting more cells, eventually causing an ulcer.

That is what people can see and feel, but a good deal more than that happens. While it is infecting skin cells and causing pain and ulcers, it also begins to attack the nerve cells in the same area. When the virus enters the nerve cell, it not only reproduces but it moves up the nerve to a bundle of nerves in the back called the sacral plexus. Once it is in the nerves, it is essentially protected from being attacked by the body’s immune system. Nerve cells can never be replaced.

That is why when nerves in the spine are damaged people become paralyzed. Since nerves cannot reproduce themselves easily, the body is careful not to bombard them with all the weapons it has to clear infections. All the inflammation that is caused by the battle to eliminate infections elsewhere would be disastrous if that occurred with nerves.

There is no sense clearing an infection if nerve cells that could never be replaced are destroyed in the process.

The herpes virus is essentially protected from an attack by our immune system as long as it hides out in the nerves of the sacral plexus when it affects the genitals, or the “dorsal root ganglion” (a cluster of nerves in the neck region of the spine) when it infects the mouth.

Unfortunately, that leaves the virus in a perfect position to sneak back out when the immune system is suppressed in any way. That is how the virus is able to cause recurrent infections, especially during times of stress, illness, or any condition or circumstance that makes our immune system less vigilant. We will discuss that in detail later.

How common are HSV-1 and HSV-2?

Worldwide (in 2012) nearly one half billion people were infected with HSV-2 between the ages of 15 and 49—and the number rises with age and the number of life partners. More women than men have herpes (14.8% versus 8% global prevalence, respectively). In the US, the number of people infected has been dropping, but the news isn’t all good. The percentage of people with a positive blood test for HSV-2 has declined. In people age 14 to 49, 21% were positive in the early 90s. By 2010, that number dropped to about 16%. Unfortunately, the improvement has been seen mostly in the white population “with stable rates in black populations, resulting in worsening racial disparities such that for every one white man, four black men are infected, with similar ratios for women.”

The reasons for this might be that access to information, education—and the medication that can reduce the risk of transmission—has not been made available to all equally.

In the United States, the prevalence of HSV-1, which accounts for the vast majority of oral herpes, has dropped 29% among 14–19 year olds, from approximately 42% to 30%, over the past 30 years. As a result, adolescents and young adults may experience their first exposure to HSV-1 with the initiation of sexual activity, including oral sex.

How can it be that some people do not have symptoms of oral herpes and of genital herpes?

It is vital to understand that 80% of people with an infection have no symptoms they recognize. For those who experience severe or frequent outbreaks, that is difficult to understand. There are multiple explanations.

The first one is related to how we physicians first described the disease.

Before there were elegant tests to culture herpes, or to test lesions for signs of herpes DNA, and before accurate blood tests out of the University of Seattle, herpes was described by doctors by what they saw—and only by what they saw. This meant that only people who had visible lesions (sores) were diagnosed and doctors thought that all those who had herpes had symptoms. It turns out that patients with severe disease were just the tip of the iceberg, but doctors didn’t realize that. Unfortunately, too many myths and outright falsehoods became “common knowledge.”

The fact is most people have an immune response that holds the disease at bay—in terms of causing symptoms, that is. They are still infected and, as we will learn later, still able to transmit the disease, but the symptoms either do not occur or are so subtle that they go unnoticed or undiagnosed. Herpes can cause such minor complaints that they are ignored.

Herpes can appear as little more than an irritation or tiny erosion. A lesion tucked away in the genital region can be so small that it cannot be seen without doing some major stretching before trying or using a magnifying lens. Or the sore is in a place that is completely inaccessible to viewing (e.g., the anus, the groin, the vagina, or hidden within a small skin fold).

Also, the symptoms may disappear so quickly that they are dismissed, or never seen in time by a doctor, or a doctor does not recognize how minor herpes can be even when seen in time. This is true of oral and genital herpes.

Nevertheless, the people who have what we call asymptomatic herpes can still transmit the disease. They can do this because they can still “shed” the virus from the skin even without having a sore or a symptom that they recognize as herpes. Asymptomatic shedding occurs from the mouth in those with oral herpes, from the anal and genital region in those with genital herpes, and even from tears in people who have had herpes of the eye. The section on asymptomatic shedding explains this in detail.


Clinical manifestations of Herpes

Clinical manifestations of Oral HSV infection

Classically, the oral symptoms are familiar to most people who either have had an outbreak or seen them in others. The initial symptoms are a sense of tingling or itching that can occur 24 hours before any lesions appear.

The first visible symptoms are redness, followed by the forming of a papule or elevation of the skin affected (usually on the very edge of the lips where they transition to the skin of the face). Then, the small roundish elevations become filled with fluid (a vesicle), which can burst and reveal a small ulcer or divet in the skin. This will be painful and ooze fluid and within just a few days heal, usually without a scar. These lesions do not form solely on the edge of the lip. They can form anywhere on the face, particularly a region between the nose and lips and out to the first fold on the cheek called the “nasolabial fold.”

The virus hides in the nerves in the back of the neck called the dorsal root ganglion. When HSV-1 reactivates and comes out of that nerve it can take a route other than to the edge of the lip. It can even cause an outbreak on the back of the neck but, most often, it is the lips where outbreaks will recur.

Oral symptoms can be more easily seen but often are not understood to be related to herpes. Minor irritations that disappear quickly might easily be dismissed as a simple cut or reaction to spicy food.

Other people might mistakenly consider unrelated irritations to be herpes on the mouth when they are not. For example, canker sores that occur inside the mouth and can recur just like herpes are sometimes misdiagnosed by patients and doctors alike as being due to the HSV-1 virus when, in reality, it is possibly an immune reaction and not an infection. The same sometimes occurs with irritation on the corners of the mouth, called angular cheilitis or perleche. This can be idiopathic, meaning it has no known cause, or can be due to the buildup of fluid at the corners of the mouth. It is a perfect spot to nurture growths of yeast or fungus (think Candida) and the irritation can even lead to small cuts and sores.

We always advise patients to confirm their diagnosis if recurrent oral lesions are completely unresponsive to herpes antiviral therapy.  

Clinical manifestations of Genital HSV infection

HSV-2 is the leading cause of genital ulcers in the United States and throughout the world. We know that because a very accurate test called a PCR test, which is far more sensitive than a culture, has found herpes in 60% of genital ulcers. Remember that most people with herpes found by blood testing have had no symptoms of herpes. What follows is a description of herpes as it appears in those who experience symptoms, in people who are seen by doctors with lesions.

First outbreak or primary outbreak

For patients who have symptoms, the first outbreak can be the worst. During primary infection, patients may experience multiple genital ulcers that can cover larger areas of skin. It can be on both sides of the groin and be quite painful. They often experience burning during urination in addition to the local pain. They can have fever, headaches, muscle and joint pain, and their lymph nodes in the groin can be swollen and painful as well. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. Therapy can shorten that period significantly.

The reason an initial outbreak can be so severe is that there are no antibodies to herpes when the virus first enters the body, (though a prior history of herpes type 1 can give someone antibodies that work a little bit to fight herpes type 2 and may make an outbreak a bit less severe.)
An initial outbreak can be caused by Herpes 1 and in developed countries like the US, the most common cause of an initial attack of herpes is actually herpes 1. Most people do not realize that someone infected with oral herpes from type 1 can perform fellatio or cunnilingus on a partner and transmit herpes 1 from their mouth to their partner’s genitals. If you think about it, why not? The problem is that many people don’t know they have oral herpes. It may be easier to see but not many people remember the cold sore they had when they were 3. Also, while most people in the past acquired herpes on the mouth as a child when exchanging saliva with other children who were infected, that has not been happening with anywhere near the same frequency. The rate of infection with Herpes 1 is lower now than at any time in the past. In the United States, HSV-1 has dropped 29% among 14–19 year olds, from 42.6% to 30.1% over the last 3 decades.

That means that adolescents who engage in sex are more likely to be exposed to Herpes 1 for the first time when having oral or vaginal sex. Changes in sexual practices have also made the transmission more likely.

Fellatio (a “blow job”) and cunnilingus (“going down”) are much more frequently practiced at younger ages and with fewer restraints imposed by cultural or social forces. That has made herpes 1 the most common cause of first outbreaks in developed countries. Nevertheless, herpes 1 and herpes 2 on the genitals do not behave identically in terms of recurrences. Herpes 1 is more “at home” in the oral region and has developed ways to deal with that environment. When on the genitals, it can cause all the same symptoms and can still be transmitted, but it has a milder course than when herpes 2 infects the genitals. This is discussed more in the section on recurrences.

Understanding how herpes can remain in the body yet be kept at bay to some degree is pivotal. Herpes enters the sacral plexus of nerves during an initial infection. As discussed above, the virus remains safe from attack by antibodies and the immune system as long as it is tucked away in the nervous system. That little trick, entering the nervous system where it neither damages the nerves nor can be attacked, makes herpes a particularly stubborn infection. It can slide down the nerves that go from the sacral plexus to the skin and cause more outbreaks in the future. These are called recurrences.

Recurrences occur in a milder version than the initial outbreak because the body is not completely defenseless. It is the ongoing battle between the herpes virus’ ability to stay safe in the nervous system and the body’s ability to mount a defense with antibodies that determines if symptoms will appear or not. In most people, the battle is a stalemate in terms of symptoms. Most people never have an outbreak or, if they do, they are so mild they are not noticed. In terms of keeping herpes under such control that the virus never exits the nervous system and sheds from the skin, the battle definitely tilts in favor of the virus.

It is in the ways herpes remains active in those who are infected, and able to spread to those who are not, that makes herpes such a difficult infection to control in terms of preventing outbreaks and preventing transmission.

However, control is possible—and that is the key.

Recurrences

While the immune system for the vast majority of people makes recurrences far less severe than a primary outbreak, periodic recurrences occur in genital HSV infections. They are also quite different in character.

First, since herpes is in the nerves of the patient, as the virus becomes more active and begins to travel down the nerve to the skin, a person may get symptoms that tell them an outbreak on the skin is about to appear.

They may get leg pain, back pain, a tingling sensation, burning, or itching. They might notice less specific symptoms like increased urination, but symptoms like fever or muscle aches are much less common than with an initial outbreak. These symptoms collectively are known as a prodrome. It is very variable but patients begin to recognize their pattern, their unique prodrome.

The outbreaks themselves are much milder. They tend to occur on one side of the body, to cover a smaller area, and are less painful. Swelling of the lymph nodes is uncommon and all the symptoms resolve much more quickly, lasting just 3–5 days.

Because herpes lives in the sacral plexus and nerves from that accumulation of nerves can reach out not just to the skin where the infection first started but to any area the nerves can go, recurrent outbreaks are not limited to the initial region it entered the body. They can occur on the buttocks, the thigh, or anywhere in the anal and genital regions. Recurrences in areas other than the genitals (e.g., thigh) have a similar pattern to those that occur on the genitals.

Also, while herpes tends to improve over time, people can get outbreaks at any point that their immune system is challenged. This can happen when another illness occurs, with cancer or cancer treatments, or with such simple changes as life stress due to divorce, moving, changing jobs, or death of a family member as examples. Excessive friction, sunburns, exhaustion, poor sleep patterns can also deplete a person’s immune system. In fact, anything that makes you less healthy or is a challenge to the system can make an outbreak more likely to occur. Over time patients not only recognize their prodromes, but they also recognize the circumstances associated with an outbreak.

In terms of the frequency of recurrences, genital HSV-2 recurs far more often than genital HSV-1. In the first year after primary infection with genital HSV-2, patients average about 5 recurrences. That drops by approximately 2 outbreaks per year in the following year. In the first year after a genital HSV-1 infection, the recurrence rate is just 1.3 outbreaks/year. That drops to a mere .7 outbreaks/year in the second year.

