• Ask how the diagnosis of genital herpes was confirmed and when this was carried out. Ideally, the person should have seen a specialist in genito-urinary medicine and had a viral culture or polymerase chain reaction (PCR) to identify the herpes simplex virus.
• Ask about symptoms, including ulcers, urethral discharge, and dysuria; discuss whether lesions are still forming, their onset (determine if started within 5 days), and whether the person experiences prodromal sensations (tingling or burning).
• Ask about previous attacks (within the last year), their frequency and severity (usually decreasing with time), and management (self-care and/or antiviral medication).
• Ask whether the person has identified personal trigger factors (e.g. sexual intercourse, sunlight, physical illness, excess alcohol, stress).
• Carry out an external examination of the genitalia and surrounding skin (lesions are usually unilateral and localized to the same area in each attack).
• Determine the person's understanding of genital herpes (prognosis, risk of transmission) and enquire (if appropriate) about the affect on self-esteem, mood, and relationships. See advice on genital herpes.

• Consider referring people:
• Who have breakthrough genital herpes episodes on suppressive treatment.
• For advice on suppressive treatment, if they are concerned about transmitting the herpes simplex virus to long-term partners who are not infected.

• Self-care measures may be helpful for some people. If not already tried, 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) and use 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).
• Try to avoid identified trigger factors (e.g. ultraviolet light, excess alcohol).
• If self-care measures are not controlling symptoms, prescribe oral aciclovir 200 mg five times a day for 5 days (it is unusual for lesions to still form after 5 days). For future attacks use either:
• Episodic antiviral treatment if attacks are infrequent (e.g. less than six attacks per year). Consider self-initiated treatment, so antiviral medication can be started early in the next attack.
• Suppressive antiviral treatment (e.g. oral aciclovir 400 mg twice daily for 6–12 months) if attacks are frequent (e.g. six or more attacks per year), causing psychological distress, or affecting the person's social life:
• After 1 year, stop treatment for a minimum period of two recurrences.
• If attacks are still considered problematic, restart suppressive treatment. If attacks are not considered problematic (off treatment), future attacks can be controlled with episodic antiviral treatment (if needed).
• If the person has breakthrough attacks on suppressive treatment, seek specialist advice.

• People with HIV and recurrent genital herpes can be treated in primary care provided that the infection is uncomplicated and not severe.
• Once the attack has resolved, refer the person to a specialist to optimize antiretroviral treatment.
• Use episodic antiviral treatment if attacks are infrequent (e.g. less than six attacks per year).
• Treat with aciclovir, using a higher dose than people who are not immunocompromised. Treatment may also need to be continued for longer.
• Prescribe oral aciclovir 400 mg three times a day for 5–10 days.
• If new lesions are still forming after 3–5 days, seek specialist advice.
• Seek specialist advice about starting suppressive antiviral treatment (off-label use) if attacks are frequent (e.g. six or more attacks per year), causing psychological distress, or affecting the person's social or sex life.
• Treatment is usually with aciclovir 400 twice a day, but the dose may sometimes need to be titrated up to 800 mg two or three times a day.
• After 1 year, stop treatment for a minimum period of two recurrences.
• If attacks are still considered problematic, restart suppressive treatment. If attacks are not considered problematic (off-treatment), future attacks can be controlled with episodic antiviral treatment (if needed).
• If the person has breakthrough attacks on suppressive treatment, seek specialist advice.
• 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.
• 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).
• Try to avoid identified trigger factors (e.g. ultraviolet light, excess alcohol).

• Explain how episodes usually last up to 10 days and on average people have 4–5 attacks in the first 2 years. Thereafter, attacks reduce in frequency and severity, but there is no cure for genital herpes at present.
• Reinforce the fact that transmission can occur when there are no symptoms (asymptomatic shedding), but that 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:
• Partners may already be infected even if they do not have symptoms, and should seek advice from a specialist in genito-urinary medicine for screening.
• Suppressive treatment may reduce the risk of transmission to uninfected partners, but specialist advice is needed.
• Reassure that genital herpes is not hereditary, nor does it increase the risk of cervical cancer or infertility.
• Explain that genital herpes can affect pregnancy, and women should inform a healthcare professional if they become pregnant.
• 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).