Genital Herpes

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What is Genital Herpes

Genital herpes is a common sexually transmitted infection (STI) that is caused by a virus. The virus spreads from person to person through sexual contact. Infection can cause itching, blisters, and sores around the genitals or rectum.

Symptoms may last several days and then go away This is called an outbreak. However, the virus remains in your body, so you may have more outbreaks in the future. The time between outbreaks varies and can be months or years.

Genital herpes affects men and women. It is particularly concerning for pregnant women because the virus can be passed to the baby during delivery and can cause serious problems. Genital herpes is also a concern for people who have a weak disease-fighting (immune) system.

What causes Genital Herpes?

Genital Herpes is caused by the herpes simplex virus (HSV) type 1 or type 2. The virus may spread through:

Sexual contact with an infected person, including vaginal, anal, and oral sex.
Contact with fluid from a herpes sore.
The skin. This means that you can get herpes from an infected partner even if he or she does not have a visible sore or does not know that he or she is infected.

What increases the risk of Genital Herpes?

You are more likely to develop Genital Herpes if:

You have sex with many partners.
You do not use latex condoms during sex.

What are the symptoms of Genital Herpes?

Most people do not have symptoms (asymptomatic) or have mild symptoms that may be mistaken for other skin problems. Symptoms of Genital Herpes may include:

Small red bumps near the genitals, rectum, or mouth. These bumps turn into blisters and then turn into sores.
Flu-like symptoms, including:
- Fever.
- Body aches.
- Swollen lymph nodes.
- Headache.
Painful urination.
Pain and itching in the genital area or rectal area.
Vaginal discharge.
Tingling or shooting pain in the legs and buttocks.

Generally, symptoms are more severe and last longer during the first (primary) outbreak. Flu-like symptoms are also more common during the primary outbreak.

How is this diagnosed?

Genital herpes may be diagnosed based on:

A physical exam.
Your medical history.
Blood tests.
A test of a fluid sample (culture) from an open sore.

How is Genital Herpes treated?

There is no cure for Genital Herpes, but treatment with antiviral medicines that are taken by mouth (orally) can do the following:

Speed up healing and relieve symptoms.
Help to reduce the spread of the virus to sexual partners.
Limit the chance of future outbreaks, or make future outbreaks shorter.
Lessen symptoms of future outbreaks.

Your health care provider may also recommend pain relief medicines, such as aspirin or ibuprofen.

Follow these instructions at home:

Sexual activity

Do not have sexual contact during active outbreaks.
Practice safe sex. Latex condoms and female condoms may help prevent the spread of the herpes virus.

General instructions

Keep the affected areas dry and clean.
Take over-the-counter and prescription medicines only as told by your health care provider.
Avoid rubbing or touching blisters and sores. If you do touch blisters or sores:
- Wash your hands thoroughly with soap and water.
- Do nottouch your eyes afterward.
To help relieve pain or itching, you may take the following actions as directed by your health care provider:
- Apply a cold, wet cloth (cold compress) to affected areas 4–6 times a day.
- Apply a substance that protects your skin and reduces bleeding (astringent).
- Apply a gel that helps relieve pain around sores (lidocaine gel).
- Take a warm, shallow bath that cleans the genital area (sitz bath).
Keep all follow-up visits as told by your health care provider. This is important.

How is this prevented?

Use condoms. Although anyone can get genital herpes during sexual contact, even with the use of a condom, a condom can provide some protection.
Avoid having multiple sexual partners.
Talk with your sexual partner about any symptoms either of you may have. Also, talk with your partner about any history of STIs.
Get tested for STIs before you have sex. Ask your partner to do the same.
Do nothave sexual contact if you have symptoms of genital herpes.

Contact a health care provider if:

Your symptoms are not improving with medicine.
Your symptoms return.
You have new symptoms.
You have a fever.
You have abdominal pain.
You have redness, swelling, or pain in your eye.
You notice new sores on other parts of your body.
You are a woman and experience bleeding between menstrual periods.
You have had herpes and you become pregnant or plan to become pregnant.