Those statistics can be misleading, however. Some patients have no outbreaks and others can experience 9 or more outbreaks per year. It is incredibly variable.

Remember, these statistics are all about symptoms. People often wonder why someone who had symptoms or who knew they had herpes, and who had outbreaks, would have sex when they had an outbreak and could transmit the disease. The problem is that herpes is shed from the skin even when people who get outbreaks feel perfectly well. Also, even the people who have no history of herpes, but in whom we know herpes is present (by blood tests), shedding of the virus from the skin occurs silently and the potential to transmit the virus exists.

This is called asymptomatic shedding and occurs in anyone who has herpes—whether they have symptoms or not.

What is asymptomatic shedding?

When a genital herpes outbreak occurs, the virus can be cultured for about 11 days with an initial outbreak and for about 4 days with a recurrence. Yet, the question is whether the virus can be found on the skin even in between outbreaks.

As it turns out, the herpes virus becomes active and can be “shed” from the skin on days when patients who have recurrences of genital HSV-2 feel perfectly well and in people who have only a positive blood test for HSV-2 and have never had an outbreak. In a pivotal study, women with symptomatic genital herpes Type 2 collected cultures from the cervix, vulva, and the rectum every day for over 3 months. They kept track of their symptoms with a daily diary, as well.

Shedding occurred without symptoms on 2% of the days in women with HSV-2 genital herpes. They shed more frequently in the 7 days prior to or following an outbreak. Shedding lasted fewer days when they were free of an outbreak but still accounted for one-third of all the days they shed the virus.

But what is the case for the over 80% of HSV-2-seropositive persons in the United States who are not aware that they are infected with HSV-2? Using a very advanced test called PCR (Polymerase Chain Reaction), samples from patients who had herpes type 2 but who had never had symptoms were compared to patients with genital HSV-2 who had symptoms in terms of shedding the herpes virus. The patients who had a history of symptoms shed the virus when they had no symptoms on 13% of days while those who only had HSV-2 by blood testing shed on 9% of days.

What is interesting is that the amount of virus shed during when no symptoms were present was essentially the same in both groups.

The precise rate of genital HSV-1 shedding in between outbreaks is not known but it is suspected it is far less than genital HSV-2 herpes. One small study using cultures, and not the much more sensitive PCR test, found shedding on only 1 out of every 200 days. Unfortunately, we know that HSV-1 also sheds asymptomatically from the mouth and in developed countries like the US, it is responsible for most of the new infections of genital herpes.

Some things are associated with a risk for shedding and some things are not. With genital herpes, time of the month in relation to menstruation, sexual orientation, and sex were not. Having a history of prior outbreaks, especially a history of more than 8 outbreaks/year, and being Caucasian, are a risk for an increase in asymptomatic genital shedding, as well as an increase in overall shedding (symptomatic and asymptomatic shedding combined).

Duration of asymptomatic shedding

Another factor associated with asymptomatic shedding is how long a patient has had the infection. The first year after acquiring genital HSV is the most difficult symptomatically—and it makes sense that would be the year with the most shedding of the virus. In one study, the shedding rate declined from one-quarter of days in the first year to 13% in the years that followed; however, the rate never seems to drop to 0. Even in people with HSV-2 who had the disease for 20 years, shedding still occurred on more than 10% of days.  

Herpes transmission

It has become clear that people who have antibodies in their blood to Herpes Type 2 shed the virus from their skin whether they have a history of outbreaks or not. Basically, if someone has antibodies to herpes, they are capable of transmitting the disease. In one study that followed the course of 144 couples in which one partner was infected and the other not infected, transmission occurred in 14 couples. In 9 of those cases, the person who transmitted the disease was completely free of symptoms—no outbreak, not even a prodrome (a warning that an attack was coming).

The other 5 transmissions happened when the person who was infected had a prodrome or developed lesions near the time the infection was transmitted. This makes sense. Shedding of the virus frequently occurs within 7 days of an outbreak, either before or after.

In another study of a vaccine that was totally ineffective 155 people acquired herpes from their partner. Only 57 people who became infected had any symptoms of herpes. That means 99 people acquired the infection and only knew about it because they were in a study and had a very accurate blood test that confirmed the infection. This is consistent with what we know, which is that the disease is most often transmitted by asymptomatic shedding (when people have no symptoms) and that the people who become infected most will have no symptoms (yet will be capable of transmitting the disease).

Some Important Information about Safe Sex

Although genital herpes is not generally a dangerous disease, most people want to do what they can to decrease the risks of transmitting the virus to their partner(s). There are a few methods that can help.

Using condoms: Condoms decrease the risks of transmitting STDs and double as contraception.

Taking suppressive therapy: Using valacyclovir daily to manage genital herpes decreases both outbreaks and asymptomatic shedding.

Asymptomatic shedding is the cause of most transmissions of herpes.

Abstaining from sex around outbreaks: Shedding is more common 7 days before and 7 days after outbreaks. Abstaining from sex for 7 days after an outbreak can decrease the risk of transmitting the herpes virus. Of course, it’s also important to abstain during your prodrome and an outbreak.

Lastly, you and your partners should always inform each other about STDs. Honesty is an important part of any sexual relationship. With treatment and a few precautions, genital herpes is highly manageable and the risk of transmitting it to a partner can be reduced significantly.

Herpes and pregnancy

In terms of transmission, women with herpes are often concerned most about transmitting the infection to their child during childbirth. They wonder how they can protect their baby if they could be shedding the virus and not have any symptoms. They wonder if they should take medication to reduce shedding the herpes virus; they fear they might need a C-section or even ask for one “just to be safe.” It is true that subclinical genital HSV shedding at the time of labor and delivery can infect a neonate and cause neonatal herpes, or herpes of the newborn—but it is exceedingly rare.

In one study, only 202 women out of more than 40,000 women who had genital HSV cultures at delivery were shedding herpes. Only a quarter of them had lesions; the rest were shedding subclinically. Out of those 40,000 women, only 10 newborns became infected but they all acquired herpes from mothers who were shedding asymptomatically.

The worst cases of newborn herpes happen when a mother becomes infected at the end of pregnancy and has not yet developed antibodies to herpes, antibodies she can share with a baby while in the womb, antibodies that go a long way toward protecting the newborn as it travels the birth canal.  

Herpes on other parts of the body

Herpes Whitlow

Herpes can infect skin on other areas of the body other than the mouth and genitals. You have learned how once the virus enters the body through the genitals and finds a home in the sacral plexus, it can travel back down any nerve in that cluster of nerves and reach the skin on the buttock, thigh, anus, rectum, or anywhere in the region of the groin.

However, the virus can enter the body any place that it lands where the skin might be more receptive because of a cut or tiny opening. This has been seen on the fingers and when herpes occurs on the finger, it is called a whitlow. This was most often seen in the past in dentist and dental healthcare providers.   

Herpes of the eye

Herpes can infect the eye and is called Herpes Simplex Keratitis. It most often involves only one eye and affects the cornea. It can cause pain, redness of the eye, tearing, light sensitivity, and a feeling like there is grit in the eye. Unlike herpes elsewhere, topical antiviral therapy is the treatment that is most effective when an outbreak occurs. It is noteworthy that viral shedding occurs in tears even when patients have no symptoms and that treatment with valacyclovir decreases the number of recurrences just like it does for infections elsewhere.

Treatment

Treatments for herpes (oral and genital) have been available for decades. The first highly effective medication was acyclovir. It proved effective in shortening outbreaks and was a boon at a time when so little seemed to work. In those early days having anything that could shorten an outbreak and even prevent them changed how people saw the disease.
Acyclovir worked in a very targeted way against Herpes DNA. In reality, there isn’t much more to a virus than its DNA and the proteins that cover it. To affect the virus, it is nearly essential to attack its DNA and that is what acyclovir does. DNA is made up of four repeating chemicals called nucleosides. How they are put together in a sequence determines everything, and we mean everything. It is the code of life. So, anything that stops a virus from making more of its DNA stops the virus from making more of itself. Acyclovir is almost an identical copy of one of those nucleosides (Guanine) that makes the code of life—almost an identical copy. One small change to the part of DNA that makes a chain grow makes it so acyclovir can be placed in the growing line of code while lacking the small structure needed so the next piece of code can be added. The chain terminates. Acyclovir is known as a synthetic nucleoside analog.


One limitation was that acyclovir was limited in how much could be absorbed through the intestines. Only 20% of it was ever used by the body. This limitation was overcome by creating something called a prodrug of acyclovir. Since Acyclovir is so poorly absorbed through the gut a mechanism was sought that would allow acyclovir to cross the bowel and get into the bloodstream.

By adding the amino acid l-valine to acyclovir, valacyclovir is created. With that extra amino acid, valacyclovir can be absorbed much better than acyclovir. Once in the body, the amino acid, valine, is severed from the valacyclovir and acyclovir can do what it does but now much more effectively since so much more of it is in the bloodstream. Twice a day or even once a day valacyclovir works better than 3–5 times/day of acyclovir. Another drug, famciclovir, uses the same concept to help penciclovir enter the body.


Different ways to use the medicine

There are any number of conditions where doctors will assure patients that no one knows their disease as the patient does. That is never truer than with herpes. Recurrences can be so subtle that patients can detect them even when clinicians may glance over them without noticing a thing. Most importantly, however, many patients learn to recognize the unique prodrome that warns them an outbreak may be coming. Patients can identify specific shifts in senses and feelings that seem trivial but are consistent signals that the virus is about to make itself known. It can be a dull ache in the back of the thigh, a small increase in the frequency of urination, an odd discomfort in the groin, a sensitivity of a particular patch of skin; it can be anything, but it is specific. While patients may not have prodromes or outbreaks, those living with herpes recurrences often can predict an outbreak with uncanny accuracy.

What follows is a general discussion of the different ways medication can be used with more specific dosing guidelines following the discussion.

Genital herpes

To treat or abort an outbreak when there are early symptoms (prodrome)

That kind of knowledge can allow some patients to use the medication to abort an outbreak. Whether oral or genital, people can take medication when their specific prodrome tells them an outbreak is on the horizon. The medication will stop an outbreak cold (often) and when it does not, it can shorten a milder outbreak than they might have had otherwise.

To prevent outbreaks when there are no symptoms but outbreaks are more likely

Patients also learn the life circumstances or behaviors that lead to more outbreaks. For some, a lack of sleep, increased alcohol, another illness, stress, too much sunlight, irritation, or anything, in fact, that can affect one’s immunity can spur an outbreak. That means that some patients can know not just when they feel an outbreak coming on but can know when they are more likely to have an outbreak due to their circumstances. They might be under stress, having more sex so more irritated, drinking a bit more than they should or missing sleep over an extended period. They will know that they should avoid those triggers and do their best to do so, but they also might want to take medication preventatively knowing they are more vulnerable at that time. Essentially they might take the medication for a week or two until the stress that is making them more susceptible to an outbreak has resolved.

To suppress outbreaks for an extended period

Another way patients can take the medication is when they know they absolutely would like to do all they can to reduce their chance of having an outbreak at a pivotal time. The classic example would be during a honeymoon but taking medication to suppress outbreaks on a daily basis can be prudent when going on vacation, starting a new job, in a new relationship, or at any time a patient feels it is how they want to approach their condition. And that’s the key.

How medication is used is completely in your hands. Learn everything you can and do not worry about using the medication in the way that suits you best. That may change as your circumstances change, or as the condition changes, or even as your mind changes.

To prevent transmission to an uninfected partner

One of the most important advances in herpes treatment came with the knowledge that transmission from an infected person to their uninfected partner could be reduced by the use of valacyclovir. Valacyclovir not only reduces the number of outbreaks a person experiences when using the medication every day but it reduces the number of days that someone sheds the virus asymptomatically. That results in fewer uninfected partners catching herpes. If a condom is worn and the medication used, the chances are reduced at least in half compared to using a condom alone.

