HERPES

herpes

Oral & genital herpes are caused by the Herpes simplex virus. Herpes virus infection is life-long & can be controlled with medication. Herpes infections in pregnant women cause serious infections for the baby.

Most people who are infected with the herpes simplex virus do not have symptoms. Of those who do develop symptoms, the first outbreak of genital herpes is worse than recurrences. The first outbreak is also associated with general symptoms aside from the rash. Women are at risk of having a herpes infection that does not cause the usual symptoms.

Genital Herpes and Herpes Simplex Viruses

In the past, genital herpes was caused mainly by the herpes simplex virus type 2 (HSV-2). But now, new genital herpes infections are caused equally by the herpes simplex virus type 1 (HSV-1) and the herpes simplex virus type 2 (HSV-2). The majority of people who are going to get a primary outbreak will do so between 3 days to 2 weeks after exposure.

The First Genital Herpes Outbreak

The rash of herpes is a cluster of vesicles on a red base. In moist areas like the vagina, herpes may cause ulcerations instead of blisters. In women, the first outbreak of genital herpes can occur on the vulva, cervix, vagina, urethra, anus, buttocks, or thighs. Men usually get an outbreak on the tip of the penis or the shaft, but rarely around the base. Men who have sex with men may also get blisters in or around the anus. The rash in men is usually mild -- only 6 to 10 blisters. The blisters in men and women are painful and contain a large number of viral particles; therefore, they are very contagious.

Other Symptoms With the First Genital Herpes Outbreak

Seventy-nine percent of people get general symptoms with the first outbreak that usually resolve within a week. Some common general symptoms include:

  • Fever to 102 degrees
  • Headache
  • Muscle aches
  • Fatigue
  • Swollen lymph nodes

Women and the First Genital Herpes Outbreak

Women are four times more likely to be infected with HSV-2 than men. For some reason, women have more severe disease and more complications during the first infection than men. If a woman gets a herpes outbreak on the cervix or vagina and not externally, she may develop vaginal discharge, pelvic pain, or burning with urination. With the first outbreak, some women may get a second round of blisters or ulcers in the second week.

How Long the First Genital Herpes Outbreak Lasts

The first herpes infection usually lasts for 2 to 3 weeks, but skin pain can last for 1 to 6 weeks. The blisters dry out and crust over. When the crusts fall off, the area is usually not contagious anymore. There is evidence that some people have low levels of virus present even when they do not have symptoms.

People need good information about genital herpes whether they have it or not. Depending on where you look or who you listen to, misinformation about genital herpes abounds. This page is a good starting point to learn what you need to know.

Genital Herpes Facts

It's estimated that 500,000 to 1,000,000 people in the United States get their first genital herpes infection every year. Some studies show that the total number of people in the United States with genital herpes is 40 to 60 million.

Genital herpes is caused by infection with the herpes simplex virus (HSV), the most common sexually transmitted infection in the world. There are two types of herpes simplex viruses:

  • Herpes simplex virus type 1 (HSV-1)
  • Herpes simplex virus type 2 (HSV-2)

HSV and Genital Herpes

HSV-2 is still the main cause of genital herpes infections. It is spread by direct contact with infected secretions, primarily through sexual contact with someone who is shedding the virus, whether they have a rash or not. Someone who has antibodies to HSV-2 has been infected by the virus. The number of people with antibodies to HSV-2 has increased by over 30% in the past 20 years, although the rate of people getting new infections is slowing down. Even though most genital herpes infections (70 to 90%) are caused by HSV-2, a smaller percentage (10 to 30%) are caused by HSV-1, although such infections are on the rise.