Summary

Genital herpes is a common sexually transmitted infection (STI) that is caused by the herpes simplex virus (HSV) type 1 or type 2.
These viruses are most often spread through sexual contact with an infected person.
You are more likely to develop this condition if you have sex with many partners or you have unprotected sex.
Most people do not have symptoms (asymptomatic) or have mild symptoms that may be mistaken for other skin problems. Symptoms occur as outbreaks that may happen months or years apart.
There is no cure for this condition, but treatment with oral antiviral medicines can reduce symptoms, reduce the chance of spreading the virus to a partner, prevent future outbreaks, or shorten future outbreaks.

Detailed Info of Genital Herpes

Genital herpes is a sexually transmitted disease caused by the human herpesviruses HSV-1 and HSV-2
Infection is spread by vaginal, anal, or oral sex with someone who has the disease
Most people with the infection have no or mild symptoms
Antiviral treatment should be offered for primary or recurrent infections to reduce the active period of viral shedding and symptoms
- Suppressive antiviral treatment can be offered to patients who have experienced more than 4 to 6 recurrences over the preceding 12 months
There is no cure for genital herpes
Condom use affords some protection against transmission
Planning of measures to prevent intrapartum transmission is an essential part of prenatal care for pregnant women with genital herpes

Pitfalls

Consider missed diagnosis of herpes in the setting of meningitis or encephalitis
Given the common mode of transmission, providers should have a high index of suspicion for other sexually transmitted diseases when performing the history and physical examination

Genital herpes infection is infection with HSV that affects the genital region
- HSV-1
  - Commonly affects mouth, gums, and lips
  - Can cause anogenital infection
- HSV-2
  - Commonly affects anogenital region
  - Can cause oral infection
HSV establishes permanent presence in dorsal root ganglia, from which symptomatic infection may recur at the original site of entry

Classification

By episode
- Primary genital HSV infection
  - True primary infection is the first HSV infection in a previously seronegative patient
    - Nonprimary infection is the first episode in a patient previously infected with another strain of HSV (eg, HSV-2 infection in a patient previously infected with HSV-1, or vice-versa). It often behaves similarly to primary HSV infection
- Recurrent genital HSV infection
By symptoms
- Symptomatic
  - Clinically apparent lesions of either first episode or recurrent episode of HSV infection
  - Ranges from mild to severe symptoms
- Asymptomatic
  - HSV shedding or serologic evidence of antibody to HSV with no symptoms noted

Diagnosis

Clinical Presentation

History

Primary episode
- Incubation period averages 4 days (range, 2-12 days)
- Patient may be unaware of exposure to HSV infection
- Symptoms may include the following:
  - Fever
  - Myalgias
  - Fatigue, malaise
  - Headache
  - Photophobia and stiff neck (aseptic meningitis occurs in about 10% of men and 30% of women experiencing a primary episode of genital HSV infection); may be accompanied by nausea and vomiting
  - Cold sores around the mouth; oral lesions can coexist with genital lesions
  - Pain or itching in anogenital region
  - Other genitourinary complaints may develop over several days as infection evolves
    - Dysuria (may be severe)
    - Urinary retention
    - Dyspareunia
    - Tenesmus due to proctitis
- Typically longer duration of symptoms and a higher rate of complications in primary episodes than in recurrent episodes
Recurrent episodes
- Mild systemic symptoms
- Anorexia and malaise
- Prodrome of sensory complaints (ie, tingling, burning, pain, numbness) in genital area approximately 1 day before visible lesions
- Genitourinary complaints are typically milder than in primary infection but can be quite troublesome in some patients

Physical examination

Fever
Signs of meningitis (eg, neck stiffness, photophobia, vomiting) may occur in primary infection
Perioral skin lesions, such as gingivitis, pharyngotonsillitis, or vesicles, often coexisting with symptomatic or asymptomatic genital HSV infection (seen during primary infection more often than in recurrences)
Painful vesicular lesions on an erythematous base; often bilateral, on labia, vulva, perineum, perianal areas, or shaft or glans of penis
- Natural history of herpetic vesicles involves stages of ulceration, crust formation, and resolution over a period of 1 to 2 weeks (sometimes longer in primary infection)
Bilateral, tender, inguinal adenopathy; more common with primary HSV episodes

Causes

Infection occurs by direct inoculation of virus into susceptible surfaces, including:
- External genital skin
- Internal mucosal surface (eg, vagina, rectum, urethra)