Fewer outbreaks and fewer episodes of shedding means fewer people become infected.

Oral herpes

Abort an outbreak at the earliest sign or symptom (prodrome)

At that earliest sign, two tablets of valacyclovir 1000 mg for a total of 2000 mg is taken by mouth as the first dose. Then, 12 hours later, 2 tablets of 1000 mg of valacyclovir, for a total of 2000 mg, is taken as the second and final dose. The second dose can be taken sooner than 12 hours but never before 6 hours have passed. Adequate hydration makes sure the medicine is cleared through the kidneys as it should be.
The medication is only approved for two doses and there is no evidence in studies to advise the use of medication once lesions have appeared.


Specific dosing recommendations for Herpes

Treatment of initial genital outbreak

In patients with a first outbreak, the symptoms can be very severe. Multiple painful, genital ulcers can cover large areas of skin on both sides of the groin. They can experience burning during urination, fever, headaches, muscle and joint pain, and swollen, painful lymph nodes in the groin. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. For such patients, treatment is vital and can shorten the outbreak and ease the symptoms significantly. For the treatment of an initial episode of herpes genitalis, the FDA recommends taking valacyclovir 1 gram (1000 mg) twice a day for 10 days starting at the first sign or symptom of lesions, preferably within 48 hours of onset. The “CDC recommends this same dose for 7 to 10 days; treatment may be extended if healing is not complete after 10 days.” For HIV-infected patients, they recommend 1 gram (1000 mg) every 12 hours for 5 to 14 days.

Treatment of herpes labialis (i.e., cold sores)

To abort an outbreak of herpes on the lips or mouth the recommendation is that the patient should take 2 grams (2000 mg) of valacyclovir at the first sign or symptom of lesions and a second dose 12 hours later. The second dose should not be taken within 6 hours of the first. Those are the only doses recommended but patients sometimes take another dose or two of just 1 gram if they continue to have symptoms, or if a mild outbreak follows.

The PDR states that for HIV-infected patients, 1 gram (1000 mg) be taken every 12 hours for 5 to 10 days. Despite what some patients do when having continued symptoms the PDR states, “there are no data supporting the effectiveness of beginning treatment after the development of clinical signs of a cold sore (e.g., papule, vesicle, or ulcer).”

Treatment of recurrent herpes genitalis, including HIV-infected patients

To treat a recurrent outbreak, the FDA recommends using 500 mg of valacyclovir twice daily for 3 days starting at the first sign or symptom of lesions—preferably within 24 hours of onset. The CDC recommendation is identical but adds in the choice of using valacyclovir 1 g (1000 mg) one time a day for 5 days. Valacyclovir 1 g taken every 12 hours for 5 to 14 days is recommended by the HIV guidelines. The PDR also states, “There are no data supporting the effectiveness of beginning treatment more than 24 hours after the onset of symptoms.”

Treatment with suppressive therapy

The PDR states that for suppressive therapy of recurrent herpes genitalis in all patients valacyclovir 1 gram (1000 mg) should be taken once daily.

However, “in patients with a history of fewer than 9 recurrences per year, 500 mg once daily may be given.” They note that “500 mg once daily regimen appears to be less effective than other regimens in patients with 10 or more episodes per year.”

The PDR continues, “Safety and efficacy of valacyclovir beyond 1 year have not been established. In HIV-infected patients, 500 mg by mouth twice daily. The safety and efficacy of therapy beyond 6 months have not been established.”

To prevent transmission to a partner

The PDR recommends the infected partner take valacyclovir 500 mg once a day to decrease the risk of transmission to the uninfected partner “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Studies also did not run for an extended period so the PDR also states, “The efficacy of reducing transmission beyond 8 months in discordant couples has not been established.” This means they can only vouch for the data for an 8 month period of time.

An important point

Being diagnosed with genital herpes means you have acquired a sexually transmitted infection. If you have been diagnosed with genital herpes, you should have been checked for other sexually transmitted infections when you were diagnosed, including but not limited to HIV and syphilis. If you have not been, you should be and this is highly recommended.

Herpes can be transmitted to a partner despite best efforts like using a condom and using antiviral suppression therapy. Patients should never engage in sex without a condom or when they have an outbreak or a prodrome. Also, as asymptomatic shedding is more common in the seven days following an outbreak it is prudent to avoid sex during that period, as well.

Herpes and the risk of HIV infection

HSV-2 infection puts a person at greater risk of acquiring HIV infection—as much as 2 to 3 times the risk of those without herpes. The reason is that herpes creates ulcers that can make it easier for HIV to enter the body but general inflammation of the genitals is also responsible for the increased vulnerability to the infection. In women and men with positive blood tests for herpes, specialized testing shows signs of inflammation on the cervixes of women and under the foreskin of men. The specialized test is the finding of CD4 T cells. This is probably the result of the body’s immune system constantly fighting the herpes virus and it is seen even when no outbreak is evident. Of note, some CD4 T cells have been shown in the lab to be more susceptible to HIV infection than skin samples tested under the same conditions. Moreover, CD4 T cells hang around in inflamed tissue long after outbreaks heal.

This is another reason why STD testing is always the rule when beginning a new sexual relationship and why, whether having an outbreak or not, a condom is essential.

HSV-2 infection in HIV-infected individuals

HIV infected persons who have genital ulcers due to herpes are more likely to transmit HIV, as HIV is shed from these ulcers. Herpes itself may behave identically in the HIV positive individual but they are more likely to develop acyclovir resistance and to have outbreaks that last longer and appear different from typical cases.

HIV positivity is a complex condition that requires careful evaluation by experts in the field.

HSV vaccines

After years of frustration, there are reasons to be optimistic that a vaccine to prevent, or even to treat, herpes may be achievable. The development of a vaccine has been spurred by the realization that controlling herpes would be a major step in controlling the spread of herpes around the world, especially in places where medication is unavailable.

Herpevac vaccine did not prevent the acquisition of genital herpes Type 2 but it did show moderate success against catching herpes Type 1 and in making the disease milder if someone caught it. The study included 8000 participants but they were all women so the data may not be consistent in men. Nevertheless, the fact that a vaccine worked for HSV-1 is encouraging, especially since so many new cases of genital herpes are due to HSV-1. A number of vaccines are being tested to see if they could reduce the number of outbreaks and, most importantly, the amount of asymptomatic shedding. One vaccine in early testing, GEN-003, reduced shedding by 55%.

The advances are being made that give hope to anyone who has the infection or is the partner of someone with the HSV virus.


Valacyclovir details: PDR information

Read full prescribing information Here  

How can Valtrex be used

Treatment of herpes labialis (i.e., cold sores)

To abort an outbreak of herpes on the lips or mouth the recommendation is that the patient should take 2 grams of Valacyclovir at the first sign or symptom of lesions and a second dose 12 hours later. The second dose should not be taken within 6 hours of the first. Those are the only doses recommended but patients sometimes take another dose or two of just 1 gram if they continue to have symptoms, or if a mild outbreak follows.

The PDR states that for HIV-infected patients, 1 gram (1000 mg) be taken every 12 hours for 5 to 10 days. Despite what some patients do when having continued symptoms the PDR states, “there are no data supporting the effectiveness of beginning treatment after the development of clinical signs of a cold sore (e.g., papule, vesicle, or ulcer).”

Treatment of Initial genital outbreak

In patients with a first outbreak, the symptoms can be very severe.

Multiple painful, genital ulcers can cover large areas of skin on both sides of the groin. They can experience burning during urination, fever, headaches, muscle and joint pain, and swollen, painful lymph nodes in the groin. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. For such patients, treatment is vital and can shorten the outbreak and ease the symptoms significantly.

For the treatment of an initial episode of herpes genitalis, the FDA recommends taking valacyclovir 1 gram (1000 mg) twice a day for 10 days starting at the first sign or symptom of lesions, preferably within 48 hours of onset. The “CDC recommends this same dose for 7 to 10 days; treatment may be extended if healing is not complete after 10 days.”

For HIV-infected patients, they recommend 1 gram (1000 mg) every 12 hours for 5 to 14 days. The PDR also notes, “The efficacy of treatment with VALTREX, when initiated more than 72 hours after the onset of signs and symptoms, has not been established.”

Treatment of Recurrent Herpes Genitalis, Including HIV-infected Patients

To treat a recurrent outbreak, the FDA recommends using 500 mg of Valacyclovir twice daily for 3 days starting at the first sign or symptom of lesions—preferably within 24 hours of onset. The CDC recommendation is identical but adds in the choice of using Valacyclovir 1 gram (1000 mg) one time a day for 5 days. Valacyclovir 1 gram taken every 12 hours for 5 to 14 days is recommended by the HIV guidelines. The PDR also states, “There are no data supporting the effectiveness of beginning treatment more than 24 hours after the onset of symptoms.”

Treatment with Suppressive Therapy

The PDR states that for suppressive therapy of recurrent herpes genitalis in all patients Valacyclovir 1 gram (1000 mg) should be taken once daily.

However, “in patients with a history of fewer than 9 recurrences per year, 500 mg once daily may be given.” They note that “500 mg once daily regimen appears to be less effective than other regimens in patients with 10 or more episodes per year.”

The PDR continues, “Safety and efficacy of valacyclovir beyond 1 year have not been established. In HIV-infected patients, 500 mg PO twice daily. The safety and efficacy of therapy beyond 6 months have not been established.”

To Prevent Transmission to a Partner

The PDR recommends the infected partner take Valacyclovir 500 mg once a day to decrease the risk of transmission to the uninfected partner “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Studies also did not run for an extended period so the PDR also states, “The efficacy of reducing transmission beyond 8 months in discordant couples has not been established.” This means they can only vouch for the data for an 8 month period of time. The PDR also states, “The efficacy of VALTREX for the reduction of transmission of genital herpes in individuals with multiple partners and non-heterosexual couples has not been established. Safer sex practices should be used with suppressive therapy.” Centers for Disease Control 26 and Prevention [CDC] Sexually Transmitted Diseases Treatment Guidelines

Maximum Dose

In children 12 years and older, adolescents, adults, and the elderly, the maximum daily dose is 4 grams if given for just 1 day and 3 grams/day if given for more than 1 day.

In children 2 years to 11 years, 3 grams/day is the maximum dose.
Safety has not been established in neonates, infants, and children less than 2 years.

Dose adjustments should be made for those with kidney impairment or issues. Decreased doses are needed as kidney impairment slows the clearing from the body of valacyclovir. The degree of impairment determines the decrease in the dosage. The elderly may have decreased kidney function and adjustments should be considered in such cases.

No adjustment is needed, generally, in patients with liver impairment.

However, if you have a liver condition or impairment, inform your doctor.

Overdose: Valtrex is not usually harmful unless you take too much for several days. An excess of Valtrex can cause vomiting, kidney problems, confusion, agitation, feeling less aware, seeing things that aren’t there, or loss of consciousness. For severe symptoms, go direction to an emergency room. Otherwise, talk to your doctor or pharmacist if you take too much Valtrex. Take the medicine pack with you.


Contraindications and Precautions

Sensitivity or Allergies: Patients with sensitivity or an allergy to any of the following medications should not use Valacyclovir: Acyclovir, Famciclovir, ganciclovir, penciclovir, valacyclovir, or valganciclovir.

Kidney Issues: Dose adjustments should be made for those with kidney impairment or issues. Decreased doses are needed as kidney impairment slows the clearing from the body of valacyclovir. The degree of impairment determines the decrease in the dosage. The PDR states, “Acute renal failure and CNS (Nervous System) toxicity have been reported in patients with underlying renal (Kidney) dysfunction who have received inappropriately high doses of valacyclovir for their level of renal (Kidney) function. Patients receiving potentially nephrotoxic(Toxic to the Kidney) drugs together with valacyclovir may have an increased risk of renal dysfunction (impairment).”

