Genital Herpes

Genital herpes is a sexually transmitted infection. It is a chronic, incurable viral disease spread by sexual contact, including oral and anal sex. It is caused by either of two viruses, the herpes simplex 2 virus (HSV-2), or the herpes simplex 1 virus (HSV-1). HSV-1 is also responsible for causing cold sores. About one-fifth of adults in the US have genital herpes, which is caused by HSV-2, and the majority are not aware that they are infected. Genital herpes usually causes sores on the genitals, but it may not have any symptoms in some people.

Symptoms
The symptoms of genital herpes may vary. Many people may not realize they have herpes, as they might have few or no symptoms. Commonly, though, the first outbreak of herpes symptoms occurs within two weeks after skin-to-skin contact with an infected person.

Most people with HSV infection have mild unrecognised or subclinical disease and are unaware of their infection. They may shed the virus intermittently in the genital tract and thus transmit the infection to their sexual partners entirely unknowingly. Perianal shedding is common in HIV negative, HSV-2 seropositive men who have sex with men and are asymptomatic. Most infections of genital herpes are transmitted by people who are unaware that they are infected or who have no symptoms when transmission occurs.

Symptoms of herpes outbreaks

 * Sores, vesicles or ulcers (called lesions) develop on the genitals, including penis, scrotum, vagina, lips of the vagina, and surrounding skin.
 * Small red bumps appear first, develop into small blisters, and then become itchy, painful sores that might develop a crust and will heal without leaving a scar.
 * They may occur on the buttocks or thighs, or on other parts of your body where the virus has entered through broken skin.
 * Sores also can appear inside the vagina and on the cervix (opening to the womb) in women, or in the urinary passage of women and men. These lesions can vary from person to person and may be mistaken for "jock itch," yeast infections, or other conditions.
 * Sometimes, there is a crack or raw area or some redness without pain, itching, or tingling.
 * Lymph nodes in the groin area (the crease between thigh and belly) may swell and grow tender.
 * Other symptoms that may accompany the first (and less often future) outbreak of genital herpes are fever, headache, muscle aches, painful or difficult urination, vaginal discharge, and swollen glands in the groin area.

Not everyone gets these symptoms, however. The sores or lesions on the genitals typically heal after a week or two, but the virus is still in the person's body, hiding within nerve cells.

Recurrence of herpes outbreaks
In most people, the virus can become active and cause outbreaks several times a year. This is called a recurrence, and infected people can have symptoms. HSV remains in certain nerve cells of your body for life. The time between outbreaks is called the latent phase. When the virus is triggered to be active, it travels along the nerves to your skin. There, it makes more virus and sometimes new sores near the site of the first outbreak. Recurrences are generally much milder than the first outbreak of genital herpes. HSV-2 genital infection is more likely to result in recurrences than HSV-1 genital infection. Recurrences become less common over time.

Symptoms from recurrences might include itching, tingling, vaginal discharge, and a burning feeling or pain in the genital or anal area. Sores may be present during a recurrence, but sometimes they are small and easily overlooked.

Sometimes, the virus can become active but not cause any visible sores or any symptoms. During these times, small amounts of the virus may be shed at or near places of the first infection, in fluids from the mouth, penis, or vagina, or from barely noticeable sores. This is called asymptomatic shedding. Even though the person is not aware of the shedding, they can still infect a sexual partner during this time. Asymptomatic shedding is an important factor in the spread of herpes.

People with herpes who have had outbreaks in the past often know when another is about to occur, because during the few days before lesions appear, they have minor symptoms like itching, burning, or tingling.

Cause
Genital herpes is caused by infection with herpes simplex virus (HSV), commonly by HSV type 2 and now increasingly by type 1. There are two types of HSV:


 * HSV type 1 most commonly infects the mouth and lips, causing sores known as fever blisters or cold sores. It can also infect the genitals.
 * HSV type 2 is the usual cause of genital herpes, but it also can infect the mouth.

Herpes simplex viruses are part of a family of DNA viruses called the Herpesviridae. Other members of this family include Epstein-Barr virus, Varicella zoster virus (which causes chickenpox) and cytomegalovirus. All members of the Herpesviridae have an affinity for nerve tissue and cause chronic infections.

Both HSV-1 and HSV-2 infections are acquired from contact with infectious secretions on oral, genital, or anal mucosal surfaces. Genital herpes can also be acquired from contact with lesions from other anatomical sites such as the eyes and non-mucosal surfaces such as herpetic whitlow on fingers or from lesions on the buttocks and trunk.

Transmission
Genital herpes is usually spread through sexual contact. There are several ways this can happen, but the common theme is skin-to-skin contact, or skin-to-mucous membrane contact. The virus is present in herpes sores, and also in saliva, semen, and vaginal fluid.


