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Therapeutics in Dermatology
A reference textbook in dermatology

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Herpes

2 January 2017, by IUSTI & EADV

ACKNOWLEDGEMENTS

The text below has been provided by IUSTI (International Union against Sexually Transmitted Infections). This text was written with the help of the IUSTI, the EADV (European Association of Dermatology and Venereology) and its task force on Sexually Tansmitted Infections, the ISIDOG (International Society for Infectious Diseases in Obstetrics and Gynecology) and the UEMS-EBDV (European Union of Medical Specialists - European Board of Dermatovenereology).

The update is from 2017

You can download the pdf (Herpes genital type 1) here

You can download the pdf (Herpes genital type 2) here

KEY POINTS 

Genital herpes type 1 is a sexually transmitted infection.

It is passed from one person to another during sex, including oral sex.

It often causes no symptoms.

Treatment is simple.

You can protect yourself by ALWAYS using condoms when you have sex.

WHAT CAUSES GENITAL HERPES? 

— It is caused by the Herpes Simplex virus (HSV). There are two types: HSV-1 and HSV-2. They are related viruses but have different clinical courses 

— Both types can affect the genitals and anal area (genital herpes), the nose and mouth (cold sores) or hands and fingers (whitlows). 

— HSV-1 causes cold sores and with an increase in oral sex, HSV-1 now commonly causes genital herpes. HSV-2 rarely causes cold sores however. 

— The virus is able to enter the body through the soft linings of the mouth, vagina, rectum, urethra (the tube where urine comes out) and under the foreskin. It can also enter through small cuts in the skin’s surface.

HOW DO YOU GET GENITAL HERPES? 

— Most people catch herpes from someone who does not know that they were infected. 

— You can catch herpes when you have sex with someone who already has the infection. This can be by vaginal sex, oral sex or anal sex or by close genital contact. 

— The most common way to catch genital HSV-1 is by receiving oral sex from a person who has a cold sore or is about to develop one – this is very rare with HSV-2 infections. The most common way to catch genital HSV-2 is during sexual contact where one partner has the virus.

— Rarely genital herpes can be passed by a person with herpes on their fingers or hands touching their partner’s genital area. 

— You may be infected with the virus for weeks, months, or even years before you show symptoms.

WHAT ARE THE SYMPTOMS OF GENITAL HERPES? 

— Most people will have no visible signs or symptoms at all. About 1 in 3 people will experience symptoms of genital herpes within 4-5 days of becoming infected. 

— On occasions, the virus may be present in the body for weeks, months or even years before the person is aware of it. If you do get symptoms it does not mean you have just caught the virus. 

— You may feel generally unwell with mild flu-like symptoms such as fever, tiredness and headache. This is often followed by stinging or itching in the genital or anal area. Small fluid-filled blisters then may occur, which then burst within a day or two and will then crust over and heal. 

— People who have been infected with HSV-1 often have a more severe first attack of genital herpes than with HSV-2. 

— The virus then becomes dormant (inactive) and remains in the body. Every now and then the virus will reactivate and be shed. 

— Even if it does not cause symptoms, when it is present on the skin, it is infectious. 

— Sometimes the virus becomes active again, causing further episodes of genital herpes- this is known as recurrent herpes. 

— People with HSV-1 will have quite infrequent recurrences - on average this will be less than once per year. Typically, a patient who is diagnosed as having HSV-2 will have 4 to 6 recurrences of the illness each year. 

— Signs and symptoms of recurrences are usually much milder and clear quicker than the first outbreak. There is often a tingling sensation or mild flu-like illness before an outbreak. A few patients also experience itching or pain in the area before a blister appears. Blisters and sores are usually fewer in number than the first episode. They often affect the same place, but may also occur nearby.

WHAT CAUSES RECURRENCES? 

Reported triggers include being run down, tired or stressed, but there is limited evidence about this. Friction from sex, masturbation, tight clothing or underwear may also trigger an episode. Exposure to UV light may trigger the recurrence of a cold sore.

DO I NEED ANY TESTS?

— Yes, a swab from a blister or sore is needed to make the diagnosis. These tests are usually very accurate and results should take less than 2 weeks. This test may be able to tell you which type of herpes you have (HSV-1 or HSV-2) which will allow your doctor to give you more accurate information on your virus type. 