Genital Herpes Infection

If someone with a normal immune system doesn't have antibodies to HSV-2, he or she hasn't been infected. If that person is exposed to HSV-2 and gets infected, this is called a primary infection. After a primary infection, the virus doesn't leave the body. It's transported back through nerves to nerve roots where it waits in an inactive (latent) form. Certain triggers can reactivate the virus, which then travels back down the nerve to the skin causing a recurrent infection. For more in-depth information about herpes infections, check out:

The Herpes Simplex Virus

The word "herpes" is taken from the Greek word "herpein" which means "to creep." The herpes simplex viruses are double-stranded DNA viruses that only infect humans. There are two types of herpes simplex viruses:

  • Herpes simplex virus type 1 (HSV-1)
  • Herpes simplex virus type 2 (HSV-2)

Herpes Simplex Virus Infections

A person can be infected with one or both herpes viruses. It has generally been believed that HSV-1 infections occurred in the mouth and HSV-2 infections occur in the genital area. Now it has been shown that either type of virus can infect either site.

How the Herpes Simplex Virus Works

The herpes virus is one of the most difficult viruses to control. Scientists study how the virus works in order to understand how to combat it. It is also important for the general public to understand how this virus works because 85 percent of the world has been infected with one of the herpes simplex viruses. The herpes virus is one of the most difficult viruses to control. Scientists study how the virus works in order to understand how to combat it. It is also important for the general public to understand how this virus works because 85 percent of the world has been infected with one of the herpes simplex viruses.

  • The virus comes in contact with broken skin or the lining of the mouth, vagina, or anus.
  • The virus goes to the nuclei of the cells and tries to reproduce itself, or replicate.
  • Though the cells are infected, most people do not get symptoms.
  • Sometimes the virus's replication process destroys the cells it has invaded causing blisters or ulcers to form on the skin.
  • The blisters or ulcers crust over and heal without scarring.
  • The virus is transported back through the nerve to important nerve branching points called ganglia deep in the body.
  • The virus stays in the ganglia in an inactive, or latent, form. During this time, the virus does not replicate. It stays in this latent form for varying amounts of time.
  • Certain triggers may cause the virus to travel back down the nerve to the skin and cause symptoms again. This is known as recurrence.

Example for the early stages of the herpes rash. Notice the cluster of vesicles all appear to be on the same red base. This is different from the rash of chicken pox (see next picture) which has an individual vesicle on a red base.

 

The Three Stages of Herpes Rash. The initial rash is a cluster of vesicles on a red base. These blisters are delicate and open easily, creating an ulcer. In areas of the skin that aren't moist, the ulcer crusts over. There is usually no scarring when the crust falls off , then leave a scar after it heals. .

Causes of Herpes Simplex Virus Recurrences

Even with a normal immune system, recurrences can happen. Sometimes the recurrence occurs spontaneously. However, the following are known triggers that can stimulate a recurrence:

Physical stress Poor emotional coping style Persistent stressors for greater than 1 week
Anxiety Fever Exposure to ultraviolet light
Nerve damage Tissue damage A suppressed immune system
Heat Cold Menstruation
Other infections Fatigue

What Triggers Genital Herpes Infections?

It is important to know what triggers a genital herpes infection because once someone has an infection with the herpes simplex virus, the virus is always in the body. After the infection is over, the virus travels deeper into the body along nerves to important nerve branching points called ganglia. While the virus is in the ganglia it's in an inactive, or latent, form.

The virus stays in this latent form until something triggers it to reactivate. Then it travels back down the nerve to the skin and causes another flare.

Even in people with normal immune systems, sometimes recurrences just spontaneously happen. However, the following are known triggers that can stimulate a recurrence:

Physical stress Poor emotional coping style Anxiety
Persistent stressors for greater than 1 week Fever Nerve damage
Tissue damage from trauma or surgery A suppressed immune system Heat
Cold Menstruation Other infections
Fatigue

This is a picture of aphthous ulcers which are often confused with cold sores, but they are not caused by the herpes virus. Apthous ulcers can occur anywhere in the mouth but do not involve the outside of the lip. Someone who has herpetic stomatitis (herpes ulcers throughout the mouth caused by an initial oral herpes infection) may have ulcers in the mouth, but they will typically have cold sores on the lip also.Aphthous ulcers can be caused by a number of factors:

  • Coxsackievirus - one of the viruses that causes colds and hand, foot, and mouth disease
  • Autoimmune diseases - Crohn's disease, ulcerative colitis, and Behcet's syndrome
  • Contact dermatitis - aspirin, strong mouthwashes, spicy foods, citrus
  • Chemotherapy medications

Symptoms

Because herpes is such a significant disease, you would think that anyone who gets infected with the virus would know it because they would get symptoms of an infection. In fact, the opposite is true. Less than one-fourth of people who have antibodies to HSV-2, meaning the virus has infected the body, are aware they have been infected.

