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Herpes Simplex Virus Infection Print E-mail

Herpes Simplex Virus Infection

Initial Episode

Description:
  • Multiple painful ulcers
  • Symptoms develop within 9 (usually 3) days of sexual contact. (Delayed symptomatic presentation beyond 4 weeks of initial herpes infection is uncommon)
  • Localised (sometimes generalised) lymphadenopathy
  • Severe external dysuria
  • A severe episode with systemic symptoms (flu like myalgia, headache) is likely to be newly-acquired infection
Diagnosis:
  • Often clinical. Can usually be confirmed by a positive HSV PCR result (but never excluded by a negative)
  • Cotton-tipped swab pressed against open lesions, broken off in virus transport medium for detection by PCR of HSV 1 or 2.
Treatment: (Link to LJF)
  • Aciclovir 200mg x5/day for 5 days or
  • Valaciclovir 500mg b.d for 5 days, unless symptoms are very mild or lesions are healing at presentation.
  • If symptoms are very severe or ulceration extensive, consider a 10 day course of therapy.
Advice to patients: the acute episode
  • Adequate rest, take time off work
  • Regular Oral analgesia
  • Drink plenty of fluids (dilute urine rather than avoid drinking to reduce need for urination)
  • A warm bath containing sodium bicarbonate or salt is soothing
  • Pass urine in the bath, or with the shower spray directed at the affected area
Notes:
  • Antiviral therapy of less use if lesions present for >5days, but treatment is indicated if new lesions are appearing at any stage.
  • Local anaesthetics may be useful in severe cases in women, as a last resort to avoid the need for suprapubic catheterisation. EMLA (Lidocaine/Prilocaine) is useful. Instillagel (Lidocaine/Chlorhexidine) is also antibacterial and is inexpensive.
  • Consider Admission: If signs of urinary retention, intractable pain, meningitis or pregnancy (1st or 3rd trimester)
Follow Up:
  • In a severe primary attack review at 5 days to confirm no new lesions appearing. If new lesions are appearing consider a further 5 days of aciclovir.
  • Otherwise review at 2 weeks with HSV isolation results:
    • Full STI screen if deferred at first visit and sexual history indicates a need
    • Advice according to HSV type isolated
  • Advise patient to return in the event of further attack with severe symptoms.
  • No need to re-attend, or for further treatment, if recurrences are infrequent and/or mild
Information for patients:
  • The first attack is usually the worst
  • Stress that although lifelong infection, recurrences can be treated if severe
  • In most cases, recurrences are an inconvenience but do not require treatment with antivirals
  • HSV1: 50% chance of recurrence, HSV 2: 89% chance of recurrence in the first year after a symptomatic initial episode
  • Recurrence rate variable. 2/3 have less recurrences in year 2 than year one, but 1/3 have more. Average decrease in recurrence rate is about 1 (0.8) per year
  • Median recurrence rate is 4-5 episodes per year for HSV 2, 1 episode per year for HSV1. Draw parallels with cold sores in childhood
  • Asymptomatic carriage common. About ¾ of new infections are from asymptomatic partners. Only 10% of people with HSV 2 antibodies give a history of genital herpes. No indication of infidelity in long term partner
  • No effect on fertility. Not a problem in pregnancy unless the primary infection occurs at the time of delivery. Many obstetricians would now allow vaginal delivery during a recurrence
  • Chance of an asymptomatic female passing HSV to a male partner with whom she has regular unprotected sex is about 1% per year. Transmission rates in other circumstances unknown but likely to be similar
  • Virus more commonly excreted in the first three months after infection than subsequently
  • Leaflet - 'What do you know about...genital herpes'
Last Updated on Friday, 01 March 2013 13:35