The Elderly: The elderly are more likely to have impaired kidneys so they might not clear valacyclovir from their system as efficiently as they should. This can lead to inappropriately high levels of valacyclovir, which means the elderly may need lower doses of valacyclovir. The elderly are also more likely to experience neurological side effects, including: agitation, hallucinations, confusion, delirium, and other abnormalities of brain function termed encephalopathy.

Dehydration: When patients are dehydrated acyclovir can reform as a solid in the kidney leading to kidney damage. Patients should all remain well hydrated when taking valacyclovir.

Newborns, Infants, and children: Safety has not been established in neonates, infants, and children less than 2 years.

Pregnancy: While a registry that collected data on the 756 pregnancies of women exposed to acyclovir in the first trimester showed no greater occurrence of birth defects than occurs in the general population, the study size was too small to guarantee safety during pregnancy.

You should not take valacyclovir if you are pregnant or trying to become pregnant, unless recommended by your obstetrician/gynecologist or other healthcare provider.

Breastfeeding: The PDR states, “According to the manufacturer, valacyclovir should be administered to a nursing mother with caution and only when indicated. Although the American Academy of Pediatrics (AAP) has not specifically evaluated valacyclovir, systemic maternal acyclovir is considered to be usually compatible with breastfeeding…Consider the benefits of breastfeeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition.”

Driving or Using Machines: Valtrex can cause side effects that affect your ability to drive. Don’t drive or use machines unless you are sure you’re not affected.

Thrombotic Thrombocytopenic Purpura/Hemolytic Uremic Syndrome (TTP/HUS): TTP/HUS is a rare condition but has occurred in patients with advanced HIV disease and also in allogeneic bone marrow transplant and renal transplant recipients participating in clinical trials of VALTREX at doses of 8 grams per day. If any of these conditions apply to you, please inform your doctor and pharmacist.


Side Effects (Overview)

What follows is a summary and does not include every side effect possible. Please, read the package insert and report any side effects you experience whether on the list below or not.

Very Common (may affect more than 1 in 10 people): headache

Common (may affect up to 1 in 10 people): feeling sick, dizziness, vomiting, diarrhea, skin reaction after exposure to sunlight (photosensitivity), rash, itching (pruritus)

Uncommon (may affect up to 1 in 100 people), feeling confused, seeing or hearing things that aren’t there (hallucinations), feeling very drowsy, tremors, feeling agitated

These nervous system side effects usually occur in people with kidney problems, the elderly or in organ transplant patients taking high doses of 8 grams or more of Valtrex a day. They usually get better when Valtrex is stopped or the dose reduced.

Other Uncommon Side Effects: shortness of breath (dyspnea), stomach discomfort, rash, sometimes itchy, hive-like rash (urticaria), low back pain (kidney pain), blood in the urine (hematuria)

Uncommon Side Effects That May Show Up In Blood Tests: reduction in the number of blood platelets which are cells that help blood to clot (thrombocytopenia), reduction in the number of white blood cells (leukopenia), increase in substances produced by the liver  

Rare (may affect up to 1 in 1,000 people): unsteadiness when walking and lack of coordination (ataxia), slow, slurred speech (dysarthria), fits (convulsions), altered brain function (encephalopathy), unconsciousness (coma), confused or disturbed thoughts (delirium)

These nervous system side effects usually occur in people with kidney problems, the elderly or in organ transplant patients taking high doses of 8 grams or more of Valtrex a day. They usually get better when Valtrex is stopped or the dose reduced.

Other Rare Side Effects: kidney problems where you pass little or no urine.

Lastly, watch out for a severe allergy. It may be rare but it can be life-threatening so being aware of the symptoms is vital.

Severe allergic reactions (anaphylaxis): These are rare in people taking Valtrex. Anaphylaxis is marked by the rapid development of flushing, itchy skin rash, swelling of the lips, face, neck, and throat—causing difficulty in breathing (angioedema), fall in blood pressure leading to collapse. If any of these occur, get emergency treatment immediately


Drug interactions

Of Note: “When VALTREX is coadministered with antacids, cimetidine and/or probenecid, digoxin, or thiazide diuretics in patients with normal renal function, the effects are not considered to be of clinical significance. Therefore, when VALTREX is coadministered with these drugs in patients with normal renal function, no dosage adjustment is recommended.” (PDR)

Aprotinin: Aprotinin is cleared in the kidney as is Valacyclovir. Together, the risk to the kidney is increased.

Bictegravir; Emtricitabine; Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.  

Cimetidine: Cimetidine may slow how quickly valacyclovir is cleared out of the body through the kidney but no dosage adjustments are recommended for patients with normal renal function.

Cobicistat; Elvitegravir; Emtricitabine; Tenofovir
Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Cobicistat; Elvitegravir; Emtricitabine; Tenofovir Disoproxil Fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Efavirenz; Emtricitabine; Tenofovir: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Rilpivirine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Rilpivirine; Tenofovir disoproxil fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Tenofovir disoproxil fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Entecavir: Entecavir can affect kidney function and should be used cautiously with valacyclovir.

Fosphenytoin: Phenytoin and fosphenytoin are anti-seizure medications. The addition of valacyclovir to phenytoin may lead to a clinically significant decrease in phenytoin serum concentrations and loss of seizure control. Adjustments in phenytoin or fosphenytoin dosing should be considered if Valacyclovir is added or stopped when a patient is on either phenytoin and fosphenytoin.

Hyaluronidase, Recombinant; Immune Globulin: Immune Globulin (IG) products can damage the kidney. If they take any other drug that can affect the kidney, including valacyclovir, the dose of IG may need to be lowered and the infusion rate slowed.

Immune Globulin IV, IVIG, IGIV: Immune Globulin (IG) products can damage the kidney. If they take any other drug that can affect the kidney, including valacyclovir, the dose of IG may need to be lowered and the infusion rate slowed.

Lamivudine; Tenofovir Disoproxil Fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Measles Virus; Mumps Virus; Rubella Virus; Varicella Virus Vaccine, Live: (Major) If possible, discontinue valacyclovir at least 24 hours before administration of the varicella-zoster virus vaccine, live. Also, do not administer valacyclovir for at least 14 days after vaccination. The medication might have the unintended effect of diminishing the protective benefit of the vaccine.

Mycophenolate: (Moderate) Valacyclovir, when added to MMF, cyclosporine, and prednisolone caused a decrease in White Blood Cells, called neutropenia. When this combination must be used careful blood monitoring is recommended.

Phenytoin: Phenytoin is an anti-seizure medication. The addition of valacyclovir to phenytoin may lead to a clinically significant decrease in phenytoin levels and loss of seizure control. Adjustments in phenytoin dosing should be considered if valacyclovir therapy is added or discontinued.

Probenecid: Probenecid can reduce the kidney’s clearance of valacyclovir causing an increase in the blood level of valacyclovir. In the absence of a decrease in renal function, no dose adjustment is needed.

Talimogene Laherparepvec: “Consider the risks and benefits of treatment with talimogene laherparepvec before administering acyclovir or other antivirals to prevent or manage herpetic infection. Talimogene laherparepvec is a live, attenuated (lessened capacity to cause disease) herpes simplex virus that is sensitive to acyclovir; coadministration with antiviral agents may cause a decrease in efficacy.”

Telbivudine: Valacyclovir can affect kidney function. Since telbivudine is also cleared by the kidney, monitoring kidney function before and during telbivudine treatment is recommended.

Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Tenofovir, PMPA: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Varicella-Zoster Virus Vaccine, Live: (Major) If possible, discontinue valacyclovir at least 24 hours before administration of the varicella-zoster virus vaccine, live. Also, do not administer valacyclovir for at least 14 days after vaccination. The medication might have the unintended effect of diminishing the protective benefit of the vaccine.


Cold Sores Treatment Plan

Valacyclovir 500 mg

Daily therapy to suppress outbreaks and reduce risk of transmission to an uninfected partner

Be sure to take your time and read everything below. It is essential for you to understand the potential risks and benefits of treatment. Please do not hesitate to reach out to our medical support team if you have ANY questions.

Overview

Herpes is not simply an infection. Too many people suffer silently, fearing to even reach out to their healthcare providers. There are few conditions where a person’s care is so dependent on their participation. Time must be dedicated to education and to formulating a plan that is under your control.

Medication is available—and it works extremely well—but how it is used and when it is used can never be more precisely applied than when a person uses the guidance of experts to craft a personalized plan.

With the education we provide below, you will be able to decide how best to utilize all the tools at your disposal. The key is to learn as much as you can and make informed decisions. The information below will help you gain a level of independence you may not have realized is possible.

Read carefully your doctor’s personalized treatment plan and all the material provided. It may well provide some new information that will be helpful to you. Nothing is sugar coated because we feel you deserve the information you need to live your life the way you want. Read it all along with the package insert and the information in the Prescribers’ Digital Reference (PDR).

One important point is that if the medicine prescribed does not improve your condition (now or at any time), or if your symptoms at any point in the future are not completely typical of your usual outbreak, then you must be seen by a physician in person and checked for other conditions.

Lastly, the plan your personal doctor has provided is just the initial plan.

You may well choose a different one after reading more about other options or, in 6 months, your life circumstances may have changed and a different plan may suit you better. Just reach out to us.  

We are here to make your life better, not to give you more challenges in finding the care you need. And don’t forget, contact us if you need us.


Your treatment plan

Your doctor has reviewed your medical information and has prescribed valacyclovir 500 mg to treat cold sores. Valacyclovir has been approved to treat cold sores in several ways. It can be taken to lessen the severity of an initial outbreak, to abort outbreaks when someone feels telltale signs (the prodrome) that tells them an outbreak is about to happen, or to prevent outbreaks and reduce the risk of transmitting herpes by taking one pill every day.

Your doctor has written a prescription for valacyclovir to be used to limit outbreaks and reduce the risk of transmitting herpes by taking one pill every day. One of the most important advances in herpes treatment came with the knowledge that transmission from an infected person to their uninfected partner could be reduced by the use of daily valacyclovir.

Valacyclovir not only reduces the number of outbreaks a person experiences when using the medication every day but it reduces the number of days that someone sheds the virus asymptomatically (shedding of the herpes virus from normal skin when a person feels completely well).

Asymptomatic shedding is how most transmissions occur. Reducing asymptomatic shedding results in fewer uninfected partners catching herpes. If a condom is worn and the medication used, the chances are cut in half compared to using a condom alone. Fewer outbreaks and fewer episodes of asymptomatic shedding means fewer people become infected.

In one study that followed the course of 144 couples in which one partner was infected and the other not infected, transmission occurred in 14 couples. In 9 of those cases, the person who transmitted the disease was completely free of symptoms—no outbreak, not even a prodrome (a warning that an attack was coming). The other 5 transmissions happened when the person who was infected had a prodrome or developed lesions near the time the infection was transmitted. As noted, the key to preventing transmission isn’t just limiting outbreaks but reducing asymptomatic shedding. Valacyclovir, taken daily, reduces the number of outbreaks a person experiences and the number of days that someone sheds the virus asymptomatically.

To reduce the number of outbreaks an infected person experiences and to reduce the risk of transmission to an uninfected partner (by up to 50%), the PDR recommends the infected partner take valacyclovir 500 mg/day.

The study measured results “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Also, the study ran only for 8 months.


Valacyclovir FAQs

An important point

Herpes can be transmitted to a partner despite best efforts like using a condom and using antiviral suppression therapy. Patients should never engage in sex without a condom or when they have an outbreak or a prodrome. Also, as asymptomatic shedding is more common in the seven days following an outbreak, it is prudent to avoid sex during that period, as well.

