HIV/AIDS

Updated 25 June 2014

Genital Herpes

Genital herpes is a viral infection causing small, painful blisters that break open and turn into ulcers.

Summary

  • Genital herpes is a sexually transmitted disease.
  • Genital herpes causes painful blisters.
  • Recurrences can occur periodically, triggered by different factors in different people.
  • There is no cure for genital herpes, but there are now drug treatments that can help to control recurrences.
  • The virus is highly contagious.
  • Outbreaks can recur periodically in an individual, especially under stress or after trauma.

Genital herpes is a viral infection causing small, painful blisters that break open and turn into ulcers.

There are two different but closely related viruses that cause genital herpes infection, most commonly the virus associated with genital herpes is herpes simplex virus (HSV) type II. However, HSV type I can also sometimes cause genital herpes. Once someone has been infected by these viruses, there is no way of ever getting rid of them. These viruses belong to a large group of viruses that can hide in a “latent” state in an individual's body after the first infection with that virus and reactivate at a later stage to cause disease once again.

The blisters or ulcers can be absent for several months or years during inactive states. The reactivation of herpes is called "recurrent herpes". Recurrences can be unpredictable or may be linked to certain conditions such as an impaired immune system, pregnancy, menstruation, skin irritation or stress.

Genital herpes is usually acquired by direct (sexual) contact with the genitals, mouth or rectal area of an infected person. The virus can also be transmitted to a baby during delivery if the mother has genital herpes, resulting in serious illness in the newborn baby and sometimes even death.

People are most at risk of passing on the virus when blisters are present. However, genital herpes can be contagious even when there are no noticeable symptoms since the virus is shed in the normal secretions of the genital tract during inactive periods.

Cause

Genital herpes is caused by the Herpes simplex virus (HSV).

There are two types of HSV. Sores on the lips known as fever blisters or cold sores are in fact oral herpes, and are usually caused by HSV type 1. HSV type 1 is often acquired in childhood by non-sexual oral contact with an infected person. If childhood infection is avoided, young adults can acquire HSV type 1 by kissing. Genital herpes, on the other hand, is most often caused by HSV type 2, and this virus is more problematic than its counterpart. However, as oral-genital sex is not uncommon, in a small number of people HSV type 1 is the cause of genital herpes, while in others HSV type 2 is the cause of oral herpes.

Through close (sexual) contact with the sores of an infected person, the virus can invade the moist mucous membranes of the genitals or surrounding skin through microscopic tears. If a person's fingers are contaminated by infected secretions, the virus can be spread by hand to other parts of the body. Although not common, a pregnant woman who is infected can pass the virus to her baby. Very rarely this happens while the baby is still in the uterus, and it more usually occurs during delivery when the baby passes through the infected birth canal.

Symptoms

Some people may acquire genital herpes without any knowledge of it – when their partner showed no symptoms at the time and they themselves did not have any initial symptoms. They may carry the infection silently or go on to have recurrences later.

However, the initial (primary) infection with genital herpes does usually have symptoms and can be very severe, with a general, flu-like viral illness along with the genital sores.

Symptoms of primary genital herpes are as follows:

  • Numbness, tingling, itching or burning in the genital area may precede the appearance of blisters (prodromal symptoms).
  • Painful blisters appear in and around the vagina or on the penis, around the anal area, or on the thighs or buttocks. Occasionally other skin sites away from the genital areas may be infected as well, such as the face and breasts. Single blisters can occur, but they usually occur in groups. A group of blisters that emerges at the same time is called a crop. In the primary infection several crops may occur one after another. The blisters are painful and tender to the touch. After a short while they look like small pink or red shallow sores (ulcers). After a few days, the blisters become crusted and then heal without scarring.
  • The whole pelvic region may ache.
  • There may be painful urination or frequent need to urinate.
  • Intercourse is likely to be very painful.
  • Glands in the groin may be tender and swollen.
  • Fever, muscle aches and headache may be present.

The primary infection is usually the most widespread and painful, and lasts the longest. Very serious cases of primary herpes can have complications such as involvement of the nervous system, with loss of ability to urinate, impotence, loss of power and feeling in the legs or even meningitis. There may also be genital complications such as the vaginal labia becoming partially stuck together during healing.

The symptoms of a recurrence are much the same as a primary infection, but are generally milder and shorter and without complications.

A baby who has been infected with herpes simplex during delivery may develop skin blisters within days. The blisters are often on the scalp or head, or in the case of a breech baby, on the buttocks. These blisters should be taken as a very serious warning sign; while in some babies the virus may not have spread beyond the skin, in many there is more general infection, with a special risk of brain infection with the Herpes simplex virus. Therefore all babies with skin blisters of herpes must be treated with acyclovir (see treatment). Some babies will not have the skin blisters at all, but have a general infection in the body, which is then very difficult to recognise as herpes.