Risk factors and/or associations

Age

Peak incidence of primary infection occurs in young sexually active adults

Sex

HSV-2 genital herpes infection is more common in women (about 16% of women, versus about 8% of men, in the United States) and in men who have sex with men

Ethnicity/race

Infection is found worldwide in all studied populations
Incidence and prevalence in the United States are higher in African Americans
HSV-2 infection is more common in the non-Hispanic Black population (34.6%) than in the non-Hispanic White population (8.1%)

Other risk factors/associations

Unprotected sex (not using condom barriers) is a risk for acquisition of genital herpes
Immunocompromised patients are at higher risk for severe manifestations of genital herpes

Diagnostic Procedures

Primary diagnostic tools

History and physical examination may be sufficient to suggest the diagnosis; however, in primary infection, presentation is often atypical (75%-90% of cases)
When a lesion is present, a viral identification test should be done to confirm diagnosis; a type-specific (ie, one that identifies HSV-1 versus HSV-2) method is preferred
- Nucleic acid amplification testing (eg, polymerase chain reaction) is preferred when available
- Antigen assays and microscopic examination (Tzanck smear) are other rapid tests that may be available as alternatives to nucleic acid amplification testing, but these are less sensitive
- Viral isolation is no longer routinely used for diagnosis
Serologic testing is not recommended for primary diagnosis, but it may be helpful under specific circumstances, including the following:
- Patients with recurrent genital symptoms or atypical symptoms and negative HSV polymerase chain reaction findings
- Patients with history of clinically made diagnosis without laboratory confirmation
- Patients with a partner who has genital HSV
- Patients requesting general evaluation for sexually transmitted disease
- Persons with HIV infection
- Persons at increased risk for HIV infection (eg, men who have sex with men)
- Pregnant women with a first episode of genital herpes (especially in the third trimester) or with active lesions at delivery
  - In conjunction with polymerase chain reaction, serologic testing can distinguish primary, nonprimary, or recurrence
  - Recommended by UK guidelines to assess consequent risk to fetus at delivery
  - Recommended by American Academy of Pediatrics for women with active lesions at delivery and no known history of genital herpes infection

Laboratory

Polymerase chain reaction techniques can be used on a wide range of fluids and tissue
- Detects HSV DNA (sensitivity and specificity exceed 95%); distinguishes HSV-1 from HSV-2
- Test of choice to diagnose or exclude HSV meningitis and neonatal infection
Direct fluorescent antigen assay test
- Distinguishes HSV-1 from HSV-2
- Direct immunofluorescence using fluid collected from a fresh lesion is 95% sensitive and yields results within a few hours
Culture isolation of HSV from vesicular lesion
- Rarely used for diagnosis since availability of polymerase chain reaction; limited by wait time for results (more than 24 hours)
Serum HSV type-specific antibody testing
- Used to document primary seroconversion if diagnosis is otherwise unconfirmed; repeated testing may be necessary if acquisition is suspected to be recent
- Also useful to confirm prior disease when lesions or symptoms are reported in the history but are not evident on examination
- Antibody titer increases generally do not occur during recurrences of HSV infection
Tzanck smear
- Glass slide preparation of vesicular fluid stained by Giemsa or Wright method
- Appearance of multinucleated giant cells indicates herpes infection, but it does not distinguish herpes simplex from varicella (herpes) zoster, nor HSV-1 from HSV-2
- Not recommended when other methods are available

Differential Diagnosis

Most common

Candidiasis
- Limited to vagina and vulva
- Thick white discharge
- Ulcers and vesicular lesions are not present
- Yeast cells are visible on potassium hydroxide preparation of vaginal secretions
Chancroid
- Painful genital ulcers and localized inguinal adenopathy
- Microscopic skin scraping or exudate antigen testing results are positive for Haemophilus ducreyi
Herpes zoster
- Unilateral pain and itching
- Unilateral vesicular rash in a dermatome zone
- Definitive identification is by polymerase chain reaction assay or direct antigen testing
Syphilis
- Primary stage: firm, single, painless genital lesion, with associated regional adenopathy in most cases
- Differentiated by clinical examination (single painless lesion is associated with syphilis, and multiple painful lesions with herpes) and confirmatory microscopy or laboratory tests, as follows:
  - Microscopy: dark ground microscopy of serous fluid reveals presence of spirochetes, eg, Treponema pallidum
  - Laboratory: nontreponemal tests are used initially, including VDRL test and rapid plasma reagin test. If either result is positive, confirmation is required with a treponemal test, such as the following:
    - Treponema pallidum hemagglutination assay
    - Fluorescent treponemal antibody absorption test

