Genital
herpes is a contagious viral infection that affects an estimated
one out of four (or 45 million) Americans. Doctors estimate
that as many as 500,000 new cases may occur each year. The
infection is caused by the herpes simplex virus (HSV). There
are two types of HSV, and both can cause genital herpes. HSV
type 1 most commonly causes sores on the lips (known as fever
blisters or cold sores), but it can cause genital infections
as well. HSV type 2 most often causes genital sores, but it
also can infect the mouth.
Both HSV
1 and 2 can produce sores in and around the vaginal area,
on the penis, around the anal opening, and on the buttocks
or thighs. Occasionally, sores also appear on other parts
of the body where broken skin has come into contact with HSV.
The virus remains in certain nerve cells of the body for life,
causing periodic symptoms in some people.
Genital
herpes infection usually is acquired by sexual contact with
someone who unknowingly is having an asymptomatic outbreak
of herpes sores in the genital area. People with oral herpes
can transmit the infection to the genital area of a partner
during oral-genital sex. Herpes infections also can be transmitted
by a person who is infected with HSV who has noticeable symptoms.
The virus is spread only rarely, if at all, by contact with
objects such as a toilet seat or hot tub.
Symptoms
Eighty
percent of people with genital herpes are unaware of their
disease because they never develop any symptoms or do not
recognize them. When symptoms do occur, they vary widely
from person to person. Symptoms of a first episode of genital
herpes usually appear within two to 10 days of infection,
and first episodes last an average of two to three weeks.
Early symptoms can include an itching or burning sensation;
pain in the legs, buttocks, or genital area; vaginal discharge;
or a feeling of pressure in the abdominal region.
Within
a few days, sores (also called lesions) appear at the site
of infection. Lesions also can occur inside the vagina and
on the cervix in women, or in the urinary passage of women
and men. Small red bumps appear first, develop into blisters,
and then become painful open sores. Over a period of days,
the sores become crusted and then heal without scarring.
Other symptoms that may accompany the first or primary episode
of genital herpes can include fever, headache, muscle aches,
painful or difficult urination, vaginal discharge, and swollen
glands in the groin area.
Recurrences
In genital
herpes, after invading the skin or mucous membranes, the
virus travels to the sensory nerves at the end of the spinal
cord. Even after the skin lesions have disappeared, the
virus remains inside the nerve cells in an inactive, latent
state. In most people, the virus will reactivate monthly.
It travels along the nerves to the skin, where it multiplies
on the surface at or near the site of the original herpes
sores, causing new sores to erupt. It also can reactivate
without causing any visible sores. At these times, small
amounts of the virus may be shed at or near sites of the
original infection, in genital secretions, or from barely
noticeable lesions. This shedding occurs without any pain
or discomfort, it may last only a day, but it is possible
to infect a sex partner during this time.
The
symptoms of recurrent episodes usually are milder than those
of the first episode and typically last about a week. A
recurrent outbreak may be signaled by a tingling sensation
or itching in the genital area, or pain in the buttocks
or down the leg. These are called prodromal symptoms, and,
for some people, they can be the most painful and annoying
part of a recurrent episode. Sometimes only the prodrome
is present and no visible sores develop. At other times,
blisters appear that may be very small and barely noticeable,
or they may break into open sores that crust over and then
disappear.
The
frequency and severity of the recurrent episodes vary greatly.
While some people recognize only one or two recurrences
in a lifetime, others may experience several outbreaks a
year. The number and pattern of recurrences often change
over time for an individual. Scientists do not know what
causes the virus to reactivate. Although some people with
herpes report that their recurrences are brought on by other
illness, stress, or menstruation, recurrences often are
not predictable. In some cases, exposure to sunlight is
associated with recurrences.
Diagnosis
The
sores of genital herpes in its active stage may be visible
to the naked eye. Several laboratory tests may be needed,
however, to distinguish herpes sores from other infections.
The most accurate method of diagnosis is by viral culture,
in which a new sore is swabbed or scraped and the sample
is added to a laboratory culture containing healthy cells.
When examined under a microscope after one to two days,
the cells show changes that indicate growth of the herpes
virus.
A newer,
more rapid, but somewhat less accurate way of diagnosing
herpes involves detection of viral protein components in
lesion swabs. These tests should be done when the sores
first appear to ensure the most reliable results. Other
laboratory tests also are available to physicians. It is
important to recognize that the virus is hard to find and
that although clinicians commonly fail to detect the virus
in an active sore, this does not mean that a person does
not have genital herpes.
A blood
test cannot determine whether a person has an active genital
herpes infection. A blood test, however, can detect antibodies
to the virus, which indicate that the person has been infected
with HSV at some time and has produced antibodies to it.
(Antibodies are proteins made by a person’s immune system
to fight infections.) Unlike antibodies to some other viruses,
however, antibodies to HSV only partially protect an individual
against another infection with a different strain or a different
type of herpes virus, and they do not prevent a reactivation
of the latent virus. The standard blood tests only reliably
indicate whether a patient has had a herpes infection, but
it cannot tell if it is oral or genital.
New
blood tests have been developed that can distinguish whether
a person has had prior type 1 or type 2 infection, or both.
These tests, however, are available mainly in research hospitals
and are not currently available in the doctor’s office.
