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Introduction

Herpes simplex virus (HSV) is transmitted by direct skin to skin contact.

There are two types of herpes simplex virus:
  • Type I – usually causes oral lesions, but can also cause genital lesions if transferred from coldsores – e.g. during oral sex
    • More than 50% of genital lesions are now caused by type I
  • Type II – sexually transmitted, can cause genital lesions. May also be transmitted to oral regions during oral sex

It is frequently acquired without symptoms at the time, and the first flare can be many months or even years later.

This initial flare is often extremely painful, and may be more widespread. Subsequent flares are typically milder. In some cases there may never be any subsequent flares.

Flares can be treated episodically with PRN anti-virals. Patients may prefer to be on long-term anti-viral therapy, particularly if flares are severe or frequent, to reduce the likely and severity of future flares.

Psychological distress about the condition often outweighs the impact of the lesions and other clinical symptoms.

Presentation

  • In contrast to HPV, will cause ulcerated, painful lesions, in the ano-genital area
  • First presentation may also causeurinary retention
  • Proctitis
  • Urethritis

First presentation is usually not related to recent sexual activity and may have been required months or years previously. 

Course of the disease

The infection cannot be eradicated completely.
  • Usually the first attack is the longest and most severe
  • Subsequent attacks may be interpreted with prodromal symptoms such as:
    • Tingling / soresness at the site of a subsequent ulcer.

Investigation

Is often diagnosed clinically, but testing is available. Testing should only be performed if it is clinically important (e.g. during pregnancy), or if there is doubt over the diagnosis.

  • Swab for HSV NAAT (nucleic acid amplification test – a type of PCR test)
  • Requires that lesions are visible. Fresh, moist lesions are most likely to generate a positive result

Treatment

Antivirals – can be topical or oral – usually oral. Shorten duration of symptoms. Typically oral are preferred to topical as they are likely more efficacious.

  • If given in the presence of prodromal symptoms, can prevent a full blown attack.
  • Dose – e.g.:
    • Valaciclovir 500mg TDS for 5 days
    • Aciclovir – 400mg TDS day for 5 days.
    • Consider longer treatment if symptoms have not yet resolved
  • Topical aciclovir cream can be prescribed for patients inbetween attacks, to be used as soon a symptoms of an attack develop.
  • In patients for whom long-term preventative (“suppressive”) therapy is desirable:
    • Valaciclovir 500mg OD PO for 6 months
    • Review the need for suppressive therapy every 6 months – the frequency and severity of flare-ups tends to decline with time

Prevention

  • Encourage condom use for ongoing partners
  • Risk of transmission is greatest when lesions are present but can also occurs when no lesions are present

Other supportive measures

  • Topical lignocaine gel may reduce pain from lesions
  • Saline baths may soothe
  • Simple analgesia
  • Give written supporting information about the diagnosis

Contact tracing is not recommended

References

  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
  • Herpes - Australian STI guidelines

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