Genital herpes simplex virus in Adult
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
- Mpox – Lesions beginning in the genital and anal area have been reported.