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Updated: Jul 22 2023

Herpes Simplex


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  • Snapshot
    • A 20-year-old college student presents to the student health clinic complaining of a painful, blistering rash on her upper lip. She says the rash has relapsed and remitted multiple times and she usually feels a mild tingling sensation in the area before a break-out of the lesions. On exam, her upper lip demonstrates clustered vesicles with an erythematous base and crusting.
  • Introduction
    • Overview
      • herpes simplex is highly-transmissible viral infection of the skin
        • characterized by painful, recurrent vesicular eruptions of the mucocutaneous surfaces
          • may occur orally or genitally
        • prodromal symptoms such as tingling may occur prior to outbreaks
        • treatment with acyclovir or valacyclovir
          • for bothersome symptoms
          • to prevent transmission to a serodiscordant sex partner
    • Associated conditions
      • HIV
      • gonorrhea
      • chlamydia
      • herpes encephalitis
      • Bell palsy
  • Epidemiology
    • Prevalence
      • high rates of infection in the general population
        • prevalence of HSV-1 is almost 50% amongst U.S. adults
        • prevalence of HSV-2 is around 12% amongst U.S. adults
      • almost 80% of infected persons are asymptomatic
    • Demographics
      • occurs in sexually active teenagers and adults
      • oral infection also commonly occurs in early childhood
        • transmission from relatives through kissing or sharing utensils
        • if child has genital disease, must rule out sexual abuse
      • almost two times more common in women than men
    • Location
      • lesions of either viral type may occur on the mouth or genitals
        • HSV-1 is more commonly found in oral infections
        • HSV-2 is more commonly found with genital infections
    • Risk factors
      • sex with an infected person
      • many sex partners
      • condomless sex
        • transmission can still occur when using barrier protection
      • HIV infection or immunosuppression
      • first sexual intercourse at a young age
      • history of STIs
    • Pathogenesis
      • caused by two major strains of the Herpes simplex virus (HSV)
        • HSV-1
          • oral-labial form
        • HSV-2
          • genital form
    • Transmission occurs from direct contact with active lesions
    • Virus resides in the dorsal root ganglia of local nerves until reactivation
      • mechanism for recurrence is not well-understood
        • immunosuppression plays a role
    • Intrahost viral spread occurs via epidermal cells
      • subsequent abnormal cell division creates multinucleated "giant cells"
  • Presentation
    • Symptoms
      • common symptoms
        • painful genital or oral burning
        • vesicular eruptions with crusting
        • tingling prodrome
        • primary genital infection
          • painful inguinal lymphadenopathy
          • fever
          • malaise
        • primary oral infection
          • gingivitis
          • oral ulcers
          • cervical lymphadenopathy
      • location
        • upper or lower lip of the mouth
        • labia, vagina, vulva, cervix
        • penis
        • anus
        • cutaneous lesion on the hand (herpetic whitlow)
        • eye (herpetic keratitis)
      • duration
        • incubation period 2-12 days
        • first outbreak may last 2-3 weeks
          • subsequent outbreaks may clear after 2-7 days
      • severity
        • often asymptomatic
        • primary eruption is most severe
          • severity decreases over time
      • aggravating factors
        • psychological stress
        • fatigue
        • menstruation
        • sunglight exposure
        • illness
      • alleviating factors
        • medication
    • Physical exam
      • inspection
        • many infections present with grouped vesicles on an erythematous base
        • genital infection
          • often presents with pedunculate papule
          • bilateral, erosive vesicles on the genitals
          • recurrence typically unilateral
        • oral infection
          • primary infection
            • severe, widespread gingivostomatitis and oral erosions
          • recurrence
            • common "cold sore"
        • herpetic whitlow
          • cutaneous lesion on the hand that can be caused by HSV-1 or HSV-2
          • most commonly seen in health care workers who come in contact with oral secretions (respiratory therapists, dentists)
  • Studies
    • Tzanck smear
      • useful for presumptive diagnosis
      • multinucleated giant cells
      • acantholytic cells
    • Culture or direct fluorecent anti-body staining
      • can be used to distinguish betwen Varicella zoster and Herpes due to similar findings on Tzanck smear
  • Differential
    • Herpes zoster virus
      • key disgintuishing factor (HZV)
        • dermatomal distribution of vesicles
    • Varicella zoster virus (VZV)
      • key distinguishing factors
        • vesiculopustular lesions
        • primarily on face, trunk, and scalp
  • Treatment
    • Lifestyle
      • avoid sunlight
      • reduce stress
    • Medical
      • acyclovir (oral or IV)
        • indicated as mainstay of treatment
        • both decreases frequency and severity of recurrences
        • side effects
          • may be nephrotoxic
          • prevent/treat nephrotoxicity with IV fluids
      • acyclovir ointment
        • may be indicated as adjunct to first line therapy
        • effective in reducing duration of viral shedding
        • does not prevent recurrence
      • acyclovir or valacyclovir suppresive therapy
        • indicated only in patients with >6 breakouts per year or with erythema multiforme
        • acyclovir taken daily
  • Complications
    • Complications
      • HSV encephalitis
        • incidence
          • 2-4/1,000,000
        • risk factors
          • immunosuppression
          • older age
          • young children
        • treatment
          • IV acyclovir
  • Prognosis
    • No cure
    • Relapsing and remitting course
      • symptoms become less severe over time
    • Treatment can improve symptoms
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