The following information (Preventing future outbreaks and Other ways to use the medication) is relevant if at some point you decide to go off suppression therapy and choose to try to abort outbreaks and use suppression therapy in some specific situations only.

Preventing Future Outbreaks

If you are just trying to abort outbreaks, make a note of everything you think may have made you more susceptible to an outbreak. Was there more irritation to the area? Did anything affect your immunity like another infection (e.g., a cold) or did you change something in your lifestyle that could have weakened your immune system (e.g., lack of sleep, stress, increased alcohol consumption)? No change is too small to note.

This is important because it will help you maintain the patterns that make herpes less likely to appear. For you, it may be a lack of sleep over a few consecutive nights that spurs most outbreaks. It might be excessive sun exposure or too much alcohol consumption. It could happen only when you are sick or just run down. Whatever it might be, over time you may come to recognize the issues and make changes that reduce the frequency of outbreaks.

Other ways to use the medication

Some patients ask if they can take the medication to prevent an outbreak when they least want to have one. The classic examples are a bride or groom on their wedding day, when first engaging in sex with a new partner, or going on that long planned and much-needed vacation with your partner or spouse. You don’t need to be getting married or about to rendezvous for a much-anticipated tryst to want to prevent a herpes outbreak at particular times. It could be that an outbreak would be uncomfortable during the holidays or at any time you determine.

That is what we mean when we say you have control. At one point in life, a person may choose to abort outbreaks when they feel them coming on, at another point they might choose suppression therapy, but that may change, too. Circumstances change; only you will be able to know how your circumstances affect which option you choose. That is why learning all you can is so important. It gives you independence. Things change and how you choose to use valacyclovir may change.

One other fact is worth noting. You have been prescribed 30 pills of valacyclovir 500 mg every month. You should always have medication on hand, so renew your prescription well before you run out. As long as valacyclovir proves effective and you are free of significant side effects, you should never have to worry about having access to what you need.

You can always drop a note to your doctor, the pharmacist, or the care team with any questions, issues, or changes you want to consider. There is no “extra” visit charge or cost if you just want to ask questions and learn more about how you can manage your condition.

Lastly, if you would like to switch to intermittent therapy, you can always hold back on getting more valacyclovir delivered.

This may be a new situation for you but as long as the medication works without causing you difficulties of any sort, you are in control.    


Herpes: condition overview

A wealth of herpes information (oral and genital)

In the United States, genital herpes caused by HSV-2 (Herpes Simplex Virus Type 2) is extremely common and the most frequent cause of genital ulcer disease. Yet, the people who have symptoms represent the smallest number of people infected. In fact, 80% of the people who have genital herpes do not know it. That means for every person with symptoms who takes the step to be treated as you have, there are 4 people who are infected but totally unaware. 

Much of what we know about herpes is different from what people learned during the height of the “fear” an infection caused when no treatment was available.

That is what we must change. We want you to learn the facts about herpes so you do not become a victim of the myths. Also, only by understanding the disease will you be able to work with your doctor to craft the right treatment plan for you as your life evolves. What suits you today may not in 6 months or in 5 years. If you understand herpes, and how medications can work in different circumstances, you will be able to take control of your life in ways you might not have known were possible.

Lastly, if you read the next few pages carefully (though seemingly simply) you probably will know more helpful facts about herpes than many doctors.

What is herpes?

Herpes is a virus. The herpes virus can barely be considered alive. It is little more than a strand of DNA (deoxyribonucleic acid), the code of life, safely hidden inside a shell of protein. On its own, a herpes virus cannot reproduce or do much of anything—until it infects us. When the herpes virus comes in contact with areas that are receptive, like the genitals or mouth, the virus invades the epithelial cells (skin cells) in that region.

Then, the DNA of the herpes virus is released into the skin cell. At that point, it quite literally takes over.

It directs the cell to make more herpes virus and, when they have made enough copies to damage the cell so severely that it bursts, millions of the newly formed viruses are released infecting more cells, eventually causing an ulcer.

That is what people can see and feel, but a good deal more than that happens. While it is infecting skin cells and causing pain and ulcers, it also begins to attack the nerve cells in the same area. When the virus enters the nerve cell, it not only reproduces but it moves up the nerve to a bundle of nerves in the back called the sacral plexus. Once it is in the nerves, it is essentially protected from being attacked by the body’s immune system. Nerve cells can never be replaced.

That is why when nerves in the spine are damaged people become paralyzed. Since nerves cannot reproduce themselves easily, the body is careful not to bombard them with all the weapons it has to clear infections. All the inflammation that is caused by the battle to eliminate infections elsewhere would be disastrous if that occurred with nerves.

There is no sense clearing an infection if nerve cells that could never be replaced are destroyed in the process.

The herpes virus is essentially protected from an attack by our immune system as long as it hides out in the nerves of the sacral plexus when it affects the genitals, or the “dorsal root ganglion” (a cluster of nerves in the neck region of the spine) when it infects the mouth.

Unfortunately, that leaves the virus in a perfect position to sneak back out when the immune system is suppressed in any way. That is how the virus is able to cause recurrent infections, especially during times of stress, illness, or any condition or circumstance that makes our immune system less vigilant. We will discuss that in detail later.

How common are HSV-1 and HSV-2?

Worldwide (in 2012) nearly one half billion people were infected with HSV-2 between the ages of 15 and 49—and the number rises with age and the number of life partners. More women than men have herpes (14.8% versus 8% global prevalence, respectively). In the US, the number of people infected has been dropping, but the news isn’t all good. The percentage of people with a positive blood test for HSV-2 has declined. In people age 14 to 49, 21% were positive in the early 90s. By 2010, that number dropped to about 16%. Unfortunately, the improvement has been seen mostly in the white population “with stable rates in black populations, resulting in worsening racial disparities such that for every one white man, four black men are infected, with similar ratios for women.”

The reasons for this might be that access to information, education—and the medication that can reduce the risk of transmission—has not been made available to all equally.

In the United States, the prevalence of HSV-1, which accounts for the vast majority of oral herpes, has dropped 29% among 14–19 year olds, from approximately 42% to 30%, over the past 30 years. As a result, adolescents and young adults may experience their first exposure to HSV-1 with the initiation of sexual activity, including oral sex.

How can it be that some people do not have symptoms of oral herpes and of genital herpes?

It is vital to understand that 80% of people with an infection have no symptoms they recognize. For those who experience severe or frequent outbreaks, that is difficult to understand. There are multiple explanations.

The first one is related to how we physicians first described the disease.

Before there were elegant tests to culture herpes, or to test lesions for signs of herpes DNA, and before accurate blood tests out of the University of Seattle, herpes was described by doctors by what they saw—and only by what they saw. This meant that only people who had visible lesions (sores) were diagnosed and doctors thought that all those who had herpes had symptoms. It turns out that patients with severe disease were just the tip of the iceberg, but doctors didn’t realize that. Unfortunately, too many myths and outright falsehoods became “common knowledge.”

The fact is most people have an immune response that holds the disease at bay—in terms of causing symptoms, that is. They are still infected and, as we will learn later, still able to transmit the disease, but the symptoms either do not occur or are so subtle that they go unnoticed or undiagnosed. Herpes can cause such minor complaints that they are ignored.

Herpes can appear as little more than an irritation or tiny erosion. A lesion tucked away in the genital region can be so small that it cannot be seen without doing some major stretching before trying or using a magnifying lens. Or the sore is in a place that is completely inaccessible to viewing (e.g., the anus, the groin, the vagina, or hidden within a small skin fold).

Also, the symptoms may disappear so quickly that they are dismissed, or never seen in time by a doctor, or a doctor does not recognize how minor herpes can be even when seen in time. This is true of oral and genital herpes.

Nevertheless, the people who have what we call asymptomatic herpes can still transmit the disease. They can do this because they can still “shed” the virus from the skin even without having a sore or a symptom that they recognize as herpes. Asymptomatic shedding occurs from the mouth in those with oral herpes, from the anal and genital region in those with genital herpes, and even from tears in people who have had herpes of the eye. The section on asymptomatic shedding explains this in detail.


Clinical manifestations of Herpes

Clinical manifestations of Oral HSV infection

Classically, the oral symptoms are familiar to most people who either have had an outbreak or seen them in others. The initial symptoms are a sense of tingling or itching that can occur 24 hours before any lesions appear.

The first visible symptoms are redness, followed by the forming of a papule or elevation of the skin affected (usually on the very edge of the lips where they transition to the skin of the face). Then, the small roundish elevations become filled with fluid (a vesicle), which can burst and reveal a small ulcer or divet in the skin. This will be painful and ooze fluid and within just a few days heal, usually without a scar. These lesions do not form solely on the edge of the lip. They can form anywhere on the face, particularly a region between the nose and lips and out to the first fold on the cheek called the “nasolabial fold.”

The virus hides in the nerves in the back of the neck called the dorsal root ganglion. When HSV-1 reactivates and comes out of that nerve it can take a route other than to the edge of the lip. It can even cause an outbreak on the back of the neck but, most often, it is the lips where outbreaks will recur.

Oral symptoms can be more easily seen but often are not understood to be related to herpes. Minor irritations that disappear quickly might easily be dismissed as a simple cut or reaction to spicy food.

Other people might mistakenly consider unrelated irritations to be herpes on the mouth when they are not. For example, canker sores that occur inside the mouth and can recur just like herpes are sometimes misdiagnosed by patients and doctors alike as being due to the HSV-1 virus when, in reality, it is possibly an immune reaction and not an infection. The same sometimes occurs with irritation on the corners of the mouth, called angular cheilitis or perleche. This can be idiopathic, meaning it has no known cause, or can be due to the buildup of fluid at the corners of the mouth. It is a perfect spot to nurture growths of yeast or fungus (think Candida) and the irritation can even lead to small cuts and sores.

We always advise patients to confirm their diagnosis if recurrent oral lesions are completely unresponsive to herpes antiviral therapy.  

Clinical manifestations of Genital HSV infection

HSV-2 is the leading cause of genital ulcers in the United States and throughout the world. We know that because a very accurate test called a PCR test, which is far more sensitive than a culture, has found herpes in 60% of genital ulcers. Remember that most people with herpes found by blood testing have had no symptoms of herpes. What follows is a description of herpes as it appears in those who experience symptoms, in people who are seen by doctors with lesions.

First outbreak or primary outbreak

For patients who have symptoms, the first outbreak can be the worst. During primary infection, patients may experience multiple genital ulcers that can cover larger areas of skin. It can be on both sides of the groin and be quite painful. They often experience burning during urination in addition to the local pain. They can have fever, headaches, muscle and joint pain, and their lymph nodes in the groin can be swollen and painful as well. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. Therapy can shorten that period significantly.

The reason an initial outbreak can be so severe is that there are no antibodies to herpes when the virus first enters the body, (though a prior history of herpes type 1 can give someone antibodies that work a little bit to fight herpes type 2 and may make an outbreak a bit less severe.)
An initial outbreak can be caused by Herpes 1 and in developed countries like the US, the most common cause of an initial attack of herpes is actually herpes 1. Most people do not realize that someone infected with oral herpes from type 1 can perform fellatio or cunnilingus on a partner and transmit herpes 1 from their mouth to their partner’s genitals. If you think about it, why not? The problem is that many people don’t know they have oral herpes. It may be easier to see but not many people remember the cold sore they had when they were 3. Also, while most people in the past acquired herpes on the mouth as a child when exchanging saliva with other children who were infected, that has not been happening with anywhere near the same frequency. The rate of infection with Herpes 1 is lower now than at any time in the past. In the United States, HSV-1 has dropped 29% among 14–19 year olds, from 42.6% to 30.1% over the last 3 decades.

That means that adolescents who engage in sex are more likely to be exposed to Herpes 1 for the first time when having oral or vaginal sex. Changes in sexual practices have also made the transmission more likely.

