Genital Herpes
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This leaflet has been written to help you understand more about genital herpes. It will tell you what it is, what causes it, what can be done about it, and where you can find more information about it.
What is genital herpes?
Herpes is a recurrent, life-long viral infection of the skin and the mucosa (moist surfaces of the mouth and genitals). When located at the lower half of the body (usually in the anogenital region) it is called genital herpes. In woman, the perineum, genitals (vulva, vagina, and cervix) and the anal region may be involved.
What causes genital herpes?
Genital herpes is caused by a virus, the Herpes Simplex Virus (HSV), mostly type II. However, HSV type I, which usually causes infection of the lips and mouth, is increasingly identified in genital herpes too.
Is genital herpes hereditary?
No, it is not hereditary.
What does genital herpes look like?
A clinically visible herpes infection often starts with an itchy or painful red spot that will develop into small blisters within a few hours which then rapidly become small open wounds (erosions); on the skin they later form little crusts. Single blisters may coalesce into bigger blisters. The blisters may be painful. In healthy people, the lesions are superficial and will heal without scars. Sometimes a raised temperature, swollen lymph nodes, muscle pain, tiredness or retention of urine may occur.
The first (primary) infection occurs when the virus penetrates the skin or the mucosa. The body will react with a defence mechanism (activation of the immune system). However, 80% of infected individuals won’t be aware of;and the viral infection remains unrecognized. The remaining 20% develop a clinically visible first (primary) infection.
Following the first infection, the virus remains latent (or sleeping) in the local nerve (nerve rootor ganglion) at the infected site for a variable period of time, often forever. In some individuals, however, the virus is reactivated from time to time (recurrence). In some people factors like menstruation, sexual intercourse, a raised temperature (for example in association with flu) or an individual’s decreased immune defence may trigger the re-occurrence. In these individuals the herpes virus returns to the site of the initial infection and a new lesion called recurrence or relapse appears. The frequency of the recurrences is variable, but the lesions are always at the same site.
The recurrent lesions may be preceded by itching or pain before they appear. This is known as a “prodrome”. Then, painful red spots, quickly covered by small blisters follow. They rapidly become small open wounds (erosions) in moist, mucosal surfaces or develop into small crusts on the skin. Single blisters may coalesce into bigger blisters. In healthy people, the lesions are superficial and will heal without scars in about 7 days.
Are there potential complications of the infection?
In healthy people, complications in genital herpes are rare.
However, when you acquire your first herpes infection, you may suffer from the following:
- transient neurological complications (for example urine retention); they usually resolve spontaneously
- an accompanying vulvo-vaginal infection occurs in 15 % of patients
- very rarely herpetic pneumonia, hepatitis or pancreatitis
In immunocompromised patients, recurrences tend to be more widespread, with deeper lesions and more frequently; they take longer to heal, sometimes with scar formation.
Are there risks for the unborn?
The baby can catch the virus by transmission from the mother via the placenta (when unborn) or during delivery.
The risk of transmission from the mother to the baby at the delivery is highest (30 to 50 %) among women who acquire genital herpes (primary herpes infection) near the time of delivery (within 6 weeks). 50% of herpes-infected neonates have either mothers with an asymptomatic primary infection with cervical virus shedding (unknown infection) or mothers with genital herpes lesions at delivery.
The risk of transmission is low (< 1 %) in recurrent herpes lesions present at delivery or if the genital HSV infection is acquired during the first half of the pregnancy.
If the baby is infected by the virus before delivery it is at risk of abnormalities mainly of the brain and the eyes.
If the baby is infected by the virus during delivery or as a new born it is at risk of an infection restricted to the skin, mucosa and/or the eyes (45%), the infection may involve the central nervous system (30%) and/or the infection may be disseminated involving many organs like lungs, liver and the brain (25%).
How do I acquire the disease?
Genital herpes is a sexually transmitted infection (STI). This means that when you have the primary infection you need to be tested for the other STIs. Your sexual partner/s, if he/she have lesions need to be examined too.
Recurrences are a reactivation of a present (latent) infection and not a new infection; therefore, you do not need to be checked for other sexually transmitted infections again.
The risk of virus transmission to a partner is higher when you have clinical symptoms (either the primary disease or a recurrence) and just before you get clinical symptoms (prodrome stage). The use of condoms does not always prevent transmission; you should therefore abstain from sexual contact when you have clinical symptoms. However, in the absence of lesions the risk of transmission is also present because of the possibility of unrecognized viral shedding. This phenomenon can occur during an unrecognized primary infection and possibly before and after clinical recurrences.