— If you have no symptoms of herpes then it is usually not possible to test you for the infection. This is because the available blood test is not very accurate and the result may not reflect whether you actually have the infection or not. 

— If you think you have symptoms that could be herpes, or worried about other infections, you should visit your family doctor or local sexual health or venereology / dermatology clinic. 

— If you have herpes, you should also be tested for other sexually transmitted infections such as HIV, syphilis, chlamydia and gonorrhoea, as you can have more than one infection at the same time.

WHAT IS THE TREATMENT FOR HERPES? 

FIRST EPISODE 

— Anti-viral medication is usually recommended for the first episode, and given within a few days of symptoms starting. Once the blisters have started to heal, it is often not effective

— It is important to keep the area clean by bathing the area with warm salty water. 

— It is important to wash your hands after touching the affected skin. 

— Ensure that you take in adequate amounts of fluids, such as water and soft drinks. 

— Some patients report a benefit from applying an ice pack to the sores (do not place the ice directly on the skin) for up to an hour at a time. Taking a cold shower and applying cold wet tea bags can also be soothing. 

— It may be helpful to wear loose fitting clothing. 

— If passing urine is painful, pass urine in the bath or pour a jug of warm water over your genitals as you pass urine. If you are unable to pass urine after several hours you should seek urgent medical attention.

RECURRENT HERPES

— If your recurrences do not cause you any trouble then it is not necessary to take medication for them, as the sores will clear up by themselves. 

— Some people find it helpful to take antiviral treatment if they get recurrent painful episodes of genital herpes. Your doctor may be able to give you tablets to keep at home, to start at the beginning of a recurrence. 

— If you have very frequent recurrences it may be possible to take a preventative treatment daily to suppress the symptoms and reduce recurrences. Speak to your doctor if this is something you would like to consider. Some people take this preventative treatment to reduce their risk of passing on the virus.

SHOULD I HAVE SEX IF I HAVE THE HSV VIRUS?

— You can only pass the virus on to someone who has not already been infected with the SAME type of herpes as you – i.e. HSV-1 or HSV-2. However, if you have HSV-2 you can infect someone already infected with HSV-1 and vice versa, although this risk may be a little smaller than the risk of infecting someone who has not been infected with either type of herpes. 

— The virus is most likely to be passed on just before, during or straight after an episode of herpes, and so the risk of passing on the virus can be reduced by avoiding sex completely during these times. 

— It is thought that most people occasionally shed virus without there being any signs or symptoms of genital herpes. This is called “asymptomatic shedding”. It is possible to pass the virus on during these periods; however, for most people that risk is small. 

— A person is more likely to shed the virus in the first year after catching the infection and if they have frequent recurrences. This risk larger with HSV-2 than with HSV-1. The longer the time between recurrences, the less common asymptomatic shedding is. 

— Using condoms has been shown to halve the risk of passing on herpes, as has taking long term preventative treatment.

HERPES AND PREGNANCY 

— If you are pregnant, or trying to become pregnant, it is important to inform your doctor and midwife that you have herpes. They will be able to give you advice about herpes in pregnancy. The risk of passing herpes to your baby is low if you have been infected before your pregnancy. Your doctor will advise you about how to reduce this risk further. 

— For men with herpes, whose partner becomes pregnant and has not already been infected with herpes, it is very important that she does not catch herpes during the pregnancy. You should speak to your doctor about how to reduce this risk.

DO I NEED TO TELL MY PARTNER?

— Telling your partner about your HSV-1 diagnosis has been shown to reduce the chance of passing on the virus. 

— You cannot get genital herpes from hugging, sharing baths or towels, from swimming pools, toilet seats or from sharing cups or cutlery. 

— Overall, the risk of genital herpes transmission (both types) is estimated at 5-10% each year. The transmission risk with HSV-1 is lower than that for HSV-2. 

— As HSV-1 can also cause common cold sores, it is likely that your partner will have been previously exposed to the virus. If your partner has already been infected with HSV-1 on their mouth (cold sores) or genitals then it is very unlikely that you will re-infect them. 

— If your partner has not already been infected with HSV-2, then taking necessary precautions (see above) will drastically reduce the risk of transmission. If your partner has already been diagnosed as having HSV-2, then you cannot pass on the virus to them again.

FURTHER HELP AND INFORMATION 

If you suspect that you have herpes or any other sexually transmitted infection, then see your family doctor or local sexual health or venereology/dermatology clinic.

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