What is herpes simplex?

Herpes is an infection that is caused by a herpes simplex virus (HSV). Oral herpes causes cold sores around the mouth or face. Genital herpes affects the genitals, buttocks or anal area. However, the infection is persistent and symptoms may recur periodically as outbreaks of sores near the site of original infection. After the initial, or primary, infection, HSV becomes latent in the cell bodies of nerves in the area. Some infected people experience sporadic episodes of viral reactivation, followed by transportation of the virus via the nerve’s axon to the skin, where virus replication and shedding occurs.

Basic symptoms:

Skin Eruptions and Pain. The first time a person experiences a herpes simplex outbreak, skin eruptions appear 2 – 12 days after the initial exposure to the virus.

• The first sign of infection is fluid accumulation (edema) at the infection site, which is quickly followed by small, grouped blisters — the characteristic HSV lesions.
• These form on an inflamed skin base, which is more visible in dry skin areas.
• The blisters then dry out and heal rapidly without scarring within 7 – 10 days. Blisters in moist areas heal more slowly than others. The lesions may sometimes itch, but itching decreases as lesions heal.
• When the crust falls off, the lesions are no longer contagious. (The virus may still be active in nearby tissue, but such persistence is rare.)
• Once HSV gains entry to a site in the body, the virus can also spread to nearby mucosal areas through nerve cells. This characteristic spreading can cause fairly large infected areas to erupt at some distance from the initial crop of sores.

The primary skin infection with either HSV-1 or HSV-2 lasts up to 2 – 3 weeks, but skin pain can last 1 – 6 weeks in a primary (the initial) HSV attack.

Other Symptoms. Some patients experience other symptoms as well, which may occur before the actual outbreak (called a prodrome ).

• Fever rising to about 102°F, muscle aches, headache, and flu-like malaise. These general symptoms usually resolve within a week.
• Lymph glands near the site may be swollen as well.

It may be especially important to identify a primary infection (if possible) and to treat it as soon as possible, since some preliminary research suggests that early treatment may limit the number of viruses that remain latent in the body and reduce the frequency of recurrent outbreaks.
Specific Symptoms of Oral Herpes
Oral herpes (herpes labialis) is most often caused by HSV-1 but can also be caused by HSV-2. It usually affects the lips and, in some primary attacks, the mucous membranes in the mouth. A facial herpes infection on the cheeks or in the nose may occur, but this condition is very uncommon.

Primary Oral Herpes Infection. If the primary (or initial) oral infection causes symptoms, they can be very painful, particularly in small children.

• Blisters form on the lips but may also erupt on the tongue.
• The blisters eventually rupture as painful open sores, develop a yellowish membrane before healing, and disappear within 3 – 14 days.
• Increased salivation and foul breath may be present.
• Rarely, the infection may be accompanied by difficulty in swallowing, chills, muscle pain, or hearing loss.

In children, the infection usually occurs in the mouth. In adolescents, the primary infection is more apt to occur in the upper part of the throat and cause soreness.

Recurrent Oral Herpes Infection. Most patients experience only a couple of outbreaks a year, although up to 10% of patients experience more frequent recurrences. (HSV-2 oral infections recur less frequently than HSV-1.) Recurrences are usually much milder than primary infections and are known commonly as cold sores or fever blisters (because they may arise during a bout of cold or flu). They usually show up on the outer edge of the lips and rarely affect the gums or throat. (Cold sores are commonly mistaken for the crater-like mouth lesions known as canker sores, which are not associated with HSV.)

Specific Symptoms of Genital Herpes

Genital herpes, which typically affects the penis, vulva, or rectum, is usually caused by HSV-2, although the rate of HSV-1 genital infection is increasing. Studies now report, in fact, that the cases of new symptomatic genital infections are equally split between HSV-1 and HSV-2. Some studies even report a higher incidence of genital HSV-1 cases. (The distinction may not matter, however, since there is no difference in treatments.) Initial genital infections due to HSV-1 may be more severe than those caused by HSV-2. Recurrences tend to be milder and less frequent than with HSV-2, however.

Primary Genital Herpes Infection. The first outbreak usually occurs in or around the genital area between 3 days and 2 weeks after exposure to the virus. If there is a long duration between the initial infection and the first outbreak of symptoms, the episode may be quite mild because the immune system has produced antibodies to the virus by that time. Also, such primary infections are less transmissible, heal faster, and produce fewer symptoms.