Treatment

Goals

For genital ulcers during primary infection or recurrences
- Limit infectious process using antiviral drug therapy
  - Reduce duration of symptoms
- Relieve pain and swelling
- Manage systemic symptoms
- Relieve urinary retention if present
Long-term suppressive therapy
- Limit recurrence frequency
- Limit shedding
- Limit probability of transmission

Disposition

Admission criteria

HSV is occasionally associated with meningitis, which requires hospitalization for IV antiviral therapy
HSV infection in an immunocompromised host requires hospitalization for IV antiviral therapy

Recommendations for specialist referral

Urinary retention may require referral to urologist
Refer to infectious diseases specialist if diagnosis is in question or for patients with complex infectious comorbidities (eg, HIV)
Consult maternal-fetal medicine specialist for aid in managing pregnancy and delivery when primary infection is acquired late in pregnancy

Treatment Options

Treatment includes drug therapy (antivirals, analgesics) and supportive care (cool compresses or baths)

Drug therapy is not curative but may shorten duration of an acute symptomatic episode and may reduce duration of viral shedding

Treatment with an antiviral agent is recommended for all patients with primary infection

Recurrences, if infrequent or minimally symptomatic, may be treated with antiviral agents episodically as needed

Patients who have frequent recurrences (eg, 4-6 times per year), or who are immunocompromised and at risk for severe disease, may benefit from ongoing suppressive antiviral therapy

Acyclovir, famciclovir, and valacyclovir are recommended agents for the first clinical episode of genital herpes, episodic treatment of recurrent infection, and daily suppressive therapy

A WHO systematic review of antiviral therapy for primary genital HSV found that acyclovir, compared with placebo, reduced duration of symptoms and lesions by 2 to 4 days, pain by 2 days, and viral shedding by 9 days, and that famciclovir and valacyclovir were essentially equivalent to acyclovir in efficacy and adverse effects
Treatment of recurrences also reduces duration of lesions, pain, and shedding
- Efficacy for episodic treatment of disease recurrences appears to be equivalent among acyclovir, famciclovir, and valacyclovir
When used suppressively, all 3 drugs appear to reduce frequency of clinical recurrences and may reduce number of lesions when clinical episodes occur; famciclovir may be somewhat less effective than the others in controlling asymptomatic viral shedding
Suppressive valacyclovir has been shown to reduce transmission of HSV-2, although not in persons with HIV coinfection

Foscarnet is used to treat resistant HSV in patients with weakened immune systems or failure of standard therapy