How is the diagnosis made?
Clinical examination is often sufficient to make the diagnosis.
A swab from a fresh lesion will be taken and allow the isolation and identification of the virus (special tests will then be performed like direct immunofluorecence tests, PCR assays or a culture). Your doctor will decide if any test is necessary to confirm the clinical diagnosis.
Biopsies of the lesions or blood tests are not useful to diagnose herpes infection and are therefore not recommended. They are only indicated in special situations, for example a blood test (herpes serology) to confirm a primary infection.
Can genital herpes be cured?
No; the virus remains in the body, usually in a silent stage. Reactivation can only be suppressed by antiviral drugs (see treatment).
How should it be treated?
There are 3 antiviral agents recommended for the treatment of genital herpes: acyclovir (ZOVIRAX®), valacyclovir (ZELITREX®), and famcyclovir (FAMVIR®).
Valacyclovir and famcyclovir should have replaced acyclovir because of their better bioavailability (can be better absorbed by the body).
However, in pregnancy and for neonates, acyclovir remains the drug of choice because its safety profile is better known.
In a primary/first infection, mild local antiseptics such as potassium permanganate (KMnO4 lotion) diluted to 1/10 000, applied twice a day for 10 minutes, may help to avoid super infection of the lesions. Oral painkillers (paracetamol) are recommended depending on the severity of the symptoms. Local anaesthetics are not recommended.
Aciclovir cream is not effective and is therefore not recommended for genital herpes lesions in general; an antiseptic cream or lotion should be used instead.
What can I do?
Specific management in pregnancy
A careful history with regard to the mother’s and her partner’s herpes infections (oral and genital) needs to be taken and should be documented. Herpes antibody tests (blood test) are not recommended as a screening test.
Primary infection during the first or the second trimester of pregnancy: Treatment with acyclovir (orally or intravenously in generalised disease) should be considered depending on the severity of the disease. Subsequently, preventive treatment with acyclovir should be considered during the 4 weeks prior to delivery in order to avoid recurrences and viral shedding around delivery, this may help to avoid a Caesarean section.
Primary herpes infection during the third trimester needs to be treated with acyclovir.
A caesarean section is indicated in pregnant women developing a primary infection within 6 weeks preceding delivery and in women with recurrent disease if they have clinical lesions at the time of delivery. It should not be performed in women with recurrent genital herpes if no lesions are observed.
What needs to be done for the baby at risk?
• If the mother carries the risk to transmit HSV to her baby, a rapid test (PCR assay) at delivery is required. A swab needs to be taken from the mother’s genital site for viral isolation. If the test is positive (the mother is carrying the virus) the baby should be treated prophylactically (even if there is no visible infection) with acyclovir.
• If the mother has had a primary infection during pregnancy (first herpes infection), the prophylactic treatment for the baby is initiated at delivery but stopped if the rapid test (PCR assay) in the mother is negative.
• If the mother has a recurrent herpes infection (an old infection that comes up from time to time), the prophylactic treatment in the baby is started only if the rapid test in the mother at delivery is positive.
• A newborn baby is also at risk of infection if a nurse or a visitor has got oral herpes!
• If a mother suffers from recurrent oral or genital herpes (an old infection that comes up from time to time) but if she had no lesions during pregnancy, investigations in the mother and the new born baby are not required.
If necessary, the baby should be treated with acyclovir intravenously (via a catheter in the blood stream). Blood tests, to check for herpes antibodies (serology) are not recommended.
Where can I find more information about genital herpes?
Web links to detailed leaflets:www.bashh.org/documents/115/115.pdf
Books
1. Centers for Disease Control and Prevention 2007 Genital Herpes : CDC Fact Sheet. Access 2008. “http://www.cdc.gov/std/herpes/STDFact-herpes.htm”
2. Patel R. et al. European guideline for the management of genital herpes. Int J STD AIDS 2001; 12 (suppl 3): 34-9
3. Leung DT, Sacks SL. Current recommendations for the treatment of genital herpes. Drugs 2000;60:1329-52
4. Corey L, Wald A. Maternal and Neonatal HSV Infections. N Engl J Med. 2009 Oct 1;361(14):1376-85
5. Aoki FY. Management of genital herpes in HIV-infected patients. Herpes 2001;8(2):41-5
Note: While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. Your own doctor will be able to advice in greater detail.
This leaflet has been prepared by the EADV task force “skin disease in pregnancy”, it does not necessarily reflect the official opinion of the EADV – August 2010 submitted to EADV