Zoé G., 27, regularly goes to the pharmacy to refill her contraceptive pill. Today, she presents herself with a prescription from her gynecologist including an antiviral. She is in fact complaining of a painful lesion on her vulva since the day before.
What is the context of the order?
What do you know about the patient?
Zoé has no particular health concerns. In a relationship for 2 years, she regularly comes to renew her estrogen-progestin contraception. The last time, however, she told you that she was particularly tired and stressed by the new job she had just started. She has just consulted her gynecologist today because she has been bothered since yesterday by a lesion in her vulva which burns terribly, especially when urinating. This is the first time this has happened to him.
What did the doctor tell him?
The gynecologist diagnosed genital herpes and took a sample from the lesions and the vagina to confirm the diagnosis and look for other sexually transmitted diseases (Chlamydia, gonococci). Serology tests for human immunodeficiency virus, syphilis and hepatitis B and C were also prescribed.
Zoe has no memory of a previous episode but the specialist explained that it was probably a recurrence of herpes because primary infections are generally more intense when they are symptomatic. A drop in immunity, fatigue and stress linked to his new job and a change in pace of life may explain why the virus, present in his body, has reactivated. Recurrences being possible, the doctor mentioned the possibility of repeating the treatment, explaining that it had to be started at the first clinical signs for better effectiveness.
What do you think?
The gynecologist explained to Zoe that she could have contracted the infection from her current partner or been infected with the virus by her previous partners. Zoé is lost in all these explanations. She wonders if her friend, who has no symptoms, should be treated as well.
1) Yes, because he certainly has herpes even if he is asymptomatic.
2) No, because if he is asymptomatic, he is not infected with a herpes virus.
3) No, if he is asymptomatic, although he may be seropositive for the Herpes simplex virus.
Answer : Zoé’s friend does not necessarily carry the herpes virus. Zoe may have actually contracted the infection years ago. He can also be seropositive for the herpes virus without having clinical manifestations. However, treatment is only indicated in the case of symptomatic lesions of herpes. There answer 3 is therefore the correct one. In practice, since one’s serological status is not known, precautions must be taken to avoid potential transmission of the infection: sexual intercourse should therefore be absolutely avoided as long as symptoms are present, even with a condom that does not cover always all the lesions.
Is the prescription consistent?
What does the prescription include?
Valaciclovir is an antiviral indicated in the prevention and treatment of herpes and shingles, and in the prophylaxis of cytomegalovirus infections. It is a nucleoside analogue which blocks viral replication but does not act on viruses in a latent state.
Paracetamol, a first-line analgesic, is prescribed to relieve burns caused by herpetic ulcerations.
Cicalfate+ is a cream containing copper and zinc salts, giving it anti-infectious and anti-inflammatory properties. Suggested to soothe irritated skin and accelerate its repair, it is also suitable for external intimate areas.
Is it consistent with the reference therapeutic strategy?
Yes, the recent 2024 recommendations from the High Authority for Health (HAS) recommend the prescription of an antiviral such as valaciclovir in recurrences of genital herpes. However, a topical antiviral is not recommended.
Are the dosages consistent?
No, the prescribed dosage corresponds to the old recommendations. The HAS recommends treatment with valaciclovir of 2,000 mg twice morning and evening on a single day in the treatment of recurrences. It is increased to 5 days at a dosage of 500 mg in the event of a primary infection during which the lesions are more severe and extensive. It is therefore appropriate to adjust the dosage of the treatment, indicate it on the prescription and inform the prescriber via secure messaging. The modification will be notified on the Act-IP platform which allows pharmaceutical interventions to be traced.
What advice should I give?
This is the first time that Zoé has used antiherpetic treatment. The terms and precautions for use should be explained, including in the event of possible recurrences.
Utilisation
Valaciclovir is taken morning and evening with a large glass of water, during or without meals.
Paracetamol should be used on demand to limit discomfort.
Cicalfate+ cream can be applied as often as needed. Protective and offering some water resistance, it can help soothe burns, particularly during urination.
When to start the antiviral?
It must be started as quickly as possible, leaving approximately 12 hours between two doses.
What to do if you forget?
The tablet can be taken up to 1 hour before the next dose. You should not double a dose.
Will the patient be able to judge the effectiveness of the treatment?
The antiviral does not act on the pain, hence the prescription of paracetamol and a soothing treatment, but it reduces the recovery time from a recurrence by approximately 1 to 2 days. It is unnecessary to continue the treatment for more than 5 days, however it may take longer for the lesions to heal completely.
What are the main side effects?
Mainly headaches and sometimes digestive disorders (nausea, vomiting, diarrhea in particular) and skin reactions (pruritus, photosensitivity). More rarely, renal damage (such as acute renal failure) and/or neurological disorders (e.g. mental confusion, agitation, confusion) may be observed, particularly in patients over 65 years of age and those with renal insufficiency.
Which ones can be managed at the pharmacy?
Headaches can be relieved with paracetamol if necessary. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided as a precaution to limit the risk of worsening the infection. Digestive disorders, which are mild and transient, generally do not require symptomatic treatment. Regular hydration is recommended to limit the risk of impaired renal function and neurological damage linked to the accumulation of the antiviral.
Wearing covering clothing or applying a sun protection product should be recommended in case of exposure to the sun during treatment.
What signs would require calling the doctor?
Any suspicion of renal and/or neurological damage, exceptional in a young woman, requires calling the doctor.
What additional advice should I give?
A gentle syndet-type cleansing gel, without perfume, is preferable for intimate cleansing to avoid any additional irritation. Dry, without rubbing, by dabbing.
It is impossible to predict whether Zoe will have future herpes outbreaks and how often they will occur. Generally, these are preceded by tingling or frequent urge to urinate. Recognizing these signs allows you to start the antiviral as quickly as possible, which will be all the more effective in limiting the duration and intensity of the flare-up.
Six months later
Zoé consulted her gynecologist again, tired and discouraged, following a new recurrence of genital herpes, the 4th in 6 months. The gynecologist prescribed long-term antiviral treatment: valaciclovir 500 mg, one tablet per day for 6 months.
Is the prescription consistent?
The initiation of prophylactic antiviral treatment is recommended in patients with at least 6 annual recurrences of genital herpes. The frequency of episodes occurring in this patient prompted the gynecologist to offer preventive treatment more quickly. The prescribed dosage is in accordance with the marketing authorization.
When will the patient be able to judge the effectiveness of the treatment?
The antiviral should immediately prevent the occurrence of new attacks or at least reduce the frequency and intensity of them. It also makes it possible to limit the risk of transmission of the infection, in particular via episodes of asymptomatic viral excretion.
With the kind proofreading of Dr. Odile Bagot, gynecologist in Strasbourg (Bas-Rhin).
Article from the Training section of n°3534, published on November 2, 2024, updated on December 20, 2024.