In about 80% of initial outbreaks of genital herpes, patients develop diffuse symptoms (flu-like discomfort and fever). The virus sheds for about 3 weeks. Symptoms in men and women are very different from each other.

In women, the pattern of a first infection is often more complicated and severe than in men with some or all of the following events:

• In addition to general flu-like discomfort, women may experience nerve pain, itching, lower abdominal pain, urinary difficulties, and yeast infections before or during the eruption of the skin blisters.
• When the outbreak occurs, blisters form raw sores (ulcers) almost immediately. Later they become crusted and fill with a grayish-white fluid. A new crop often occurs during the second week and is accompanied by swollen lymph glands in the groin. The symptoms may last as long as 6 weeks.
• Lesions commonly appear around the vaginal opening, on the buttocks, in the vagina, or on the cervix. If lesions occur inside the vagina, they are not visible and pain may be minimal. Such women, then, may be unaware that they have genital herpes. In such cases, the blisters produce a discharge that is still highly infectious.
• Lesions develop in places other than the genital region in 10 – 18% of primary HSV-2 infections. In most of these cases, outbreaks occur in the urethra (the channel that carries urine) where they can cause painful burning during urination. Inflammation of the internal reproductive organs, including the uterus lining (endometrium) and the fallopian tubes, is rare.

In men, about 6 – 10 blisters typically develop on the head or shaft of the penis. They rarely occur at the base. In some cases, they can occur on the buttocks, around the anus, or on the thighs.

Recurrent Genital Herpes Infection. In general, recurrences are much milder than the initial outbreak. The virus sheds for a much shorter period of time (about 3 days) compared to in an initial outbreak of 3 weeks. Women may have only minor itching, and the symptoms may be even milder in men.

On average, individuals experience four recurrences a year, although this varies widely depending on the severity of the initial outbreak. Men, for example, have 20% more recurrences of genital herpes than women even though their symptoms are milder. There are also some differences in frequency of recurrence depending on whether genital herpes is caused by HSV-2 or HSV-1:

• HSV-2 Genital Herpes Recurrences. HSV-2 genital infections recur more often than HSV-1, and they tend to be more severe. Up to 90% of HSV-2 genital infections recur within the first year after primary infection. Many patients report 5 – 8 recurrences in the first year, but some experience them as often as every 2 weeks. Some, though, have only one initial outbreak without any subsequent recurrences, a rate more typical of those with HSV-1.
• HSV-1 Genital Herpes Recurrences. In one study, 38% of patients with HSV-1 genital infections had no recurrences in the first year after primary infection, 35% had one recurrence, and 27% had 2 or more recurrences. The average time to recurrence was about 7.5 months. Only 7% of those with genital HSV-1 had two or more recurrences annually for at least 2 years.

Diagnosis of genital herpes is made most easily and accurately at the time of an active herpes infection, preferably when symptoms are noticed for the first time.This is because at this time, genital secretions and blisters containing fluid necessary for confirmation of infection are likely to be present, and a definitive diagnosis provides patient and doctor with the necessary information to agree the best course of treatment.During the first appointment, the doctor will take a medical history, and perform a physical examination.

The physical examination – Classic signs of HSV infection such as fluid filled blisters or lesions are relatively easy to identify, however a physical examination is not always reliable because of the wide range of symptoms associated with the infection. Some of the signs of genital herpes can be confused with other conditions such as candidiasis (thrush), urinary tract infections or skin conditions affecting the genital area.In order to confirm a diagnosis of genital HSV infection, it is necessary to prove the presence of the herpes simplex virus. Detection of HSV type specific antibodies in the bloodstream may be helpful but cannot define the site of HSV infection.The usual procedure is for the doctor to perform a swab test, in which a sample of the fluid from a blister, from ulcers, or a sample of a genital secretion, is taken and sent away for analysis.Laboratory analysis is usually made either by virus culture (where the virus is grown in material known as a culture medium) or by antigen detection where components of the virus are specifically identified.Because it is possible for a person with genital herpes to have another sexually transmitted infection at the same time, a full genital check should be made. For women this may include a cervical smear test.It is important to note that having genital herpes is not associated with the development of cervical cancer.The physician may also use one or more of the following most commonly used methods to diagnose genital herpes, depending on each situation…

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