Fellatio (a “blow job”) and cunnilingus (“going down”) are much more frequently practiced at younger ages and with fewer restraints imposed by cultural or social forces. That has made herpes 1 the most common cause of first outbreaks in developed countries. Nevertheless, herpes 1 and herpes 2 on the genitals do not behave identically in terms of recurrences. Herpes 1 is more “at home” in the oral region and has developed ways to deal with that environment. When on the genitals, it can cause all the same symptoms and can still be transmitted, but it has a milder course than when herpes 2 infects the genitals. This is discussed more in the section on recurrences.

Understanding how herpes can remain in the body yet be kept at bay to some degree is pivotal. Herpes enters the sacral plexus of nerves during an initial infection. As discussed above, the virus remains safe from attack by antibodies and the immune system as long as it is tucked away in the nervous system. That little trick, entering the nervous system where it neither damages the nerves nor can be attacked, makes herpes a particularly stubborn infection. It can slide down the nerves that go from the sacral plexus to the skin and cause more outbreaks in the future. These are called recurrences.

Recurrences occur in a milder version than the initial outbreak because the body is not completely defenseless. It is the ongoing battle between the herpes virus’ ability to stay safe in the nervous system and the body’s ability to mount a defense with antibodies that determines if symptoms will appear or not. In most people, the battle is a stalemate in terms of symptoms. Most people never have an outbreak or, if they do, they are so mild they are not noticed. In terms of keeping herpes under such control that the virus never exits the nervous system and sheds from the skin, the battle definitely tilts in favor of the virus.

It is in the ways herpes remains active in those who are infected, and able to spread to those who are not, that makes herpes such a difficult infection to control in terms of preventing outbreaks and preventing transmission.

However, control is possible—and that is the key.

Recurrences

While the immune system for the vast majority of people makes recurrences far less severe than a primary outbreak, periodic recurrences occur in genital HSV infections. They are also quite different in character.

First, since herpes is in the nerves of the patient, as the virus becomes more active and begins to travel down the nerve to the skin, a person may get symptoms that tell them an outbreak on the skin is about to appear.

They may get leg pain, back pain, a tingling sensation, burning, or itching. They might notice less specific symptoms like increased urination, but symptoms like fever or muscle aches are much less common than with an initial outbreak. These symptoms collectively are known as a prodrome. It is very variable but patients begin to recognize their pattern, their unique prodrome.

The outbreaks themselves are much milder. They tend to occur on one side of the body, to cover a smaller area, and are less painful. Swelling of the lymph nodes is uncommon and all the symptoms resolve much more quickly, lasting just 3–5 days.

Because herpes lives in the sacral plexus and nerves from that accumulation of nerves can reach out not just to the skin where the infection first started but to any area the nerves can go, recurrent outbreaks are not limited to the initial region it entered the body. They can occur on the buttocks, the thigh, or anywhere in the anal and genital regions. Recurrences in areas other than the genitals (e.g., thigh) have a similar pattern to those that occur on the genitals.

Also, while herpes tends to improve over time, people can get outbreaks at any point that their immune system is challenged. This can happen when another illness occurs, with cancer or cancer treatments, or with such simple changes as life stress due to divorce, moving, changing jobs, or death of a family member as examples. Excessive friction, sunburns, exhaustion, poor sleep patterns can also deplete a person’s immune system. In fact, anything that makes you less healthy or is a challenge to the system can make an outbreak more likely to occur. Over time patients not only recognize their prodromes, but they also recognize the circumstances associated with an outbreak.

In terms of the frequency of recurrences, genital HSV-2 recurs far more often than genital HSV-1. In the first year after primary infection with genital HSV-2, patients average about 5 recurrences. That drops by approximately 2 outbreaks per year in the following year. In the first year after a genital HSV-1 infection, the recurrence rate is just 1.3 outbreaks/year. That drops to a mere .7 outbreaks/year in the second year.

Those statistics can be misleading, however. Some patients have no outbreaks and others can experience 9 or more outbreaks per year. It is incredibly variable.

Remember, these statistics are all about symptoms. People often wonder why someone who had symptoms or who knew they had herpes, and who had outbreaks, would have sex when they had an outbreak and could transmit the disease. The problem is that herpes is shed from the skin even when people who get outbreaks feel perfectly well. Also, even the people who have no history of herpes, but in whom we know herpes is present (by blood tests), shedding of the virus from the skin occurs silently and the potential to transmit the virus exists.

This is called asymptomatic shedding and occurs in anyone who has herpes—whether they have symptoms or not.

What is asymptomatic shedding?

When a genital herpes outbreak occurs, the virus can be cultured for about 11 days with an initial outbreak and for about 4 days with a recurrence. Yet, the question is whether the virus can be found on the skin even in between outbreaks.

As it turns out, the herpes virus becomes active and can be “shed” from the skin on days when patients who have recurrences of genital HSV-2 feel perfectly well and in people who have only a positive blood test for HSV-2 and have never had an outbreak. In a pivotal study, women with symptomatic genital herpes Type 2 collected cultures from the cervix, vulva, and the rectum every day for over 3 months. They kept track of their symptoms with a daily diary, as well.

Shedding occurred without symptoms on 2% of the days in women with HSV-2 genital herpes. They shed more frequently in the 7 days prior to or following an outbreak. Shedding lasted fewer days when they were free of an outbreak but still accounted for one-third of all the days they shed the virus.

But what is the case for the over 80% of HSV-2-seropositive persons in the United States who are not aware that they are infected with HSV-2? Using a very advanced test called PCR (Polymerase Chain Reaction), samples from patients who had herpes type 2 but who had never had symptoms were compared to patients with genital HSV-2 who had symptoms in terms of shedding the herpes virus. The patients who had a history of symptoms shed the virus when they had no symptoms on 13% of days while those who only had HSV-2 by blood testing shed on 9% of days.

What is interesting is that the amount of virus shed during when no symptoms were present was essentially the same in both groups.

The precise rate of genital HSV-1 shedding in between outbreaks is not known but it is suspected it is far less than genital HSV-2 herpes. One small study using cultures, and not the much more sensitive PCR test, found shedding on only 1 out of every 200 days. Unfortunately, we know that HSV-1 also sheds asymptomatically from the mouth and in developed countries like the US, it is responsible for most of the new infections of genital herpes.

Some things are associated with a risk for shedding and some things are not. With genital herpes, time of the month in relation to menstruation, sexual orientation, and sex were not. Having a history of prior outbreaks, especially a history of more than 8 outbreaks/year, and being Caucasian, are a risk for an increase in asymptomatic genital shedding, as well as an increase in overall shedding (symptomatic and asymptomatic shedding combined).

Duration of asymptomatic shedding

Another factor associated with asymptomatic shedding is how long a patient has had the infection. The first year after acquiring genital HSV is the most difficult symptomatically—and it makes sense that would be the year with the most shedding of the virus. In one study, the shedding rate declined from one-quarter of days in the first year to 13% in the years that followed; however, the rate never seems to drop to 0. Even in people with HSV-2 who had the disease for 20 years, shedding still occurred on more than 10% of days.  

Herpes transmission

It has become clear that people who have antibodies in their blood to Herpes Type 2 shed the virus from their skin whether they have a history of outbreaks or not. Basically, if someone has antibodies to herpes, they are capable of transmitting the disease. In one study that followed the course of 144 couples in which one partner was infected and the other not infected, transmission occurred in 14 couples. In 9 of those cases, the person who transmitted the disease was completely free of symptoms—no outbreak, not even a prodrome (a warning that an attack was coming).

The other 5 transmissions happened when the person who was infected had a prodrome or developed lesions near the time the infection was transmitted. This makes sense. Shedding of the virus frequently occurs within 7 days of an outbreak, either before or after.

In another study of a vaccine that was totally ineffective 155 people acquired herpes from their partner. Only 57 people who became infected had any symptoms of herpes. That means 99 people acquired the infection and only knew about it because they were in a study and had a very accurate blood test that confirmed the infection. This is consistent with what we know, which is that the disease is most often transmitted by asymptomatic shedding (when people have no symptoms) and that the people who become infected most will have no symptoms (yet will be capable of transmitting the disease).

Some Important Information about Safe Sex

Although genital herpes is not generally a dangerous disease, most people want to do what they can to decrease the risks of transmitting the virus to their partner(s). There are a few methods that can help.

Using condoms: Condoms decrease the risks of transmitting STDs and double as contraception.

Taking suppressive therapy: Using valacyclovir daily to manage genital herpes decreases both outbreaks and asymptomatic shedding.

Asymptomatic shedding is the cause of most transmissions of herpes.

Abstaining from sex around outbreaks: Shedding is more common 7 days before and 7 days after outbreaks. Abstaining from sex for 7 days after an outbreak can decrease the risk of transmitting the herpes virus. Of course, it’s also important to abstain during your prodrome and an outbreak.

Lastly, you and your partners should always inform each other about STDs. Honesty is an important part of any sexual relationship. With treatment and a few precautions, genital herpes is highly manageable and the risk of transmitting it to a partner can be reduced significantly.

Herpes and pregnancy

In terms of transmission, women with herpes are often concerned most about transmitting the infection to their child during childbirth. They wonder how they can protect their baby if they could be shedding the virus and not have any symptoms. They wonder if they should take medication to reduce shedding the herpes virus; they fear they might need a C-section or even ask for one “just to be safe.” It is true that subclinical genital HSV shedding at the time of labor and delivery can infect a neonate and cause neonatal herpes, or herpes of the newborn—but it is exceedingly rare.

In one study, only 202 women out of more than 40,000 women who had genital HSV cultures at delivery were shedding herpes. Only a quarter of them had lesions; the rest were shedding subclinically. Out of those 40,000 women, only 10 newborns became infected but they all acquired herpes from mothers who were shedding asymptomatically.

The worst cases of newborn herpes happen when a mother becomes infected at the end of pregnancy and has not yet developed antibodies to herpes, antibodies she can share with a baby while in the womb, antibodies that go a long way toward protecting the newborn as it travels the birth canal.  

Herpes on other parts of the body

Herpes Whitlow

Herpes can infect skin on other areas of the body other than the mouth and genitals. You have learned how once the virus enters the body through the genitals and finds a home in the sacral plexus, it can travel back down any nerve in that cluster of nerves and reach the skin on the buttock, thigh, anus, rectum, or anywhere in the region of the groin.

However, the virus can enter the body any place that it lands where the skin might be more receptive because of a cut or tiny opening. This has been seen on the fingers and when herpes occurs on the finger, it is called a whitlow. This was most often seen in the past in dentist and dental healthcare providers.   

Herpes of the eye

Herpes can infect the eye and is called Herpes Simplex Keratitis. It most often involves only one eye and affects the cornea. It can cause pain, redness of the eye, tearing, light sensitivity, and a feeling like there is grit in the eye. Unlike herpes elsewhere, topical antiviral therapy is the treatment that is most effective when an outbreak occurs. It is noteworthy that viral shedding occurs in tears even when patients have no symptoms and that treatment with valacyclovir decreases the number of recurrences just like it does for infections elsewhere.

Treatment

Treatments for herpes (oral and genital) have been available for decades. The first highly effective medication was acyclovir. It proved effective in shortening outbreaks and was a boon at a time when so little seemed to work. In those early days having anything that could shorten an outbreak and even prevent them changed how people saw the disease.
Acyclovir worked in a very targeted way against Herpes DNA. In reality, there isn’t much more to a virus than its DNA and the proteins that cover it. To affect the virus, it is nearly essential to attack its DNA and that is what acyclovir does. DNA is made up of four repeating chemicals called nucleosides. How they are put together in a sequence determines everything, and we mean everything. It is the code of life. So, anything that stops a virus from making more of its DNA stops the virus from making more of itself. Acyclovir is almost an identical copy of one of those nucleosides (Guanine) that makes the code of life—almost an identical copy. One small change to the part of DNA that makes a chain grow makes it so acyclovir can be placed in the growing line of code while lacking the small structure needed so the next piece of code can be added. The chain terminates. Acyclovir is known as a synthetic nucleoside analog.


