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Treatment of genital herpes should be initiated empirically with acyclovir. Acyclovir should be considered first-line therapy because treatment of genital herpes with acyclovir reduces the severity of herpetic lesions, and lesions caused by acyclovir tend to recur at the same location. Acyclovir is contraindicated for HSV-1 genital infections in pregnant women and women of childbearing potential, who are breastfeeding, who have not taken adequate birth control during the prior 6 months, and who have not been evaluated to determine if they are at risk for the potential for teratogenicity, embryotoxicity, or other adverse reactions (141). Acyclovir is the preferred treatment for HSV-2 infection in adults. Therapy for HSV-2 should be initiated based on the results of rapid antigen tests; however, if the results of rapid antigen tests are negative, patients should be treated based on clinical criteria. Topical antivirals may be used for HSV infections at mucous membranes, such as those of the mouth or the eyes. Topical antivirals might be used in conjunction with systemic therapy for HSV-1 and HSV-2 infections of the eye. The FDA-approved indications for use of topical antivirals include treatment of keratitis caused by HSV-1 and HSV-2; for those patients for whom systemic therapy is not appropriate, topical antiviral therapy is a good therapeutic option (142).

In some situations, the presence of HSV-1 and HSV-2 can be detected by virus isolation or fluorescent antibody testing of skin lesions obtained by tissue biopsy, or by virus isolation or fluorescent antibody testing of vesicle fluid obtained by direct examination of a lesion or by swabbing of the anal canal or genital tract. Abnormal findings should be discussed with the patient; for example, the presence of herpes simplex virus DNA in the absence of clinical manifestations of a herpesvirus infection suggests a previous infection, and the absence of virus might indicate reactivation. If results are positive, a second sample should be submitted to confirm viral culture results (143). The following additional diagnostic procedures might be considered in clinical settings that present challenges for more traditional diagnostic testing (e.g.