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BASICS

Description

  • Vesicular rash primarily on oral and genital areas caused by HSV-1 and HSV-2.
  • Historically, HSV-1 caused oral/facial infections, HSV-2 genital infections.
  • Primary genital HSV-1 infection now as common as HSV-2 genital infection.
  • Viral shedding greatest during primary infection, decreases with recurrences.

Epidemiology

  • Affects all ages.
  • HSV-1 mainly acquired in childhood; HSV-2 in young to middle adulthood.

  • 1 million new cases annually.

  • Seroprevalence: HSV-1 ~49%, HSV-2 ~12%; ~90% adults have HSV-1 antibodies by adulthood; 30% adults have HSV-2 antibodies.
  • WHO estimates 417 million with HSV-1 (age 15-49), 400 million with genital HSV-2.
  • 1 in 5 pregnant women seropositive for HSV-2.

Etiology and Pathophysiology

  • HSV-1 and HSV-2 are dsDNA viruses, family Herpesviridae.
  • Transmission by contact with infected skin during viral shedding.
  • Vertical transmission during childbirth possible.

Risk Factors

  • Immunocompromised states (age, chemotherapy, malignancy, diabetes, AIDS).
  • Atopic eczema in children.
  • Sexual contact with infected persons (condoms reduce but do not eliminate risk).
  • Occupational exposure (dental workers at higher risk for HSV-1).
  • Neonatal herpes primarily via vaginal delivery; higher risk with primary maternal infection.
  • Herpes gladiatorum in contact sports via skin abrasions.

General Prevention

  • Avoid contact with immunocompromised, elderly, and newborns if active lesions.
  • Hand hygiene.
  • Avoid sharing drinks, utensils, toothbrushes, or kissing with active lesions.
  • Avoid sexual contact during active genital lesions.
  • Counsel on condom use and suppressive antiviral therapy to reduce shedding.

DIAGNOSIS

History

  • Many unaware of exposure.
  • Prodrome: fatigue, low-grade fever, itching, tingling days before primary outbreak.
  • Recurrent outbreak prodrome: pain, burning, tingling 6–48 hours before lesions.
  • Triggers: sunlight, fever, trauma, menses, stress.

Physical Exam

  • Clustered vesicles evolving into painful ulcers with erythematous base.
  • Primary gingivostomatitis (children): fever, sore throat, multiple oral ulcers, cervical adenopathy.
  • Primary keratoconjunctivitis: unilateral conjunctivitis, blepharitis with vesicles.
  • Eczema herpeticum: diffuse vesicular eruption on atopic dermatitis areas.
  • Herpetic whitlow: painful finger infection with vesicles.
  • Congenital infection: multisystem disease including jaundice, seizures, chorioretinitis.
  • Recurrent disease: herpes labialis, ocular herpes keratitis, blepharitis, dendritic corneal ulcers.

Differential Diagnosis

  • Impetigo, aphthous stomatitis, herpes zoster, syphilitic chancre, folliculitis.
  • Herpangina (coxsackievirus), Stevens-Johnson syndrome, fungal infections, bacterial superinfection, lymphogranuloma venereum.

Diagnostic Tests

  • Clinical diagnosis common; reserve testing for atypical/immunocompromised.
  • Tzanck smear: multinucleated giant cells.
  • HSV culture: gold standard but limited by 20% false negatives.
  • HSV type-specific antibody testing.
  • HSV IgM not clinically useful.

TREATMENT

General Measures

  • Symptom relief with cool dressings (aluminum acetate).
  • Sitz baths for genital lesions causing urinary discomfort.
  • IV hydration for severe pediatric gingivostomatitis or eczema herpeticum.

Medications

First Line

  • Start treatment preferably during prodrome or within 1 day of symptoms.
  • Topical penciclovir 1% cream q2h during waking hours for oral lesions.
  • Acyclovir PO:
  • Primary mucocutaneous/genital: 400 mg 5x/day × 5 days.
  • Severe cases: IV acyclovir q8h then complete 10-day PO.
  • Recurrence options: 200 mg 5x/day ×5d, 400 mg 3x/day ×5d, 800 mg BID ×5d or 800 mg TID ×2d.
  • Suppression: 400 mg BID daily.
  • HSV keratitis: Acyclovir 400 mg PO 5x/day; topical preferred first-line.
  • Neonatal HSV: 60 mg/kg/day IV q8h ×14-21 days.
  • Valacyclovir for herpes labialis/genital infections and suppression.
  • Famciclovir alternatives.

Second Line

  • Foscarnet IV for acyclovir-resistant HSV.
  • Other topical antivirals (idoxuridine, brivudine) not US-approved.
  • Lidocaine topical analgesics for vulvar/penile pain.
  • Docosanol OTC topical.

Precautions

  • Renal dosing adjustments for antivirals.
  • Drug interactions (probenecid increases levels of acyclovir/valacyclovir).

ISSUES FOR REFERRAL

  • Refer recurrent keratoconjunctivitis to ophthalmology.
  • Neonates with suspected exposure or signs require immediate IV treatment and specialized care.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

  • Pregnancy:
  • Cesarean and/or acyclovir if active genital lesions or prodrome at delivery.
  • Daily oral antivirals after 36 weeks to prevent delivery outbreaks.
  • Avoid fetal scalp electrodes, vacuum, forceps if maternal HSV.
  • Neonatal care critical for exposed or infected infants.

ONGOING CARE

Follow-Up Recommendations

  • Usually no follow-up if treated and healed within 10 days.
  • Extensive cases reviewed in 1 week.
  • Consider suppressive therapy for frequent recurrences.

Diet

  • Avoid salty, acidic, sharp foods if oral lesions present.

Patient Education

  • Virus remains dormant; psychological impact acknowledged.
  • Hygiene to prevent spread to self and others.
  • Safe sexual practices and disclosure to partners.

PROGNOSIS

  • Primary disease lasts 5-14 days.
  • Antivirals shorten duration, reduce complications, and recurrences.
  • Viral shedding briefer in recurrences.
  • Newborns and immunocompromised at highest risk for morbidity/mortality.
  • HSV remains latent in dorsal root ganglia with possible reactivation.

COMPLICATIONS

  • HSV-2 increases HIV risk.
  • Herpes encephalitis, pneumonia, hepatitis.
  • Disseminated herpes, urinary retention.
  • Neonatal infection.

REFERENCES

  1. McQuillan G, Kruszon-Moran D, Markowitz LE, et al. Prevalence of HPV in adults aged 18-69: United States, 2011-2014. NCHS Data Brief. 2017;(280):1-8.

  2. Sauerbrei A. Optimal management of genital herpes: current perspectives. Infect Drug Resist. 2016;9:129-141.

  3. Rahimi H, Mara T, Costella J, et al. Effectiveness of antiviral agents for the prevention of recurrent herpes labialis: a systematic review and metaanalysis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113(5):618-627.

  4. Sawleshwarkar S, Dwyer DE. Antivirals for herpes simplex viruses. BMJ. 2015;351:h3350.

CLINICAL PEARLS

  • 25-30% of US adults have HSV-2 antibodies; >80% have HSV-1 antibodies.
  • Most infected unaware, facilitating asymptomatic transmission.
  • Suppressive antivirals reduce transmission and recurrence frequency.