One limitation was that acyclovir was limited in how much could be absorbed through the intestines. Only 20% of it was ever used by the body. This limitation was overcome by creating something called a prodrug of acyclovir. Since Acyclovir is so poorly absorbed through the gut a mechanism was sought that would allow acyclovir to cross the bowel and get into the bloodstream.

By adding the amino acid l-valine to acyclovir, valacyclovir is created. With that extra amino acid, valacyclovir can be absorbed much better than acyclovir. Once in the body, the amino acid, valine, is severed from the valacyclovir and acyclovir can do what it does but now much more effectively since so much more of it is in the bloodstream. Twice a day or even once a day valacyclovir works better than 3–5 times/day of acyclovir. Another drug, famciclovir, uses the same concept to help penciclovir enter the body.


Different ways to use the medicine

There are any number of conditions where doctors will assure patients that no one knows their disease as the patient does. That is never truer than with herpes. Recurrences can be so subtle that patients can detect them even when clinicians may glance over them without noticing a thing. Most importantly, however, many patients learn to recognize the unique prodrome that warns them an outbreak may be coming. Patients can identify specific shifts in senses and feelings that seem trivial but are consistent signals that the virus is about to make itself known. It can be a dull ache in the back of the thigh, a small increase in the frequency of urination, an odd discomfort in the groin, a sensitivity of a particular patch of skin; it can be anything, but it is specific. While patients may not have prodromes or outbreaks, those living with herpes recurrences often can predict an outbreak with uncanny accuracy.

What follows is a general discussion of the different ways medication can be used with more specific dosing guidelines following the discussion.

Genital herpes

To treat or abort an outbreak when there are early symptoms (prodrome)

That kind of knowledge can allow some patients to use the medication to abort an outbreak. Whether oral or genital, people can take medication when their specific prodrome tells them an outbreak is on the horizon. The medication will stop an outbreak cold (often) and when it does not, it can shorten a milder outbreak than they might have had otherwise.

To prevent outbreaks when there are no symptoms but outbreaks are more likely

Patients also learn the life circumstances or behaviors that lead to more outbreaks. For some, a lack of sleep, increased alcohol, another illness, stress, too much sunlight, irritation, or anything, in fact, that can affect one’s immunity can spur an outbreak. That means that some patients can know not just when they feel an outbreak coming on but can know when they are more likely to have an outbreak due to their circumstances. They might be under stress, having more sex so more irritated, drinking a bit more than they should or missing sleep over an extended period. They will know that they should avoid those triggers and do their best to do so, but they also might want to take medication preventatively knowing they are more vulnerable at that time. Essentially they might take the medication for a week or two until the stress that is making them more susceptible to an outbreak has resolved.

To suppress outbreaks for an extended period

Another way patients can take the medication is when they know they absolutely would like to do all they can to reduce their chance of having an outbreak at a pivotal time. The classic example would be during a honeymoon but taking medication to suppress outbreaks on a daily basis can be prudent when going on vacation, starting a new job, in a new relationship, or at any time a patient feels it is how they want to approach their condition. And that’s the key.

How medication is used is completely in your hands. Learn everything you can and do not worry about using the medication in the way that suits you best. That may change as your circumstances change, or as the condition changes, or even as your mind changes.

To prevent transmission to an uninfected partner

One of the most important advances in herpes treatment came with the knowledge that transmission from an infected person to their uninfected partner could be reduced by the use of valacyclovir. Valacyclovir not only reduces the number of outbreaks a person experiences when using the medication every day but it reduces the number of days that someone sheds the virus asymptomatically. That results in fewer uninfected partners catching herpes. If a condom is worn and the medication used, the chances are reduced at least in half compared to using a condom alone.

Fewer outbreaks and fewer episodes of shedding means fewer people become infected.

Oral herpes

Abort an outbreak at the earliest sign or symptom (prodrome)

At that earliest sign, two tablets of valacyclovir 1000 mg for a total of 2000 mg is taken by mouth as the first dose. Then, 12 hours later, 2 tablets of 1000 mg of valacyclovir, for a total of 2000 mg, is taken as the second and final dose. The second dose can be taken sooner than 12 hours but never before 6 hours have passed. Adequate hydration makes sure the medicine is cleared through the kidneys as it should be.
The medication is only approved for two doses and there is no evidence in studies to advise the use of medication once lesions have appeared.


Specific dosing recommendations for Herpes

Treatment of initial genital outbreak

In patients with a first outbreak, the symptoms can be very severe. Multiple painful, genital ulcers can cover large areas of skin on both sides of the groin. They can experience burning during urination, fever, headaches, muscle and joint pain, and swollen, painful lymph nodes in the groin. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. For such patients, treatment is vital and can shorten the outbreak and ease the symptoms significantly. For the treatment of an initial episode of herpes genitalis, the FDA recommends taking valacyclovir 1 gram (1000 mg) twice a day for 10 days starting at the first sign or symptom of lesions, preferably within 48 hours of onset. The “CDC recommends this same dose for 7 to 10 days; treatment may be extended if healing is not complete after 10 days.” For HIV-infected patients, they recommend 1 gram (1000 mg) every 12 hours for 5 to 14 days.

Treatment of herpes labialis (i.e., cold sores)

To abort an outbreak of herpes on the lips or mouth the recommendation is that the patient should take 2 grams (2000 mg) of valacyclovir at the first sign or symptom of lesions and a second dose 12 hours later. The second dose should not be taken within 6 hours of the first. Those are the only doses recommended but patients sometimes take another dose or two of just 1 gram if they continue to have symptoms, or if a mild outbreak follows.

The PDR states that for HIV-infected patients, 1 gram (1000 mg) be taken every 12 hours for 5 to 10 days. Despite what some patients do when having continued symptoms the PDR states, “there are no data supporting the effectiveness of beginning treatment after the development of clinical signs of a cold sore (e.g., papule, vesicle, or ulcer).”

Treatment of recurrent herpes genitalis, including HIV-infected patients

To treat a recurrent outbreak, the FDA recommends using 500 mg of valacyclovir twice daily for 3 days starting at the first sign or symptom of lesions—preferably within 24 hours of onset. The CDC recommendation is identical but adds in the choice of using valacyclovir 1 g (1000 mg) one time a day for 5 days. Valacyclovir 1 g taken every 12 hours for 5 to 14 days is recommended by the HIV guidelines. The PDR also states, “There are no data supporting the effectiveness of beginning treatment more than 24 hours after the onset of symptoms.”

Treatment with suppressive therapy

The PDR states that for suppressive therapy of recurrent herpes genitalis in all patients valacyclovir 1 gram (1000 mg) should be taken once daily.

However, “in patients with a history of fewer than 9 recurrences per year, 500 mg once daily may be given.” They note that “500 mg once daily regimen appears to be less effective than other regimens in patients with 10 or more episodes per year.”

The PDR continues, “Safety and efficacy of valacyclovir beyond 1 year have not been established. In HIV-infected patients, 500 mg by mouth twice daily. The safety and efficacy of therapy beyond 6 months have not been established.”

To prevent transmission to a partner

The PDR recommends the infected partner take valacyclovir 500 mg once a day to decrease the risk of transmission to the uninfected partner “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Studies also did not run for an extended period so the PDR also states, “The efficacy of reducing transmission beyond 8 months in discordant couples has not been established.” This means they can only vouch for the data for an 8 month period of time.

An important point

Being diagnosed with genital herpes means you have acquired a sexually transmitted infection. If you have been diagnosed with genital herpes, you should have been checked for other sexually transmitted infections when you were diagnosed, including but not limited to HIV and syphilis. If you have not been, you should be and this is highly recommended.

Herpes can be transmitted to a partner despite best efforts like using a condom and using antiviral suppression therapy. Patients should never engage in sex without a condom or when they have an outbreak or a prodrome. Also, as asymptomatic shedding is more common in the seven days following an outbreak it is prudent to avoid sex during that period, as well.

Herpes and the risk of HIV infection

HSV-2 infection puts a person at greater risk of acquiring HIV infection—as much as 2 to 3 times the risk of those without herpes. The reason is that herpes creates ulcers that can make it easier for HIV to enter the body but general inflammation of the genitals is also responsible for the increased vulnerability to the infection. In women and men with positive blood tests for herpes, specialized testing shows signs of inflammation on the cervixes of women and under the foreskin of men. The specialized test is the finding of CD4 T cells. This is probably the result of the body’s immune system constantly fighting the herpes virus and it is seen even when no outbreak is evident. Of note, some CD4 T cells have been shown in the lab to be more susceptible to HIV infection than skin samples tested under the same conditions. Moreover, CD4 T cells hang around in inflamed tissue long after outbreaks heal.

This is another reason why STD testing is always the rule when beginning a new sexual relationship and why, whether having an outbreak or not, a condom is essential.

HSV-2 infection in HIV-infected individuals

HIV infected persons who have genital ulcers due to herpes are more likely to transmit HIV, as HIV is shed from these ulcers. Herpes itself may behave identically in the HIV positive individual but they are more likely to develop acyclovir resistance and to have outbreaks that last longer and appear different from typical cases.

HIV positivity is a complex condition that requires careful evaluation by experts in the field.

HSV vaccines

After years of frustration, there are reasons to be optimistic that a vaccine to prevent, or even to treat, herpes may be achievable. The development of a vaccine has been spurred by the realization that controlling herpes would be a major step in controlling the spread of herpes around the world, especially in places where medication is unavailable.

Herpevac vaccine did not prevent the acquisition of genital herpes Type 2 but it did show moderate success against catching herpes Type 1 and in making the disease milder if someone caught it. The study included 8000 participants but they were all women so the data may not be consistent in men. Nevertheless, the fact that a vaccine worked for HSV-1 is encouraging, especially since so many new cases of genital herpes are due to HSV-1. A number of vaccines are being tested to see if they could reduce the number of outbreaks and, most importantly, the amount of asymptomatic shedding. One vaccine in early testing, GEN-003, reduced shedding by 55%.

The advances are being made that give hope to anyone who has the infection or is the partner of someone with the HSV virus.


Valacyclovir details: PDR information

Read full prescribing information Here  

How can Valtrex be used

Treatment of herpes labialis (i.e., cold sores)

To abort an outbreak of herpes on the lips or mouth the recommendation is that the patient should take 2 grams of Valacyclovir at the first sign or symptom of lesions and a second dose 12 hours later. The second dose should not be taken within 6 hours of the first. Those are the only doses recommended but patients sometimes take another dose or two of just 1 gram if they continue to have symptoms, or if a mild outbreak follows.

The PDR states that for HIV-infected patients, 1 gram (1000 mg) be taken every 12 hours for 5 to 10 days. Despite what some patients do when having continued symptoms the PDR states, “there are no data supporting the effectiveness of beginning treatment after the development of clinical signs of a cold sore (e.g., papule, vesicle, or ulcer).”

Treatment of Initial genital outbreak

In patients with a first outbreak, the symptoms can be very severe.

Multiple painful, genital ulcers can cover large areas of skin on both sides of the groin. They can experience burning during urination, fever, headaches, muscle and joint pain, and swollen, painful lymph nodes in the groin. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. For such patients, treatment is vital and can shorten the outbreak and ease the symptoms significantly.

For the treatment of an initial episode of herpes genitalis, the FDA recommends taking valacyclovir 1 gram (1000 mg) twice a day for 10 days starting at the first sign or symptom of lesions, preferably within 48 hours of onset. The “CDC recommends this same dose for 7 to 10 days; treatment may be extended if healing is not complete after 10 days.”

