• Ideally, all people with suspected genital herpes should be referred to a specialist in genito-urinary medicine for diagnosis, treatment, screening for sexually transmitted infections, counselling, and follow up.
• It is essential to refer the following people to the appropriate speciality:
• Pregnant women.
• Immunocompromised individuals.
• People with HIV can be treated in primary care provided that the infection is uncomplicated and not severe. However, prompt referral is indicated if there is no response to treatment (i.e. lesions are still forming after 3–5 days of treatment).
• Those with severe local secondary infection.
• Anyone with systemic herpes infection (e.g. meningitis).

• Prescribe oral aciclovir (200 mg five times a day) within 5 days of the start of the episode or while new lesions are forming. Continue for 5 days, or longer if new lesions are still forming while on treatment. 
• Self-care measures may be useful for some people. If appropriate, advise the person to:
• Clean the affected area with plain or salt water to help prevent secondary infection and promote healing of lesions.
• Apply vaseline or a topical anaesthetic (e.g. lidocaine 5%) to lesions to help with painful micturition, if required.
• Increase fluid intake to produce dilute urine (which is less painful to void). Urinate in a bath or with water flowing over the area to reduce stinging.
• Avoid wearing tight clothing, which may irritate lesions.
• Take adequate pain relief (e.g. oral paracetamol).
• Avoid sharing towels and flannels with household members (although it is very unlikely that the virus would survive on an object long enough to be passed on, it is sensible to take steps to prevent this).
• Advise all people to abstain from sex (including non-penetrative and orogenital sex) until follow up, or until lesions have cleared.

• Ideally, all people with HIV and suspected genital herpes should be referred to a specialist in genito-urinary medicine for diagnosis, treatment, screening for sexually transmitted infections, counselling regarding risks to themselves and others, and follow up (especially if they are known to have a low CD4 count).
• However, if referral is declined, people with HIV can be treated in primary care provided that the infection is uncomplicated and not severe.
• Treat with oral aciclovir 400 mg five times a day for 7–10 days — the dose is higher and the duration longer than for people who are not immunocompromised.
• If new lesions are still forming after 3–5 days, seek specialist advice.
• If infection is severe, the person is systemically unwell, or complications are suspected, admit for treatment with intravenous aciclovir.
• In the absence of antiretroviral treatment, primary genital herpes may be severe and prolonged with risk of progressive, multifocal, and coalescing mucocutaneous anogenital lesions.
• Complications include fulminant hepatitis, pneumonia, neurological disease, and disseminated infection.
• Self-care measures may be useful for some people. If appropriate, advise the person to:
• Clean the affected area with plain or salt water to help prevent secondary infection and promote healing of lesions.
• Apply vaseline or a topical anaesthetic (e.g. lidocaine 5%) to lesions to help with painful micturition, if required.
• Increase fluid intake to produce dilute urine (which is less painful to void). Urinate in a bath or with water flowing over the area to reduce stinging.
• Avoid wearing tight clothing, which may irritate lesions.
• Take adequate pain relief (e.g. oral paracetamol).
• Avoid sharing towels and flannels with household members (although it is very unlikely that the virus would survive on an object long enough to be passed on, it is sensible to take steps to prevent this).
• Advise all people to abstain from sex (including non-penetrative and orogenital sex) until follow up, or until lesions have cleared.

• People should be followed up by a specialist in genito-urinary medicine (GUM): to be given the opportunity to discuss the implication of the diagnosis; to receive counselling; to discuss the transmission risk and prognosis; and to be screened for other sexually transmitted infections (STIs).
• For people unwilling to attend GUM:
• Follow up after 5 days to determine the effectiveness of treatment and discuss the virology swab result. Explain that even with a negative swab result, they may still have genital herpes. The diagnosis can only be confirmed by further attacks and herpes simplex virus detection.
• Explain that a first clinical episode may not necessarily indicate recent infection nor that a partner has been unfaithful (if appropriate). They could have acquired the infection (sub-clinically) years previously, or the herpes virus (type 1) may have spread from elsewhere on their body (such as lips or fingers).
• Explain that transmission can occur when there are no symptoms (asymptomatic shedding), but the risk is higher when symptomatic. Advise the person to:
• Avoid sex (including orogenital sex) if lesions are present.
• Use condoms with new or uninfected partners. Explain that condoms cannot completely prevent transmission, due to close skin contact or contact with infected secretions during foreplay.
• Advise people who are concerned about transmitting genital herpes to long-term partners that their partner may already be infected even if they do not have symptoms, and that they should seek advice from a specialist in GUM for screening.
• Explain there is no cure for genital herpes at present. However, symptoms improve (reduce in frequency and severity) with time and can be well controlled. On average, people have 4–5 attacks of genital herpes a year in the first 2 years.
• Consider screening for other STIs. For more information, see the CKS topic on Chlamydia - uncomplicated genital.
• Provide written information (patient information leaflets) from the Herpes Viruses Association (HVA) at www.hva.org.uk/pil.html or the Family Planning Association www.fpa.org.uk. Offer people further support from the Herpes Viruses Association's helpline 0845 123 2305 (weekdays) or www.herpes.org.uk.

• Although rare, consider the possibility of sexual abuse in any child or young person with genital herpes, particularly in the following circumstances:
• The child is younger than 13 years of age, unless there is clear evidence of mother-to-child transmission during birth, or of blood contamination.
• The young person is 13 to 15 years of age, unless there is clear evidence of mother-to-child transmission during birth, blood contamination, or that the STI was acquired from consensual sexual activity with a peer.
• The young person is 16 to 17 years of age and there is no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity and there is a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or with a person in a position of trust (such as a teacher, sports coach, minister of religion) or there is concern that the young person is being exploited.
• Follow appropriate child protection procedures and refer to a paediatrician if necessary.

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).