With a primary infection, if symptoms are going to develop, they usually happen 3 to 7 days after the exposure. The symptoms of a primary infection can last up to 3 weeks and are worse than symptoms of a recurrent infection. Often the symptoms can be confused with other medical problems, especially in women. You can read more about herpes symptoms here:

Genital Herpes Symptoms in Women

is a lifelong disease that causes painful outbreaks of blisters in the genital area. Herpes simplex virus can infect men and women equally, but the pattern of infection is different.

Genital Herpes Transmission

The herpes simplex virus is transmitted during close personal contact through the exchange of saliva, semen, cervical fluid, or vesicle fluid from active lesions. The virus generally does not infect the dead, keratinized cells in the epidermis. It must come in contact with mucosal cells or abraded skin to begin replication and infection.

Genital Herpes Transmission in Women

Women are approximately 4 times more likely to acquire a herpes simplex type 2 infection than men. Susceptible women have a higher likelihood of contracting genital herpes from an infected man than a susceptible man becoming infected by a woman. In other words, if a non-infected man and woman each have intercourse with an infected partner, the woman is more likely than the man to contract a herpes simplex virus infection.

Cold sores and fever blisters are caused by the Herpes Simplex Virus. Cold sores are caused by Herpes Simplex Virus type 1 (HSV 1) more often than the Herpes Simplex Virus type 2 (HSV 2) . Cold sores start like this one with vesicles and progress like genital Herpes lesions to ulcers, crusting, then healing without a scar. Learn more about the course of cold sores and the treatment of cold sores.

 

This is another picture of an early cold sore on the lip. Note that there is not much redness yet. Recurrent Oral Herpes Virus infections occur on the lip, not inside the mouth. However, the first Oral Herpes Virus infection can involve ulcers throughout the mouth and can be painful.

Why Women are at Greater Risk with Genital Herpes

Women may be more susceptible to genital herpes infections because:

  • The genital area has a greater surface area of cells moist with body fluids (mucosal cells) than men.
  • Hormone changes during a woman’s menstrual cycle may affect the immune system, making it easier for the herpes simplex virus to cause an infection.

First Genital Herpes Outbreak in Women

The first genital herpes outbreak is more painful and lasts longer than recurrent genital herpes outbreaks in both men and women. However, women tend to have more severe disease and higher rates of complications during the first genital herpes outbreak. In women, herpes lesions can occur anywhere in the genital area including the vulva, inside the vagina, on the cervix, and urethra. Herpes lesions can also occur in areas other than the genital area such as the buttocks and thighs. These first lesions are infectious for an average of 3 weeks, longer than in men and longer than recurrences in women, because the blisters contain a large number of infectious viral particles.

• Pictures of Herpes Simplex Virus Infections

Other Symptoms with the First Genital Herpes Outbreak

In addition to a rash in the genital area, women can also get swollen lymph nodes in the groin and burning with urination. Complications of the first outbreak in women include difficulty urinating in 10 percent to 15 percent of women and meningitis, an inflammation of the fluid surrounding the brain in up to 1 out of 4 women.

Confusing Symptoms with Genital Herpes in Women

Even though women may have more severe disease, they may have symptoms that are not attributed to herpes. A woman who has herpes lesions inside the vagina or on the cervix may have pelvic pain and discharge that may be misdiagnosed as a yeast infection, cervicitis (an inflammation of the cervix), or pelvic inflammatory disease. Herpes lesions that involve the urethra may be misdiagnosed as a urinary tract infection or bladder dysfunction. With recurrent infections, women may experience only irritation in the genital area without a rash. It is important that women with vaginal discharge or recurrent vaginal symptoms be tested for herpes.