Course

When a person is first exposed to and infected with the virus, there is an "incubation period" while the virus starts to multiply and before any symptoms occur. The incubation period is usually three to seven days.

Then prodromal symptoms can be present for 48 hours before the formation of blisters. In a primary infection new crops of blisters may keep appearing for up to two weeks, and the whole illness may last for up to four weeks.

During the initial infection the virus travels to deep nerve centres at the base of the spinal cord and remains there for life. When reactivated, the virus travels down the nerve fibres to the original site of infection, where it multiplies, causing new blisters to erupt.

Some people come to recognise the warning signs (prodromal symptoms) of a recurrence. Recurrences are usually shorter than the first infection, lasting about a week in all.

The extent and frequency of recurrences vary greatly. Some people may never or rarely have recurrent breakouts, while others may have several recurrences per year. There appears to be a connection between the frequency and severity of the primary infection and the likelihood of recurrences; those people who have a severe primary infection are likely to have symptomatic recurrences. People who have suppressed immune systems because of chronic illness or certain types of medications may suffer more frequent and longer-lasting attacks. Sunburn, pregnancy, menstruation or skin irritation caused by tight clothing or sexual intercourse may also reactivate the virus. It is controversial whether psychological stress is a triggering factor, as some researchers believe that stress is a consequence of recurrences rather than a trigger.

The virus can also reactivate without any obvious symptoms. Small amounts of the virus may be shed from microscopic blisters or ulcers and from genital or oral secretions. Therefore even a person without any symptoms can still infect others.

There is a tendency for recurrences to be most frequent in the first year after initial infection, with decreasing recurrences after that.

Risk factors

  • People who have unprotected sex
  • People who have multiple sexual partners
  • Gender – women are at greater risk of infection than men.
  • Babies born to women with genital herpes, especially if it is a primary infection
  • People with a compromised immune system – especially those with HIV/AIDS are very prone to frequent, severe recurrences of herpes.

When to see a doctor

A doctor should be seen if:

  • There are symptoms of genital herpes or when a person suspects that he/she may have been infected.
  • A pregnant women has a history of genital herpes – their health professionals should be informed so that they are aware of the possibility of infection of the baby during delivery.
  • A baby has been exposed to genital herpes during delivery and shows skin blisters and/or signs of dullness and poor feeding a few days after birth.

Visit preparation

If you think you may have genital herpes, abstain from sexual activity while waiting for an appointment.

Diagnosis

Diagnosis is made when an outbreak is present, based on appearance and a positive culture of the virus in the laboratory.

For a reliable culture result, fluid or cells swabbed from a blister should be collected as soon as possible after the blisters appear. Several tests may be necessary to distinguish herpes from other infections.

In some cases a false negative culture result can lead people to incorrectly believe that there is no infection. If there is doubt about the result, a blood test can be performed that will detect antibodies to the virus. This will indicate whether someone has been infected with the virus at any time in the past and is therefore a herpes carrier. Some laboratories offer tests that can show antibodies specifically for HSV type 1 or HSV type 2, but be aware that these tests are not perfect yet, often are not specific enough and may give a false diagnosis of the illness. There is also a test that can be used to diagnose primary or recurrent infection know as the HSV IgM test. This test can be used to confirm the diagnosis in individuals that are clinically ill when they present to their doctor or people that suspect that they may be infected with HSV.

A positive blood test is mixed news. It means that a person is a herpes carrier but it also means that they are immune to infection from someone else. Therefore, if both you and your partner have antibodies to HSV type 1 and type 2, you are not at risk from each other.

Treatment

Home

A number of home treatments can relieve pain, speed healing, stop the spread of infection and prevent recurrences.

For pain relief:

  • Warm baths may help to relieve pain.
  • Aspirin, paracetamol or codeine can reduce pain.

To speed healing of the blisters:

  • Never try to rupture a blister, as this could lead to bacterial infections.
  • Keep the infected area dry and clean to prevent the development of secondary infections.
  • Drying agents can help to dry out and heal ruptured blisters. These agents include hydrogen peroxide, calamine lotion and Burrow's solution. Tea tree oil may also help dry up sores.
  • A cool hair dryer can be used to keep away moisture.
  • Add three tablespoons salt to a warm bath and follow with a cold bath. Soak about 15 minutes in each.