Analgesics may ameliorate the discomfort; OTC drugs are usually sufficient

Drug therapy

Numerous antiviral regimens have been studied; regimens below are those recommended by CDC, but WHO and regional guidelines may differ slightly
Antiviral regimens for primary infection
- Acyclovir
  - Oral
    - Acyclovir Oral tablet; Children and Adolescents 12 to 17 years†: 400 mg PO 3 times per day or 200 mg PO 5 times per day for 7 to 10 days in immunocompetent patients; duration may be extended if incomplete healing. For HIV-infected patients, guidelines recommend 400 mg PO 3 times per day for 7 to 10 days.
    - Acyclovir Oral tablet; Adults: 200 mg PO every 4 hours, 5 times per day, for 10 days is FDA-approved dosage. Guidelines recommend 400 mg PO 3 times per day or 200 mg PO 5 times per day for 7 to 10 days in immunocompetent patients and 400 mg PO 3 times per day for 7 to 10 days in HIV-infected patients.
  - IV
    - Acyclovir Sodium Solution for injection; Children and Adolescents 12 to 17 years: 5 mg/kg/dose IV every 8 hours for 5 to 7 days. Use IBW for dosing obese patients.
    - Acyclovir Sodium Solution for injection; Adults: 5 mg/kg/dose IV every 8 hours for 5 days. Use IBW for dosing obese patients.
    - For severe infection (including meningitis)
      - Acyclovir Sodium Solution for injection; Children and Adolescents 12 to 17 years: 10 mg/kg/dose IV every 8 hours for 14 to 21 days. FDA-approved duration is 10 days; however, relapse has been reported with 10-day courses. In HIV-infected patients, treat for 21 days. Use IBW for dosing obese patients.
      - Acyclovir Sodium Solution for injection; Adults: 10 mg/kg/dose IV every 8 hours for 14 to 21 days. FDA-approved duration is 10 days; however, relapse has been reported with 10-day courses. Use IBW for dosing obese patients.
- Valacyclovir
  - Valacyclovir Hydrochloride Oral tablet; Adolescents†: 1 g PO twice daily for 10 days starting at the first sign or symptom of lesions, preferably within 48 hours of onset. CDC recommends this same dose for 7 to 10 days. For HIV-infected patients, 1 g PO every 12 hours for 7 to 10 days is recommended. No data support efficacy of treatment initiation 72 hours after sign/symptom onset.
  - Valacyclovir Hydrochloride Oral tablet; Adults: 1 g PO twice daily for 10 days starting at the first sign or symptom of lesions, preferably within 48 hours of onset. CDC recommends this same dose for 7 to 10 days. For HIV-infected patients, 1 g PO every 12 hours for 7 to 10 days is recommended. No data support efficacy of treatment initiation 72 hours after sign/symptom onset.
- Famciclovir
  - Famciclovir Oral tablet; Adolescents: AAP recommends 250 mg PO 3 times daily for 7—10 days. In HIV-infected patients, guidelines recommend 500 mg PO twice daily for 5—14 days.
  - Famciclovir Oral tablet; Adults: CDC recommends 250 mg PO 3 times daily for 7—10 days or until clinical resolution. In HIV-infected patients, guidelines recommend 500 mg PO twice daily for 5—14 days.
Antiviral regimens for episodic treatment of recurrent infection
- Acyclovir
  - Acyclovir Oral tablet; Children and Adolescents 12 to 17 years†: 200 mg PO 5 times daily for 5 days; 400 mg PO 3 times daily for 5 days; 800 mg PO 3 times daily for 2 days; or 800 mg PO twice daily for 5 days; initiate at first sign of prodrome or lesions. For HIV-infected patients, 400 mg PO 3 times daily for 5 to 10 days.
  - Acyclovir Oral tablet; Adults: 200 mg PO every 4 hours, 5 times a day for 5 days, initiated at first sign or symptom or recurrence is FDA-approved dosage. Guidelines recommend initiating one of the following doses at the first sign of prodrome or genital lesions: 400 mg PO 3 times per day for 5 days; 800 mg PO 3 times per day for 2 days; or 800 mg PO twice daily for 5 days. For HIV-infected patients, 400 mg PO 3 times per day for 5 to 10 days.
- Valacyclovir
  - Valacyclovir Hydrochloride Oral tablet; Adolescents†: 500 mg PO twice daily for 3 days; CDC also recommends 1 g PO once daily for 5 days. Initiate at the first sign/symptom of lesions, preferably within 24 hours of onset. For HIV-infected patients, 1 g PO every 12 hours for 5 to 10 days. No data support the efficacy of treatment initiation 24 hours after sign/symptom onset.
  - Valacyclovir Hydrochloride Oral tablet; Adults: 500 mg PO twice daily for 3 days; CDC also recommends 1 g PO once daily for 5 days. Initiate at the first sign/symptom of lesions, preferably within 24 hours of onset. For HIV-infected patients, 1 g PO every 12 hours for 5 to 10 days. No data support efficacy of treatment initiation 24 hours after sign/symptom onset.
- Famciclovir
  - Famciclovir Oral tablet; Adolescents†: 500 mg PO twice daily for 5—14 days in HIV-infected patients.
  - Famciclovir Oral tablet; Adults: In immunocompetent patients, 1000 mg PO twice daily for 1 day. CDC recommends 125 mg PO twice daily for 5 days, 1000 mg PO twice daily for 1 day, or 500 mg PO once then 250 mg PO twice daily for 2 days. In HIV-infected patients, 500 mg PO twice daily for 7 days, although guidelines recommend treating for 5—14 days. Initiate treatment at the first sign or symptom; efficacy not established with initiation more than 6 hours after symptom onset or lesion formation.
Antiviral regimens for suppressive therapy
- Acyclovir
  - Acyclovir Oral tablet; Adults: 400 mg PO twice daily. Alternatively, 200 mg PO 3 to 5 times daily. In patients with HIV, guidelines recommend 400 to 800 mg 2 to 3 times daily. Reevaluate need for suppressive therapy annually.
- Valacyclovir
  - Valacyclovir Hydrochloride Oral tablet; Adolescents†: 500 mg or 1 g PO daily; 500 mg/day may be less effective for those with 10 or more episodes/year; 500 mg PO twice daily for HIV-infected patients.
  - Valacyclovir Hydrochloride Oral tablet; Adults: For immunocompetent patients, 1 g PO once daily. May reduce dose to 500 mg PO daily in patients with a history of 9 or fewer recurrences per year. For HIV patients, 500 mg PO twice daily.
- Famciclovir
  - Famciclovir Oral tablet; Adolescents†: For chronic suppression of herpes simplex infection in HIV-infected patients, guidelines recommend 500 mg PO twice daily.
  - Famciclovir Oral tablet; Adults: For immunocompetent patients, 250 mg PO twice daily for up to 1 year for herpes genitalis. For chronic suppression of herpes simplex infection in HIV-infected patients, guidelines recommend 500 mg PO twice daily.
Antiviral regimen for resistant strains in immunocompromised patients
- Foscarnet
  - Must be administered via slow IV infusion; adequate hydration is recommended both before and during treatment to minimize renal toxicity
  - Renal function should be monitored throughout therapy and doses adjusted accordingly
  - Foscarnet Sodium Solution for injection; Adolescents†: 40 mg/kg IV every 8 to 12 hours for 2 to 3 weeks or until lesions are healed. 40 to 80 mg/kg IV every 8 hours is recommended by CDC for genital herpes.
  - Foscarnet Sodium Solution for injection; Adults: 40 mg/kg IV every 8 to 12 hours for 2 to 3 weeks or until lesions are healed. 40 to 80 mg/kg IV every 8 hours is recommended by CDC for genital herpes.

