Genital herpes simplex virus in AdultSee also in: Cellulitis DDx,Anogenital
Alerts and Notices
SynopsisGenital herpes simplex virus is a sexually transmitted viral infection caused by herpes simplex virus type 2 (HSV-2) and type 1 (HSV-1). Most cases of recurrent genital herpes are caused by HSV-2, but an increasing proportion of anogenital herpetic infections have been attributed to HSV-1 (in particular, among young women and men who have sex with men [MSM]). This viral infection is spread from direct contact with active lesions (most common) or asymptomatic shedding (less common) of infected individuals. In women, vulvar, vaginal, and perineal lesions are most common. In men, lesions most commonly occur on the glans penis or penile shaft. Unilateral involvement of the upper buttock is another common presentation of HSV-2 in both women and men (sacral HSV).
Mucocutaneous HSV infection is characterized by initial outbreaks (primary infection), periods of latency (regional sensory ganglia), and recurrent flares localized to the area of the initial outbreak (recurrent infection). Stress, ultraviolet light, fever, tissue damage, and immunosuppression have all been associated with triggering recurrent flares.
The initial eruption usually develops within 5-7 days of inoculation and consists of painful vesicles, pustules, and/or erosions on an erythematous base that are scattered over the affected anatomic site. A prodrome of fever, malaise, and lymphadenopathy may precede or accompany the primary mucocutaneous eruption. In women, there can be severe local symptoms of vulvovaginal pain, dysuria, and vaginal discharge. If the anorectal area is primarily affected, there may be rectal pain and proctitis from intra-anal and rectal erosions.
Recurrent eruptions are usually less severe (fewer lesions, more localized, and less painful), resolve within 1 week, and lack a prodromal phase. Sacral HSV localizes to the upper buttock unilaterally, but bilateral involvement may sometimes be seen. Patients with genital HSV have an average of 4-7 recurrent outbreaks per year.
Low socioeconomic status, early age of first intercourse, a high number of sexual partners, and a history of prior sexually transmitted disease all confer an increased risk of developing genital HSV.
It is important to note that even when asymptomatic, a person sheds the virus and can, therefore, transmit the disease to another.
Immunocompromised Patient Considerations:
HSV infection in human immunodeficiency virus (HIV)-infected patients and other immunodeficiency states with T-cell defects is common and often presents with more severe and chronic disease. Recurrent outbreaks are more painful, more widespread, last longer, are poorly responsive to therapy, and have a higher risk of viremic dissemination. In addition, genital HSV infections in immunocompromised patients can have atypical presentations. Verrucous and exophytic nodules resembling condyloma acuminatum and verrucous carcinoma (Buschke-Lowenstein tumor) have been described. Chronic, nonhealing, painful ulcers occur, particularly in the perianal region. Infection with genital HSV confers an increased risk of acquiring and transmitting HIV. Others at risk for this include marrow and solid organ transplant patients and patients with lymphoma and leukemia.
Pregnant individuals with primary HSV infection are at increased risk for severe illness, ie, dissemination and hepatitis, particularly in the third trimester.
A60.9 – Anogenital herpesviral infection, unspecified
33839006 – Genital herpes simplex
Differential Diagnosis & Pitfalls
- Cellulitis / superinfected traumatic erosions
- Contact dermatitis
- Fixed drug eruption
- Lymphogranuloma venereum
- Bullous impetigo
- Herpes zoster
- Erosive lichen planus
- Fournier or gas gangrene
- Behçet syndrome
- Pyoderma gangrenosum
- Ecthyma gangrenosum
- Granuloma inguinale
- Cytomegalovirus (CMV)
- Juvenile gangrenous vasculitis of the scrotum
- Lipschutz ulcer
- Monkeypox – Lesions beginning in the genital and anal area have been reported.
Patient Information for Genital herpes simplex virus in Adult
OverviewHerpes simplex infection of the genitals, or genital herpes, is a common recurrent skin condition associated with infection by the herpes simplex virus (HSV). HSV infection usually appears as a group of small vesicles (fluid-filled blisters), erosions (sore areas of missing skin), or crusts (scabs) around the mouth, nose, genitals, buttocks, and lower back, although infections can develop almost anywhere on the skin. These sores can come back periodically in the same sites, called recurrent infections.
Infections with HSV are very contagious and are spread by direct contact with the skin lesions. There are 2 types of HSV: herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). HSV-1 is the most common cause of infections around the mouth, lips, nose, and face, although HSV-2 can also be a cause, and HSV-2 more commonly causes lesions on the genitals and buttocks (sometimes called sacral herpes).
Both types of HSV produce 2 kinds of infections: primary and recurrent. HSV causes a primary infection in most people who are exposed to the virus. Appearing 5-7 days after a person's first exposure to HSV, the sores of a primary infection last about 2-4 weeks. These sores heal completely, rarely leaving a scar. Affected individuals carry the virus in their bodies for the rest of their lives.
Certain triggers can cause the hibernating (latent) virus to wake up, become active, and travel back to the skin. These recurrent HSV infections may develop frequently (every few weeks), or they may never develop. Recurrent infections tend to be milder than primary infections and generally occur in the same location as the primary infection.
