Genital Herpes

Background

• Herpes genitalis is one of the most common sexually transmitted infections.
• Majority of cases are caused by herpes simplex virus (HSV)-2, although HSV-1 is responsible for increasing number of anogenital infections in developed countries, especially in young women, and men who have sex with men.
• HSV is highly infectious and transmitted via saliva, direct contact, or sexual activity.
• HSV is a recurrent disease with recurrence rates within first year:
  • about 70%-90% for patients with symptomatic genital HSV-2
  • about 20%-50% for patients with symptomatic genital HSV-1

Evaluation

• Most infections are asymptomatic. When primary infection is symptomatic, classic presentation is bilateral clusters of erythematous papules and vesicles on external genitalia, usually 4-7 days after sexual exposure. Systemic symptoms may be present.
• Genital herpes recurrences are typically unilateral and less severe.
• HSV-1 cannot be differentiated from primary HSV-2 infection on clinical exam alone.
• Clinical diagnosis should be confirmed with laboratory tests.
• Swab from base of unroofed genital lesion can be tested by viral culture and polymerase chain reaction (PCR) of HSV DNA.
  • Viral testing has higher yield if tested when genital lesion is at vesicular or pustular phase.
  • Because viral shedding can be intermittent, lack of HSV detection by culture or PCR does not indicate lack of infection.
• All patients with genital ulcers should have serologic testing for syphilis (Treponema pallidum).
• All patients with any sexually transmitted infection should be offered testing for HIV.
• Serologic assays might be useful in select clinical circumstances.
• Consider other causes of genital ulcers if the clinical presentation is not clear, including:
  • chancroid (Haemophilus ducreyi) - usually multiple painful ulcers
  • lymphogranuloma venereum (LGV) (Chlamydia trachomatis) - usually painless ulcers but may be followed by painful adenopathy

Management

• In addition to providing pain relief, antiviral medication can be started while waiting for laboratory confirmation.
• Pain relief measures may include:
  • sitz baths in which only hips and buttocks are immersed.
  • analgesics until antiviral drugs take effect.
• Centers for Disease Control and Prevention (CDC) treatment guidelines:
  • Recommended treatment options for first clinical episode:
    • acyclovir 400 mg orally 3 times daily for 7-10 days
    • famciclovir 250 mg orally 3 times daily for 7-10 days
    • valacyclovir 1 g orally twice daily for 7-10 days
  • Recommended treatment options for daily suppressive therapy for recurrent genital herpes:
    • acyclovir 400 mg orally twice daily
    • famciclovir 250 mg orally twice daily
    • valacyclovir 500 mg orally once daily (might be less effective than other dosing regimens in patients with ≥ 10 recurrences per year)
    • valacyclovir 1 g orally once daily
  • Recommended treatment options for episodic therapy for recurrent genital herpes if the patient is able to start treatment during prodromal period or within 1 day of lesion onset:
    • acyclovir 800 mg orally twice daily for 5 days or 3 times daily for 2 days
    • famciclovir 125 mg orally twice daily for 5 days
    • famciclovir 1 g orally twice daily for 1 day
    • famciclovir 500 mg orally once, followed by 250 mg twice daily for 2 days
    • valacyclovir 500 mg orally twice daily for 3 days
    • valacyclovir 1 g orally once daily for 5 days
• During pregnancy:
  • Suppressive viral therapy with acyclovir 400 mg orally 3 times daily or valacyclovir 500 mg orally 2 times daily is recommended starting at 36 weeks gestation to women with a clinical history of genital herpes (Strong recommendation).
  • Consider continuation of antiviral therapy until delivery for primary outbreaks that occur during the third trimester (Weak recommendation).
  • Cesarean delivery for herpes simplex virus (HSV)
    • is indicated for women with active genital lesions or prodromal symptoms, such as vulvar pain or burning at time of presentation to labor and delivery (Strong recommendation).
    • may be considered in women with primary or nonprimary first-episode genital HSV infection during the third trimester (Weak recommendation).
• Counsel infected patients and their sex partners about potential for recurrent episodes and about risks of transmission.
  • Sexual transmission of HSV can occur during asymptomatic periods.
  • Patients should abstain from sexual activity with uninfected partners when lesions or prodromal symptoms are present.
  • Risk of HSV-2 sexual transmission can be decreased by daily use of valacyclovir.
  • Consistent and correct use of latex condoms reduces risk of genital herpes.
• Routine serologic screening for HSV in asymptomatic adults and adolescents, including pregnant women, is not recommended.