Herpes simplex

The aim of this leaflet

This leaflet has been written to help you understand more about genital herpes. It will tell you what it is, what causes it, what can be done about it, and where you can find more information about it.

What is genital herpes?

Herpes is a recurrent, life-long viral infection of the skin andthe mouth and genitals. When located around the genitals (vulva, vagina, and cervix and anus) it is called genital herpes.

What causes genital herpes?

Genital herpes is caused by a virus, the Herpes Simplex Virus (HSV -mostly type 2sometimes type 1which usually causes infection of the lips and mouth).  

Is genital herpes hereditary?

No, it is not hereditary.  

What does genital herpes look like?

A visible herpes infection often starts with an itchy or painful red spot that will develop into small blisters within a few hours which then rapidly become small open wounds (erosions); on the skin they later form little crusts. Single blisters may join up to form bigger blisters. The blisters may be painful. In healthy people, the lesions are superficial and will heal without scars. Sometimes a raised temperature, swollen lymph glands, muscle pain, tiredness or difficulties passing urine (retention of urine) may occur.
The first (primary) infection occurs when the virus penetrates the skin or the mucosa. The body will react with a defence mechanism (activation of the immune system). However, 80% of infected individuals are not aware ofthe viral infection which remains unrecognized. About 20% develop a visible first (primary) infection. 
Following the first infection, the virus remains latent (or sleeping) in the local nerve  at the infected site for a variable period of time, often forever. In some people, the virus is becomes active from time to time (recurrence). In some women factors like menstruation, sexual intercourse, a raised temperature (for example with flu), a decreased immune defences/system may trigger the recurrence, or it may happen for no obvious reason. In these individuals the herpes virus returns to the site of the initial infection and a new lesion called recurrence or relapse appears. The frequency of the recurrences is variable, but the blisters are always at the same site. The recurrent blisters may be preceded by itching or pain before they appear. This is known as a “prodrome”. Then the spots and blisters appear, and will heal without scars in about 7 days. 

Are there potential complications of the infection?

In healthy people, complicationsin genital herpes are rare.
However, when you acquire your first herpes infection, you may suffer from the following:

  • short lived nerve problems(such as urine retention) which usually clear without treatment
  • an added infection with yeast (thrush/candida) or bacteriaof the inner and outer genitals occurs in  some of patients
  • very rarely the herpes affects the lungs (herpetic pneumonia), liver (hepatitis) or pancreas (pancreatitis)

In patients with a lowered immune system (e.g. in HIV infected individuals or cancer), recurrences tend to be more frequent and widespread, with deeper lesions that take longer to heal, and may form scars.  

Are there risks for the unborn baby?

The baby can catch the virus from the mother through the placenta (during pregnancy) or during delivery. 
The risk of transmission from the mother to the baby highest (30 -50 %)  at delivery i for women who acquire genital herpes (primary herpes infection) near the time of delivery (within 6 weeks). 
Half of new born babies with a herpes infection have either mothers with an asymptomatic primary infection with cervical virus shedding or mothers with genital herpes lesions at delivery.
The risk of transmission is low (< 1 %) in recurrent herpes lesions present at delivery or if the genital HSV infection is acquired during the first half of the pregnancy.
If the baby is infected by the virus before delivery it is at risk of problems with the brain and the eyes. Herpes virus transmission to the baby is mainly during delivery  rather than during pregnancy. The risk for infection depends mainly on the severity and timing of the mother’s infection, and is highest in primary infection near delivery, or if the mother is very ill with herpes, or the baby is premature.
If the baby is infected by the virus during delivery or as a new born the infection may be restricted to the skin, mucosa and/or the eyes (45%), the infection may involve the brain (30%) or the infection may be widespread involving many organs like lungs, liver and the brain (25%).  

How do I acquire the disease?

Genital herpes is a sexually transmitted infection (STI). This means that when you have the primary infection you need to be tested for the other STIs. Your sexual partner/s, if he/she has lesions need to be examined too.
Recurrences are a reactivation of a still present (but latent=sleeping) infection and not a new infection; therefore, you do not need to be checked for other sexually transmitted infections again each time.
The risk of virus transmission to a partner is higher when you have blisters and just before you get clinical symptoms (prodrome). The use of condoms does not always prevent transmission; you should therefore not have sexual contact when you have clinical symptoms. However, in the absence of lesions the risk of transmission is still present because of the possibility of unrecognized viral shedding which can occur  in a long term faithful relationship.  