Nondrug and supportive care

Cool compresses
Cool perineal baths/sitz baths

Comorbidities

Consider possibility of coinfection with other sexually transmitted infections (eg, chlamydia, gonorrhea, syphilis, hepatitis B, HIV) at time of diagnosis
HIV
- Higher doses of medication therapy may be required
Immunocompromised state
- Higher doses of initial medication therapy may be required
- Consider suppressive medication therapy
- Recurrent episodes may be more severe and prolonged

Special populations

Pregnant women
- Risk to fetus depends on whether maternal infection is primary or recurrent and whether active lesions are present at time of delivery
- During pregnancy:
  - Recurrent infection is associated with transmission to the fetus in about 2% of cases and is less likely to occur early in pregnancy
  - Risk in nonprimary infection is about 25%
  - Transmission to fetus:
    - May occur in up to 57% of cases with primary infection
    - Risk is much higher (30%-50%) when primary infection occurs near term
    - Transmission happens in less than 1% of cases in which:
      - Primary infection occurs during first half of pregnancy
      - Women with preexisting infection have recurrences early in pregnancy
    - Primary infection during pregnancy may result in miscarriage, prematurity, or growth restriction; whether there is increased risk of stillbirth is a matter of controversy
  - Acyclovir is considered safe in pregnancy and should be administered for first episodes; CDC also recommends treatment of recurrences
- Pregnant women with active genital lesions at time of delivery may transmit infection to neonate during delivery
  - Risk of transmission with vaginal delivery is about 41% in primary infection and 0% to 3% in recurrences
    - Risk is probably increased with use of scalp monitoring and with prolonged rupture of membranes
  - Neonatal herpes can cause life-threatening complications if infection is disseminated or involves central nervous system
  - Examine all women for herpetic lesions at onset of labor
  - Cesarean delivery in women with active lesions minimizes risk of transmission to fetus and is recommended in such circumstances; UK guidelines recommend cesarean delivery if a primary episode has occurred in the 6 weeks before delivery
  - Viral suppression for the last month of pregnancy may avert the need for cesarean delivery; recommended doses are:
    - Acyclovir 400 mg PO 3 times/day
    - Valacyclovir 500 mg PO twice daily
- Infants born to women with active lesions, especially if delivered vaginally, must be followed closely and expectantly, and they must be treated promptly if infection develops. Guidelines differ with regard to laboratory evaluation and treatment of asymptomatic neonates
Immunocompromised persons, including persons who have malignancies, who receive immunosuppressants (eg, transplant patients), or who have advanced HIV infection are at risk for severe infection due to HSV
- Infections may involve larger surface area and may take longer to heal
- Infections may disseminate
- Increased likelihood of developing resistance to antiviral agents