 * Sex with a person who is having an outbreak of sores is a common way of spreading herpes.
 * Sex with a person who is not having an outbreak, but who is still infected, can also spread the virus.
 * If a person's mouth is infected with HSV-1, the cold sore virus, that person can spread herpes to the partner's genitals.
 * People with HSV-1 who have an active cold sore should avoid oral sex, since this raises the risk of spreading genital herpes to the partner.
 * Even if a person with HSV-1 does not have a cold sore, he or she can still spread herpes to the partner's genitals via oral sex. Condoms or dental dams reduce, but don't eliminate, the risk of transmission.
 * Anal sex can spread genital herpes.
 * A pregnant woman with herpes can pass the infection to her baby during birth.

Condoms help to prevent the spread of genital herpes, but they are not foolproof. The only ways to completely prevent the spread of genital herpes is to refrain from all genital contact with other people, or to be monogamous with someone who is not infected.

Diagnosis
Many people have herpes without having any symptoms, or they may have had symptoms of herpes in the past without recognizing them. Sometimes herpes can be diagnosed by a health care provider who examines typical lesions, but this method is unreliable because the lesions can vary so much. The best way to tell if a person has herpes is to be tested.


 * If lesions are present, there are three kinds of tests that can be done by scraping the lesions.
 * Viral culture: If virus grows out of a scraping from a fresh lesion, then herpes is present. It may take up to 10 days for virus to grow. If it doesn't grow, herpes may still be present, as the test does not always work, especially in a lesion that isn't fresh or that is recurrent. HSV-1 and HSV-2 can be distinguished with this test.
 * PCR: This test detects tiny amounts of DNA. It is also called the HSV DNA test. This test is best if lesions are not fresh, or when used on spinal fluid if the person has encephalitis (a brain infection that may be caused by herpes virus).
 * Tzanck smear: This is an older test that stains human cells with dye and looks for virus within the cells. It works quickly, but isn't very accurate and cannot distinguish between HSV-1, HSV-2, and the chickenpox virus (Varicella zoster). For these reasons, it isn't recommended by the Centers of Disease Control.


 * There are also blood tests that look for antibodies to both HSV-1 and HSV-2. Lesions don't have to be present. These tests are often ordered in people with encephalitis (a brain infection that may be caused by the herpes virus) as well as in pregnant women.
 * IgM: The body makes IgM antibodies shortly after the first infection. These antibodies last for weeks, then dwindle as the body then begins to make IgG (see below). If IgM antibodies to HSV-1 or HSV-2 are present in the blood, this indicates either an active outbreak or a very recent one. If they are not present, a positive IgG may still mean the person has been infected in the past.
 * IgG: The body makes IgG antibodies after the initial infection and continues to make them throughout life. If IgG antibodies to HSV-1 or HSV-2 are present, the person has been infected at some point in the past.

Newer tests exist, but vary in availability and cost.

Treatment
Genital herpes is a lifelong condition, and though outbreaks can be partially controlled, the virus cannot be eradicated from the body. Treatments fall into two main categories: antiviral medications and symptomatic care.

Antiviral medications
There are three antiviral medications used to treat herpes. The object of treatment is to reduce the duration of an outbreak, and to reduce the amount of infectious viral shedding from the body, both during and between outbreaks. These medications are taken orally. Dosing regimens vary.


 * Acyclovir (Zovirax, or generic). This is the oldest of the three medications, and has to be taken more frequently than the other two.
 * Valacyclovir (Valtrex)
 * Famiciclovir (Famvir)

These medications are taken during and after the first outbreak for several days. They are then taken during subsequent outbreaks to reduce the duration of symptoms. Some people take antivirals daily over months or years in order to help suppress outbreaks. This is best for people who have very frequent outbreaks, or to reduce the risk of spreading the virus to partners who do not have HSV-2.

People taking antiviral medications should still use condoms or dental dams during sex, as the medications don't completely prevent viral transmission to sex partners.

Symptomatic care
Many people learn to recognize certain "triggers" that tend to lead to outbreaks. Stress, menstruation, friction, poor diet and other factors can predispose people to getting an outbreak, so an important part of self-care is to avoid these triggers wherever possible.

Once an outbreak occurs, though, here are some tips to ease the discomfort:


 * Avoid touching the sores, and keep hands clean (herpes occasionally spreads to the fingers)
 * Sitz baths (sitting in a few inches of cool water) or ice packs wrapped in a cloth
 * Cool hair dryer on the area
 * Cornstarch on the sores (women should avoid talcum powder, as it is linked to ovarian cancer)
 * Loose-fitting cotton underclothes
 * Acetaminophen or ibuprofen for pain
 * If urination is painful, urinating in a bath or shower dilutes the urine and may reduce pain
 * Avoid perfumed or harsh soaps and bubble baths
 * Avoid douching
 * Avoid sex during outbreaks and prodromes (the days before an outbreak when itching or tingling may occur)

People with herpes often benefit from seeking counseling or joining a support group, as the social stigma attached to this disease can be great.

