Genital herpes: diagnosis, treatment - Sexually Transmitted Diseases

The term herpes is used to describe two distinct but antigenically related serotypes of herpes simplex virus. Herpes simplex virus type 1 (Herpes Simplex Virus-1) is most commonly associated with oropharyngeal disease; type 2 (Herpes Simplex Virus-2) is most closely associated with genital disease.

Diagnosis

A presumptive diagnosis of genital herpes commonly is made on the basis of the presence of dark-field-negative, vesicular, or ulcerative genital lesions. A history of similar lesions or recent sexual contact with an individual with similar lesions also is useful in making the diagnosis.
Tissue culture is the most specific (100%) and sensitive method (80% to 90%) of confirming the diagnosis of first-episode genital herpes

Treatment

The goals of therapy in genital herpes infection are to shorten the clinical course, prevent complications, prevent the development of latency and/or subsequent recurrences, decrease disease transmission, and eliminate established latency.
Palliative and supportive measures are the cornerstone of therapy for patients with genital herpes. Pain and discomfort usually respond to warm saline baths or the use of analgesics, antipyretics, or antipruritics.
Specific chemotherapeutic approaches to treating genital herpes fall into six major areas: antiviral compounds, topical surfactants, photodynamic dyes, immune modulators, vaccines, and interferons.
Specific recommendations are given in Table Treatment of Genital Herpes.
Oral acyclovir, valacyclovir, and famciclovir are the treatments of choice for outpatients with first-episode genital herpes. Treatment does not prevent latency or alter the subsequent frequency and severity of recurrences.
Continuous oral antiviral therapy reduces the frequency and the severity of recurrences in 70% to 90% of patients experiencing frequent recurrences.
Acyclovir, valacyclovir, and famciclovir have been used to prevent reactivation of infection in patients seropositive for Herpes Simplex Virus who undergo transplantation procedures or induction chemotherapy for acute leukemia.

TABLE. Presentation of Genital Herpes Infections

General	Incubation period 2-14 days (mean – 4 days)
General	Can be caused by either Herpes Simplex Virus-1 or Herpes Simplex Virus-2
Classification of Infection
First-episode primary	Initial genital infection in individuals lacking antibody to either Herpes Simplex Virus-1 or Herpes Simplex Virus-2
First-episode nonprimary	Initial genital infection in individuals with clinical or serologic evidence of prior Herpes Simplex Virus (usually Herpes Simplex Virus-1) infection
Recurrent	Appearance of genital lesions at some time following healing of first-episode infection
Signs and Symptoms
First-episode infections	Most primary infections are asymptomatic or minimally symptomatic
	Multiple painful pustular or ulcerative lesions on external genitalia developing over a period of 7-10 days; lesions heal in 2-4 wk (mean 21 days)
	Flulike symptoms (e.g., fever, headache, malaise) during first fews after appearance of lesions
	Others – local itching, pain or discomfort; vaginal or urethral discharge, tender inguinal adenopathy, paresthesias, urinary retention
	Severity of symptoms greater in females than in males
	Symptoms are less severe (e.g., fewer lesions, more rapid lesion healing, fewer or milder systemic symptoms) with nonprimary infections
	Symptoms more severe and prolonged in the immunocompromised
	On average viral shedding lasts approximately 11-12 days for primary infections and 7 days for nonprimary infections
Recurrent	Prodrome seen in approximately 50% of patients prior to appearance of recurrent lesions; mild burning, itching, or tingling are typical prodromal symptoms
	Compared to primary infections, recurrent infections associated with (1) fewer lesions that are more localized, (2) shorter duration of active infection (lesions heal within 7 days), and (3) milder symptoms
	Severity of symptoms greater in females than in males
	Symptoms more severe and prolonged in the immunocompromised
	On average viral shedding lasts approximately 4 days
Therapeutic implications of Herpes Simplex Virus-1 versus Herpes Simplex Virus-2 genital infection	Primary infections due to Herpes Simplex Virus-1 and Herpes Simplex Virus-2 virtually indistinguishable Recurrence rate is greater following primary infection with Herpes Simplex Virus-2
	Recurrent infections with Herpes Simplex Virus-2 tend to be more severe
Complications	Secondary infection of lesions; extragenital infection due to autoinoculation; disseminated infection (primarily in immuncompromised patients); meningitis or encephalitis; neonatal transmission

The safety of acyclovir therapy during pregnancy is not established, although there is no evidence of teratogenic effects in humans.