For HIV-infected patients, they recommend 1 gram (1000 mg) every 12 hours for 5 to 14 days. The PDR also notes, “The efficacy of treatment with VALTREX, when initiated more than 72 hours after the onset of signs and symptoms, has not been established.”

Treatment of Recurrent Herpes Genitalis, Including HIV-infected Patients

To treat a recurrent outbreak, the FDA recommends using 500 mg of Valacyclovir twice daily for 3 days starting at the first sign or symptom of lesions—preferably within 24 hours of onset. The CDC recommendation is identical but adds in the choice of using Valacyclovir 1 gram (1000 mg) one time a day for 5 days. Valacyclovir 1 gram taken every 12 hours for 5 to 14 days is recommended by the HIV guidelines. The PDR also states, “There are no data supporting the effectiveness of beginning treatment more than 24 hours after the onset of symptoms.”

Treatment with Suppressive Therapy

The PDR states that for suppressive therapy of recurrent herpes genitalis in all patients Valacyclovir 1 gram (1000 mg) should be taken once daily.

However, “in patients with a history of fewer than 9 recurrences per year, 500 mg once daily may be given.” They note that “500 mg once daily regimen appears to be less effective than other regimens in patients with 10 or more episodes per year.”

The PDR continues, “Safety and efficacy of valacyclovir beyond 1 year have not been established. In HIV-infected patients, 500 mg PO twice daily. The safety and efficacy of therapy beyond 6 months have not been established.”

To Prevent Transmission to a Partner

The PDR recommends the infected partner take Valacyclovir 500 mg once a day to decrease the risk of transmission to the uninfected partner “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Studies also did not run for an extended period so the PDR also states, “The efficacy of reducing transmission beyond 8 months in discordant couples has not been established.” This means they can only vouch for the data for an 8 month period of time. The PDR also states, “The efficacy of VALTREX for the reduction of transmission of genital herpes in individuals with multiple partners and non-heterosexual couples has not been established. Safer sex practices should be used with suppressive therapy.” Centers for Disease Control 26 and Prevention [CDC] Sexually Transmitted Diseases Treatment Guidelines

Maximum Dose

In children 12 years and older, adolescents, adults, and the elderly, the maximum daily dose is 4 grams if given for just 1 day and 3 grams/day if given for more than 1 day.

In children 2 years to 11 years, 3 grams/day is the maximum dose.
Safety has not been established in neonates, infants, and children less than 2 years.

Dose adjustments should be made for those with kidney impairment or issues. Decreased doses are needed as kidney impairment slows the clearing from the body of valacyclovir. The degree of impairment determines the decrease in the dosage. The elderly may have decreased kidney function and adjustments should be considered in such cases.

No adjustment is needed, generally, in patients with liver impairment. However, if you have a liver condition or impairment, inform your doctor.

Overdose: Valtrex is not usually harmful unless you take too much for several days. An excess of Valtrex can cause vomiting, kidney problems, confusion, agitation, feeling less aware, seeing things that aren’t there, or loss of consciousness. For severe symptoms, go direction to an emergency room. Otherwise, talk to your doctor or pharmacist if you take too much Valtrex. Take the medicine pack with you.


Contraindications and Precautions

Sensitivity or Allergies: Patients with sensitivity or an allergy to any of the following medications should not use Valacyclovir: Acyclovir, Famciclovir, ganciclovir, penciclovir, valacyclovir, or valganciclovir.

Kidney Issues: Dose adjustments should be made for those with kidney impairment or issues. Decreased doses are needed as kidney impairment slows the clearing from the body of valacyclovir. The degree of impairment determines the decrease in the dosage. The PDR states, “Acute renal failure and CNS (Nervous System) toxicity have been reported in patients with underlying renal (Kidney) dysfunction who have received inappropriately high doses of valacyclovir for their level of renal (Kidney) function. Patients receiving potentially nephrotoxic(Toxic to the Kidney) drugs together with valacyclovir may have an increased risk of renal dysfunction (impairment).”

The Elderly: The elderly are more likely to have impaired kidneys so they might not clear valacyclovir from their system as efficiently as they should. This can lead to inappropriately high levels of valacyclovir, which means the elderly may need lower doses of valacyclovir. The elderly are also more likely to experience neurological side effects, including: agitation, hallucinations, confusion, delirium, and other abnormalities of brain function termed encephalopathy.

Dehydration: When patients are dehydrated acyclovir can reform as a solid in the kidney leading to kidney damage. Patients should all remain well hydrated when taking valacyclovir.

Newborns, Infants, and children: Safety has not been established in neonates, infants, and children less than 2 years.

Pregnancy: While a registry that collected data on the 756 pregnancies of women exposed to acyclovir in the first trimester showed no greater occurrence of birth defects than occurs in the general population, the study size was too small to guarantee safety during pregnancy.

You should not take valacyclovir if you are pregnant or trying to become pregnant, unless recommended by your obstetrician/gynecologist or other healthcare provider.

Breastfeeding: The PDR states, “According to the manufacturer, valacyclovir should be administered to a nursing mother with caution and only when indicated. Although the American Academy of Pediatrics (AAP) has not specifically evaluated valacyclovir, systemic maternal acyclovir is considered to be usually compatible with breastfeeding…Consider the benefits of breastfeeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition.”

Driving or Using Machines: Valtrex can cause side effects that affect your ability to drive. Don’t drive or use machines unless you are sure you’re not affected.

Thrombotic Thrombocytopenic Purpura/Hemolytic Uremic Syndrome (TTP/HUS): TTP/HUS is a rare condition but has occurred in patients with advanced HIV disease and also in allogeneic bone marrow transplant and renal transplant recipients participating in clinical trials of VALTREX at doses of 8 grams per day. If any of these conditions apply to you, please inform your doctor and pharmacist.


Side Effects (Overview)

What follows is a summary and does not include every side effect possible. Please, read the package insert and report any side effects you experience whether on the list below or not.

Very Common (may affect more than 1 in 10 people): headache

Common (may affect up to 1 in 10 people): feeling sick, dizziness, vomiting, diarrhea, skin reaction after exposure to sunlight (photosensitivity), rash, itching (pruritus)

Uncommon (may affect up to 1 in 100 people), feeling confused, seeing or hearing things that aren’t there (hallucinations), feeling very drowsy, tremors, feeling agitated

These nervous system side effects usually occur in people with kidney problems, the elderly or in organ transplant patients taking high doses of 8 grams or more of Valtrex a day. They usually get better when Valtrex is stopped or the dose reduced.

Other Uncommon Side Effects: shortness of breath (dyspnea), stomach discomfort, rash, sometimes itchy, hive-like rash (urticaria), low back pain (kidney pain), blood in the urine (hematuria)

Uncommon Side Effects That May Show Up In Blood Tests: reduction in the number of blood platelets which are cells that help blood to clot (thrombocytopenia), reduction in the number of white blood cells (leukopenia), increase in substances produced by the liver  

Rare (may affect up to 1 in 1,000 people): unsteadiness when walking and lack of coordination (ataxia), slow, slurred speech (dysarthria), fits (convulsions), altered brain function (encephalopathy), unconsciousness (coma), confused or disturbed thoughts (delirium)

These nervous system side effects usually occur in people with kidney problems, the elderly or in organ transplant patients taking high doses of 8 grams or more of Valtrex a day. They usually get better when Valtrex is stopped or the dose reduced.

Other Rare Side Effects: kidney problems where you pass little or no urine.

Lastly, watch out for a severe allergy. It may be rare but it can be life-threatening so being aware of the symptoms is vital.

Severe allergic reactions (anaphylaxis): These are rare in people taking Valtrex. Anaphylaxis is marked by the rapid development of flushing, itchy skin rash, swelling of the lips, face, neck, and throat—causing difficulty in breathing (angioedema), fall in blood pressure leading to collapse. If any of these occur, get emergency treatment immediately


Of Note: “When VALTREX is coadministered with antacids, cimetidine and/or probenecid, digoxin, or thiazide diuretics in patients with normal renal function, the effects are not considered to be of clinical significance. Therefore, when VALTREX is coadministered with these drugs in patients with normal renal function, no dosage adjustment is recommended.” (PDR)

Aprotinin: Aprotinin is cleared in the kidney as is Valacyclovir. Together, the risk to the kidney is increased.

Bictegravir; Emtricitabine; Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.  

Cimetidine: Cimetidine may slow how quickly valacyclovir is cleared out of the body through the kidney but no dosage adjustments are recommended for patients with normal renal function.

Cobicistat; Elvitegravir; Emtricitabine; Tenofovir
Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Cobicistat; Elvitegravir; Emtricitabine; Tenofovir Disoproxil Fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Efavirenz; Emtricitabine; Tenofovir: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Rilpivirine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Rilpivirine; Tenofovir disoproxil fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Tenofovir alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Emtricitabine; Tenofovir disoproxil fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Entecavir: Entecavir can affect kidney function and should be used cautiously with valacyclovir.

Fosphenytoin: Phenytoin and fosphenytoin are anti-seizure medications. The addition of valacyclovir to phenytoin may lead to a clinically significant decrease in phenytoin serum concentrations and loss of seizure control. Adjustments in phenytoin or fosphenytoin dosing should be considered if Valacyclovir is added or stopped when a patient is on either phenytoin and fosphenytoin.

Hyaluronidase, Recombinant; Immune Globulin: Immune Globulin (IG) products can damage the kidney. If they take any other drug that can affect the kidney, including valacyclovir, the dose of IG may need to be lowered and the infusion rate slowed.

Immune Globulin IV, IVIG, IGIV: Immune Globulin (IG) products can damage the kidney. If they take any other drug that can affect the kidney, including valacyclovir, the dose of IG may need to be lowered and the infusion rate slowed.

Lamivudine; Tenofovir Disoproxil Fumarate: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Measles Virus; Mumps Virus; Rubella Virus; Varicella Virus Vaccine, Live: (Major) If possible, discontinue valacyclovir at least 24 hours before administration of the varicella-zoster virus vaccine, live. Also, do not administer valacyclovir for at least 14 days after vaccination. The medication might have the unintended effect of diminishing the protective benefit of the vaccine.

Mycophenolate: (Moderate) Valacyclovir, when added to MMF, cyclosporine, and prednisolone caused a decrease in White Blood Cells, called neutropenia. When this combination must be used careful blood monitoring is recommended.

Phenytoin: Phenytoin is an anti-seizure medication. The addition of valacyclovir to phenytoin may lead to a clinically significant decrease in phenytoin levels and loss of seizure control. Adjustments in phenytoin dosing should be considered if valacyclovir therapy is added or discontinued.

Probenecid: Probenecid can reduce the kidney’s clearance of valacyclovir causing an increase in the blood level of valacyclovir. In the absence of a decrease in renal function, no dose adjustment is needed.

Talimogene Laherparepvec: “Consider the risks and benefits of treatment with talimogene laherparepvec before administering acyclovir or other antivirals to prevent or manage herpetic infection. Talimogene laherparepvec is a live, attenuated (lessened capacity to cause disease) herpes simplex virus that is sensitive to acyclovir; coadministration with antiviral agents may cause a decrease in efficacy.”

Telbivudine: Valacyclovir can affect kidney function. Since telbivudine is also cleared by the kidney, monitoring kidney function before and during telbivudine treatment is recommended.

Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Tenofovir Alafenamide: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Tenofovir, PMPA: Tenofovir is primarily excreted via the kidneys, as is valacyclovir, so Tenofovir should not be used if a patient is on valacyclovir or has been on it recently.

Varicella-Zoster Virus Vaccine, Live: (Major) If possible, discontinue valacyclovir at least 24 hours before administration of the varicella-zoster virus vaccine, live. Also, do not administer valacyclovir for at least 14 days after vaccination. The medication might have the unintended effect of diminishing the protective benefit of the vaccine.