Monitoring

Otherwise healthy patients who receive ongoing suppressive therapy do not require laboratory monitoring
Some guidelines suggest annual reevaluation of the need for continued medication in patients on suppressive therapy

Complications

HSV encephalitis
- Rarely, encephalitis symptoms can occur with primary HSV-1 (in less than 0.1% of HSV-1 cases)
  - Personality changes
  - Memory problems
  - Weakness or lack of muscle coordination
  - Focal or generalized paralysis
  - Hearing or vision defects
  - Speech impairments
- Very rarely due to HSV-2 and therefore extremely uncommon as a complication of genital herpes
HSV sepsis
- Dissemination of HSV-1 and HSV-2 can rarely occur, typically in immunocompromised patients
- End-organ effects (eg, acute liver failure)
Urinary incontinence, urinary retention, and constipation
- Due to bladder and rectal end-organ effects of herpes involvement via sacral nerves
Secondary sites of infection may occur via autoinoculation (eg, herpetic whitlow on fingers, eye infection)
Recurrence of genital herpes is the rule

Prognosis

Prognosis is fair in most cases of primary and recurrent genital herpes
- Recurrences may be rare to frequent
- Treatment of genital herpes is aimed at reducing severity and frequency of the disease; it is not curative
- Frequency of relapse tends to decline over time
  - In patients who have been receiving suppressive therapy for several years, it is reasonable (but not necessary) to consider a trial off antiviral medication
  - Development of drug resistance is rare in immunocompetent persons receiving suppressive therapy
When passed from mother to infant, genital herpes infection can have serious consequences

Screening

At-risk populations

Neonates born to mothers with active lesions of genital herpes
In the United States, routine serologic screening is not recommended for the general population or for pregnant women

Screening tests

Pregnant patients
- Routine screening tests are not recommended
- Perform detailed genital examination to evaluate for suspicious lesions
- If history or examination suggests genital herpes (or patient has not received prenatal care), examine for active herpes at onset of labor
CDC suggests that screening by viral culture or polymerase chain reaction assay of specimens from mucous membranes should be considered for neonates born vaginally to women with known or suspected active herpes infection
American Academy of Pediatrics recommends that all neonates born to women with visible genital lesions of HSV should undergo the following:
- Culture and polymerase chain reaction from conjunctivae, mouth, nasopharynx, and perineum
- Blood polymerase chain reaction
- Lumbar puncture for cell count, chemistries, and polymerase chain reaction
- Serum ALT measurement

Prevention

US Preventive Services Task Force recommends prevention counseling in all adolescents and adults at risk for sexually transmitted infection
Other than complete abstinence, no method is completely effective
Advise patient on several methods that can reduce the probability of genital herpes acquisition, as follows:
- Use condoms consistently: condom use is partially (about 30%) protective against both transmission and acquisition of virus; effectiveness correlates with the percentage of time condoms are used
- Avoid sexual contact during symptomatic episodes
- Use suppressive therapy doses of antiviral therapy in the infected partner to help prevent transmission to uninfected persons
Advise women who are pregnant and who have no history of genital herpes to abstain from sexual contact with a partner who has a history of infection for the duration of the third trimester
- Serologic screening of the partner may be appropriate
In pregnant women known to have a history of genital herpes, antiviral suppressive therapy for the last month of pregnancy may be beneficial in reducing the need for cesarean delivery and reducing the risk of neonatal herpes in the fetus
- In women known to have a history of genital herpes and in women who have not had prenatal care, examine for the presence of herpetic lesions by inspection and, if possible, laboratory confirmation; consider cesarean delivery if herpetic lesions are present

References

1: WHO: WHO Guidelines for the Treatment of Genital Herpes Simplex Virus. WHO website. Published 2016. Accessed July 14, 2021. https://www.who.int/reproductivehealth/publications/rtis/genital-HSV-treatment-guidelines/en/ Reference