Holistic and alternative treatments
There are many products being sold as herpes treatments or even cures. The reason doctors don't prescribe them is that these products either haven't been carefully studied by unbiased researchers, or because they have been so studied and found not to be effective. That means they just aren't likely to work. It also means that we don't really know if they're safe, or what their side effects may be.

Even if some people claim that these treatments worked for them, it is hard to say whether it was the treatment, a placebo effect, or some unknown factor that was actually responsible. People with herpes are most likely to improve if they stick to treatments that have been carefully studied and found to be effective and safe.

Prevention
People with herpes should follow a few simple steps to avoid spreading the infection to other places on their body or other people.


 * Avoiding touching the infected area during an outbreak, and washing hands after contact with that area.
 * Avoiding sexual contact (vaginal, oral, or anal) from the time of your first genital symptoms until symptoms are completely gone.
 * Avoiding oral-genital contact if they or their partner has any symptoms of oral herpes.

In general:


 * Barrier methods during sex, such as condoms and dental dams, help to prevent the spread of genital herpes, but does not prevent all transmission. Transmission can still occur since condoms may not cover all infected areas.
 * Antiviral medications taken by the infected partner also reduce but do not eliminate the risk of spreading herpes to an uninfected parter. Recently, the Food and Drug Administration approved valacyclovir (Valtrex) for use in preventing transmission of genital herpes. It has to be taken continuously by the infected person, and while it significantly decreases the risk of the transmission of herpes, transmission can still occur.
 * The only ways to completely prevent the spread of genital herpes is to refrain from all genital contact with other people, or to be monogamous with someone who is not infected.
 * A vaccine is currently being tested. It would only work to prevent herpes in women.

Complications
Fortunately, herpes rarely causes serious disease in healthy adults. There are some exceptions to this rule, though.

Herpes and weakened immune systems

 * In some people whose immune systems do not work properly, however, genital herpes outbreaks can be unusually severe and long lasting.

HIV and herpes

 * Genital herpes, like other genital diseases that cause sores, is important in the spread of HIV infection. A person infected with herpes may have a greater risk of getting HIV. This may be due to the open sores caused by the herpes infection (the HIV virus can more easily enter through herpes sores) or by other factors in the immune system. In addition, HIV-positive people may be more contagious for herpes.
 * The HIV virus multiplies faster in HIV-positive people with herpes.
 * HIV-positive people, with their weakened immune systems, may have worse herpes outbreaks and require higher doses of antiviral medications for herpes than HIV-negative people.

Herpes in pregnancy

 * Mothers with herpes or whose sex partners have herpes are at risk of passing on the virus to their babies during the birth process, particularly if they have lesions during the birth. Half of babies who contract herpes this way will die of the virus, as it overwhelms their immature immune systems.
 * Prenatal testing is important to prevent this catastrophic complication.
 * Pregant women who are ready to deliver but have active outbreaks generally receive Caesarean sections, which prevents the baby from passing through the infected birth canal.

Ocular herpes

 * Occasionally, people with normal immune systems can get herpes infection of the eye, called ocular herpes. Ocular herpes is usually caused by HSV-1 but sometimes by HSV-2. It can occasionally result in serious eye disease, including blindness.

Herpes encephalitis

 * Herpes is one of many viruses that can cause encephalitis, a rare brain infection that may affect adults, children, or neonates.
 * HSV-1, the cold sore virus, is usually responsible for herpes encephalitis in adults, and HSV-2 in neonates.
 * Common symptoms include headache, fever, and flulike symptoms, although those symptoms may indicate many other possible illnesses as well.
 * People who have these symptoms as well as suspected herpes sores on the face or genitals should seek medical care.

Social Issues
Herpes is considered a socially embarrassing disease, and many people may feel contaminated or unlovable after learning that they have it. However, support groups are available. Often people with herpes prefer to date each other, and there are dating groups for this purpose. Fortunately, people with herpes can have healthy and fulfilling relationships despite their disease.

Incidence
In the United States, an estimated 40-60 million people are infected with HSV-2, with an incidence of 1-2 million infections a year. The prevalence of genital herpes in developing countries varies from 2-74% according to the country. In some African countries that are experiencing HIV epidemics, HSV-2 is highly prevalent (≥70%), and there is evidence that genital HSV increases the risk of HIV infection and that people with both are more likely to transmit HIV infection.

Research
Click here to learn more about recent and current herpes clinical trials.

Links to Clinical Images
DermAtlas: Genital Herpes Images

DermNetNZ: Genital Herpes Images

Skinsight: Genital Herpes Images