Treatment
During
an active herpes episode, whether primary or recurrent,
it is important to follow a few simple steps to speed healing
and to avoid spreading the infection to other sites of the
body or to other people:
- Keep
the infected area clean and dry to prevent secondary infections
from developing.
- Try
to avoid touching the sores; wash hands after contact
with the sores.
- Avoid
sexual contact from the time symptoms are first recognized
until the sores are completely healed, i.e., the scab
has fallen off and new skin has formed over the site of
the lesion.
Researchers
have shown that the oral form of acyclovir (Zovirax®)
is a superior and safe treatment that helps patients with
first or recurrent episodes of genital herpes. The oral
form of the drug is taken five times a day and markedly
shortens the course of the first episode, and limits the
severity of recurrences, particularly if taken within 24
hours of onset of symptoms. People who have very frequent
recurrent episodes of the disease can take oral acyclovir
twice daily to suppress the virus’ activity and prevent
most recurrences. Acyclovir is not a cure for herpes – the
virus remains in the body for life; but while taken regularly,
the medicine interferes with the virus’ ability to reproduce
itself. This type of therapy also may reduce the risk of
transmission to sexual partners.
The
U.S. Food and Drug Administration recently approved two
new drugs, famciclovir (Famvir®) and valacyclovir
(Valtrex®), to treat recurrent episodes of genital
herpes. Famciclovir also has been approved for use in suppressing
viral activity and preventing recurrences. These two drugs
are taken less frequently than acyclovir, i.e., three times
a day for an episode and once a day to help stop further
recurrences.
Complications
Usually,
genital herpes infections do not cause permanent disability
or long-term damage in healthy adults. In people who have
suppressed immune systems, however, HSV episodes can be
long-lasting and unusually severe. A pregnant woman who
develops a first episode of genital herpes can pass the
virus to her fetus and may be at higher risk for premature
delivery. Half of the babies infected with herpes either
die or suffer neurologic damage. A baby born with herpes
can develop encephalitis (inflammation of the brain), severe
rashes, and eye problems. Acyclovir can greatly improve
the outcome for babies with neonatal herpes, particularly
if they are treated immediately. With early detection and
treatment, most of these serious complications can be lessened.
The
newborn’s chances of infection depend on whether the mother
is having a recurrent or a first outbreak. If the mother
is having her first outbreak (especially with HSV 1) near
or at the time of a vaginal birth, the baby’s risk of infection
is approximately one in three. If the outbreak is a recurrence,
the baby’s risk is very low (less than one in 30). Because
of the danger of infection to the baby, however, the physician
will perform a cesarean section if herpes lesions are detected
in or near the birth canal during labor. Some physicians
also perform a viral culture at the time of delivery to
detect viral shedding in women known to have had genital
herpes outbreaks in the past. But because it takes days
to weeks to get results, and because culture of virus is
very difficult, this approach has limited usefulness.
It is
important to remember that most women with genital herpes
do not have signs of active infection with the virus at
delivery.
HSV
and AIDS
Genital
herpes, like other genital ulcer diseases, increases the
risk of acquiring HIV, the virus that causes AIDS, by providing
an accessible point of entry for HIV. Also, prior to effective
therapy for AIDS, persons with HIV had severe herpes outbreaks,
and this may help transmit both herpes and HIV infections
to others.
Prevention
People
with early signs of a herpes outbreak or with visible sores
should not have sexual intercourse until the sores have
healed completely. Between outbreaks, using condoms during
sexual intercourse may offer partial protection. Use of
chronic suppressive acyclovir therapy offers promise for
reducing transmission.
Research
Scientists
supported by NIAID are concentrating their efforts in several
areas of investigation, including determining what causes
the virus to reactivate, finding better treatments to prevent
transmission and recurrence of HSV, and developing and testing
a safe and effective vaccine and safe, effective topical
microbicides.
Other
scientists have developed an experimental test that can
be used to screen blood samples for evidence of herpes infection
and can accurately distinguish type 1 from type 2 infections.
Rapid diagnostic tests have been developed that can detect
active virus in a pregnant woman at the time of delivery.
These tests may be able to identify exposed infants who
should be observed carefully or receive immediate care.
Emotional
Support
Recurrences
of genital herpes can be distressing, inconvenient, and
sometimes painful. Concern about transmitting the disease
to others and disruption of sexual relations during active
outbreaks of the sores can affect personal relationships.
Patients can cope with and manage the disease effectively,
however, with proper counseling, improved treatments, and
preventive measures. Counseling and help for those who have
genital herpes is often available from local or state health
departments. In addition, both the American Social Health
Association and the Health Advice Company operate hotlines
for questions and concerns:
National
Herpes Hotline - 919/361-8488
9 a.m to 7 p.m. Eastern Time, Monday through Friday
Health
Advice Company - 888/ADVICE-8 (888/238-4238)
9 a.m. to 5 p.m. Eastern Time, Monday through Friday
For
Printed Information
Herpes Resource
Center
American Social Health Association
P.O. Box 13827
Research Triangle Park, NC 27709-9940
800/230-6039
Health Advice
Company
2515 East Highway 54
2200 Century Plaza
Durham, NC 27713
http://www.advicecenter.com
The American
College of Obstetricians and Gynecologists
409 12th Street, S.W.
P.O. Box 96920
Washington, DC 20090-6920
202/863-2518
http://www.acog.org
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