To prevent spread of infection:

  • Use a disposable glove to apply medication.
  • When blisters are present, wash hands to prevent infection of other body parts.
  • Avoid touching the eyes or mouth after touching blisters or applying ointments. It is particularly important not to touch your eyes, because there is a risk of spreading the infection to them, resulting in corneal ulcers.
  • Avoid sharing clothing or towels that come into contact with blisters.

To prevent recurrences:

  • General good health may help your immune system fight recurrences – get enough sleep, follow a healthy diet, stop smoking, reduce alcohol intake, get regular exercise, practice stress management and relaxation techniques.
  • Wear sunscreen when outdoors.
  • Wear loose underwear, preferably cotton, to avoid irritation of the skin.
  • Do not use douches, feminine hygiene deodorants, perfumed soaps or other chemicals in the genital area.

For anxiety and despondency: People who suffer recurrent genital herpes can feel depressed and angry, and feel low in self-esteem. They may be anxious about infecting others and about having to inform a new partner that they have genital herpes. It can be helpful to discuss the issues with a well-informed person, and long-term suppressive therapy can improve the situation immensely.

Medication

Genital herpes is usually treated with an anti-viral drug called acyclovir, as well as two new variations of acyclovir, called valaciclovir and famciclovir.

Although acyclovir is available as a cream, studies show that cream applied to the skin is of very little if any benefit. For benefit to be had from acyclovir it should be taken orally (in life-threatening situations a doctor may give acyclovir intravenously). Acyclovir has been in use for many years and has been shown to be a remarkably safe drug, even in babies and children or when taken for long periods. Acyclovir is particularly useful in lessening and shortening the symptoms of primary genital herpes. It is of less benefit in recurrences and if used, should be taken as early as possible, preferably as soon as a person feels the prodromal symptoms of itching or burning, before the blisters have even appeared.

The biggest breakthrough in the treatment of genital herpes in recent years has been the use of acyclovir to control recurrences of genital herpes. People who are unfortunate enough to have frequent recurrences of genital herpes (say six or more recurrences in a year) can now be offered hope in the form of long-term "suppressive therapy" with acyclovir. This might start out at the full dose of acyclovir, but can usually be reduced to half the normal dose after a month or two . While this treatment is not a guarantee against any recurrences, it is very often most successful in reducing them. Usually the treatment is kept up for a year in the first place, and then the person and the doctor can reassess the situation.

Fortunately the price of acyclovir has recently come down dramatically in South Africa, due to the expiry of its exclusive patent with certain pharmaceutical companies.

Another possible place for treatment with acyclovir is following unintended exposure to herpes. While this has not yet been proven to be of benefit, it could be considered in certain situations, in the same way that anti-retroviral drugs are being used in instances of HIV exposure such as rape.

Pregnant women

Until a few years ago it was recommended that pregnant women with a history of genital herpes or even a positive blood test have regular vaginal swabs for culture in the weeks prior to delivery. A caesarean section would be performed if a swab were positive. It is now known that weekly cultures poorly predict the risk to the baby. Also, as the risk of infection to the baby is very low and caesarean section is not a guarantee that infection will be avoided, caesarean section for genital herpes is controversial.

A caesarean section would probably be performed if blisters were present in or near the birth canal at the time of delivery. However, in the absence of these signs, some doctors would now rather avoid caesarean section and treat the baby with acyclovir as a protective measure. There are studies underway to see whether treating the mother with acyclovir around the time of delivery will reduce the risk of transmitting the virus to the baby.

Whatever course is decided on by the doctor and parents, it would be important to observe the baby closely after delivery and intervene with treatment with acyclovir at the slightest sign that infection may have taken place.

Prevention

  • Practise safer sex. Use condoms every time during intercourse and foreplay. The female condom, which has recently been launched in South Africa, can also reduce the risk of infection.
  • Ask sexual partner(s) if they have had herpes, but be aware that genital herpes also can be asymptomatic.
  • Do not have sex with someone who has genital sores or oral sex with someone with cold sores.
  • Do not become sexually intimate when drinking alcohol or using other drugs; drugs reduce a person's ability to make sensible decisions regarding safer sex.

Reviewed by Dr Eftyhia Vardas BSc(Hons), MBBCh, DTM&H, DPH, FC Path (Virol), MMed (Virol), Clinical Virologist, Director HIV AIDS Vaccine Division, Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, University of the Witwatersrand and senior lecturer, Department of Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand

 

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Dr Sindisiwe van Zyl qualified at the University of Pretoria before working for an HIV/AIDS NPO in Soweto for many years. She was named one of the Mail & Guardian's Top 200 Young South Africans in 2012.

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