Who’s At RiskHSV infections occur in people of all races / ethnicities, ages, and sexes. Genital herpes can affect anyone who is sexually active.
Herpes is spread from person to person by direct skin-to-skin contact. The virus is most contagious when there are visible sores in the genital region. HSV can also be spread when there are no sores present, however, which is called asymptomatic shedding. Only about 20% of people who are infected with HSV develop visible blisters or sores, which means most people with HSV have not been diagnosed and are unaware of their condition. This means they can unknowingly transmit the infection to their sexual partners.
Signs & SymptomsShortly after exposure to the virus, a newly infected person may develop vesicles or pustules (pus-filled bumps), occurring singly or in a group. These vesicles and pustules are usually quite fragile, so people may never notice them but instead see tiny erosions (open sores). These painful erosions subsequently become scabbed over. The scabs eventually fall off, leaving a red or hyperpigmented (darker) area that finally fades. The primary outbreak typically lasts 2-4 weeks.
In women, the most common locations for genital herpes infection are the external genitalia, vagina, cervix, buttocks, and anus. In men, the most common locations are the penis, scrotum, upper thighs, buttocks, and anus.
Primary genital HSV infection can be severe, with many painful blisters causing pain and burning with urination and vaginal or urethral discharge. People may also develop fever, headaches, muscle aches, and fatigue with a primary outbreak.
Recurrent HSV infections are usually milder than the primary infection, but the lesions look similar. Many people with recurrent HSV infections have burning, tingling, or pain in the area of the outbreak up to 24 hours before any visible signs. This is called the prodromal phase of the infection.
Most people will have a recurrence of genital herpes during the first year after a primary infection. Note, however, that some people never develop the symptoms of a primary HSV infection and may mistake a recurrent infection for a primary infection. On average, most people will get about 4 outbreaks per year, although the frequency of recurrence is variable and tends to decrease over the years.
A recurrence of genital herpes usually occurs spontaneously, but it can also be triggered by:
- Fever or illness.
- Sun exposure.
- Hormonal changes, such as those due to menstruation or pregnancy.
- Trauma (eg, a cut).
- Friction to the area (eg, with sexual intercourse or tight-fitting clothes).
Self-Care GuidelinesAcetaminophen (Tylenol) or ibuprofen (Advil, Motrin) may help reduce pain, fever, and muscle aches that accompany the herpes sores. Applying ice packs or baking soda compresses to the affected areas may relieve some of the swelling and discomfort. Wear loose-fitting clothes and cotton underwear, and keep the infected area clean and dry.
Because HSV infections are very contagious, it is important to take the following steps to prevent spread of the virus during the prodromal phase (burning, tingling, or pain) and active phase (presence of blisters or sores) of genital HSV infections:
- Avoid sharing towels and other personal care items.
- Wash your hands with soap and water if you touch an active lesion. HSV can be spread to other parts of your body via infected hands.
- Avoid sexual contact (including oral, vaginal, and anal sex) during both the prodromal phase and the active phase.
When to Seek Medical CareIf you develop new painful sores in or around the genitals, see a medical professional as soon as possible because HSV treatment is much more effective if started early.
Recurrent outbreaks of genital HSV usually do not require medical care. However, because some people have milder forms of herpes, see a medical professional for any recurring rash in the genital area, even if you think it is just from bug bites, jock itch, or any other condition.
If you have an underlying medical condition such as cancer or HIV, if you have undergone organ transplantation, or if you are pregnant, you are at higher risk for more serious complications from genital herpes. Seek medical advice as soon as possible if you develop any lesions.
Genital herpes can also be passed to a newborn baby during delivery through contact with a lesion in the genital tract. Be sure to speak with your obstetrician or other medical professional about the possible risk to your baby if you have genital herpes.
TreatmentsMost HSV infections are easy for medical professionals to diagnose. On occasion, however, a swab from the infected skin may be sent to the laboratory to confirm the diagnosis. A blood test can also be performed to determine if you have been exposed to the virus. Your medical professional may recommend a blood test for your partner to determine if they have been exposed to herpes in the past or if they are at risk for contracting the virus.
Untreated HSV outbreaks will go away on their own, but antiviral medications can reduce symptoms, shorten their duration, and decrease the chance of spreading the virus. These medicines are most effective if taken during the first 24 hours of symptoms. If you experience burning and tingling before the appearance of blisters, you can start antiviral medications as soon as you start feeling the symptoms. Unfortunately, these medicines do not cure HSV infections.
Treatment for primary and recurrent HSV infections are oral antiviral medications such as acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir). Talk to your medical professional about getting a prescription for these medicines for possible future outbreaks, as they are most effective if taken early.
If you have frequent or severe herpes outbreaks, your medical professional may recommend taking an antiviral medication every day, called suppressive therapy, to decrease the frequency and severity of outbreaks. This type of therapy may also be effective in decreasing the chance that an uninfected partner will acquire the virus. If you are taking a daily antiviral medicine to suppress your outbreaks, talk to your medical professional yearly about potentially stopping these medicines or seeing if you still need daily treatment.
Genital herpes simplex virus in AdultSee also in: Cellulitis DDx,Anogenital