How is the diagnosis made?

Clinical examination is often sufficient to make the diagnosis. 
A swab from a fresh lesion will be taken to confirm the viral infection if your doctor decides the test is necessary.
Biopsies of the lesions or blood tests are not useful.  

Can genital herpes be cured?

No; the virus remains in the body, usually in a silent stage. Reactivation can only be suppressed by antiviral drugs (see treatment).  

How should it be treated?

There are 3 antiviral agents recommended for the treatment of genital herpes: acyclovir (ZOVIRAX®), valacyclovir (ZELITREX®), and famcyclovir (FAMVIR®).
Valacyclovir and famcyclovir should be used because they are better absorbed by the body. However, in pregnancy and for new born babies, acyclovir or valacyclovir are the drugs of choice because its safety profile is better known.
In a primary/first infection, mild local antiseptics such as potassium permanganate (KMnO4 lotion) diluted to 1/10 000 (pale pink), applied twice a day for 10 minutes, may help to avoid super infection of the lesions.Painkillers by mouth (paracetamol) are recommended for pain. Local anaesthetics are not recommended. 
Aciclovir cream is not effective and is therefore not recommended for genitalherpes, antiseptic cream or lotion should be used instead to prevent added infections.  

What can I do?

Specific management in pregnancy
A careful history with regard to the mother’s and her partner’s herpes infections (oral and genital) needs to be taken and should be documented. Herpes antibody tests(blood test) are not recommended as a screening test.
Primary infection during the first or the second trimester of pregnancy: 
Treatment with acyclovir (by mouth or by a drip in generalised disease) may be used depending on the severity of the disease. Treatment with acyclovir or valacyclovir may be used for 4 weeks before delivery to prevent recurrences and viral shedding around delivery; a Caesarean section is usually not needed.
Primary herpes infection during the third trimester must be treated with acyclovir or valacyclovir.
A caesarean section is needed in pregnant women developing a primary infection in the 6 weeks preceding delivery and in women with recurrent disease if they have lesions at the time of delivery. It should not be performed in women with recurrent genital herpes if no lesions are observed. 

What needs to be done for the baby at risk?
  • If the mother carries the risk to transmit HSV to her baby (an old infection that comes back from time to time), a rapid test (PCR assay) at delivery is required. A swab needs to be taken from the mother’s genital site to detect the virus. If the test is positive (the mother is carrying the virus) the baby should be treated with valacyclovir or acyclovir even if there is no visible infection.
  • If a mother suffers from recurrent oral or genital herpes (an old infection that comes back from time to time) but she had no lesions during pregnancy, investigations in the mother and the new born baby are not required.
  • If the mother has had a primary infection during pregnancy (first herpes infection) preventative treatment for the baby is started at delivery but is stopped if the rapid test (PCR assay) in the mother is negative.
  • A newborn baby is also at risk of infection if a nurse or a visitor has got oral herpes!

If necessary, the baby should be treated with valacyclovir or  acyclovir (with a drip). Blood tests, to check for herpes antibodies (serology) are not recommended.  

Where can I find more information about genital herpes?

 1. Centers for Disease Control and Prevention 2007Genital Herpes : CDC Fact Sheet. Access 2008. “http://www.cdc.gov/std/herpes/STDFact-herpes.htm”
2. Patel R. et al. European guideline for the management of genital herpes. Int J STD AIDS 2001; 12 (suppl 3):34-9
3. Leung DT, Sacks SL. Current recommendations for the treatment of genital herpes. Drugs 2000;60:1329-52
4.Corey L, Wald A.Maternal and Neonatal HSV Infections. N Engl J Med. 2009 Oct 1;361(14):1376-85
5. Aoki FY. Management of genital herpes in HIV-infected patients. Herpes 2001;8(2):41-5
While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. Your own doctor will be able to advice in greater detail.
This leaflet has been prepared by the EADV Task Force “Skin disease in pregnancy”, it does not necessarily reflect the official opinion of the EADV
Update July 2013