Herpes and Pregnancy

The Effect of the Herpes Simplex Virus on Mother and Infant

Because a woman has genital herpes, does not mean she cannot have children. Twenty percent to 25 percent of pregnant women have genital herpes. However, the herpes simplex virus does pose a risk to the unborn child in certain situations. Knowing more about the risks of genital herpes infections during pregnancy helps mothers-to-be and their partners make informed decisions to protect themselves and their child.

Herpes Simplex Virus Infections

The herpes simplex virus causes a variety of infections and has specific characteristics. The following give more information on the basics of herpes simplex virus infections:

  • Pictures of Herpes Simplex Virus Infections
  • How the Herpes Simplex Virus Works
  • The First Genital Herpes Outbreak
  • Genital Herpes Treatments
  • Cold Sores - Oral Herpes

Risk Factors for Infant Herpes Simplex Infections

The risk of transmitting the herpes simplex virus to a baby depends on several factors:

  • Exposure of the infant to herpes lesions during delivery
  • Whether the mother has antibodies to the herpes simplex virus
  • Whether the infant has time to acquire these antibodies before delivery

Transmission Rates for Infant Herpes Simplex Infections

To illustrate how an infant's risk changes based on the above factors:

  • A woman who experiences a first outbreak of genital herpes during the third trimester and who has not developed antibodies to the virus by the onset of labor has a 33 percent chance of transmitting the virus to her infant.
  • On the other hand, a woman who experiences a recurrent outbreak of genital herpes, because she already has antibodies to the herpes virus and has passed them to her unborn child, has a 3 percent chance of transmitting the virus to her infant.

Effect of the Herpes Simplex Virus on Mother

Many women have been exposed to the herpes simplex virus and have developed antibodies to the virus, but may not have had an outbreak of genital herpes. During pregnancy, the immune system becomes less effective and these women may have a first outbreak. This type of outbreak carries the same risk as a recurrent infection for the infant -- less risk of neonatal disease than with a primary infection. About 80 percent of women who are infected with the herpes simplex virus will have a recurrence during their pregnancy. Pregnant women previously infected with herpes will have an average of 3 recurrences during pregnancy.

Effect of the Herpes Simplex Virus on Infant

In infants who are known to have a herpes simplex virus infection, only less than one third have mothers who had ever had a herpes rash or a sexual partner with a herpes rash. Many neonatal infections occur because of viral shedding from the cervix without evidence of a rash, usually after a primary infection. Most cases of transmission of herpes simplex occur during labor and delivery. For every 10 neonatal herpes infections, 6 to 7 are acquired because the mother acquires an asymptomatic first outbreak. Transmission of the herpes simplex virus to a newborn (neonate) can have devastating effects. The extent of the herpes simplex infection can range from a rash on the skin, to involvement of the eyes and mouth, to infection of the brain, to infection throughout the body. All infants suspected of having a herpes simplex virus infection should be treated with IV acyclovir. The length of treatment is determined by the body system involved in the infection.

Herpes Simplex Type

The herpes simplex type determines the risk to the infant. A primary or recurrent HSV-1 infection during labor is more easily transmitted to the infant but the disease is limited to the mouth, eyes, and mucous membranes. Primary infection with HSV-2 is more likely to affect the central nervous system causing seizures, meningitis, developmental delay, and death.

Delivery

Currently all women who have an outbreak of genital herpes, primary or recurrent, should have a cesarean section to reduce the exposure of the infant to the herpes simplex virus.

Treatment of Herpes in Pregnancy

Current recommendations by the American College of Obstetricians and Gynecologists (ACOG) are to treat all primary outbreaks of genital herpes with antiviral medications, including primary outbreaks in pregnant women. The antiviral medications available to treat genital herpes are acyclovir, famciclovir, and valacyclovir. Acyclovir has the most data on the safety of use in pregnancy. A registry of over 1000 pregnant women who were exposed to acyclovir during early pregnancy suggests that acyclovir is probably safe as there were no increases in birth defects.

Precautions for Pregnant Women Without Herpes

While any woman who has never had herpes should be cautious about having sex with someone who might have herpes, pregnant women should take extra precautions in their third trimester including:

  • Avoid intercourse and oral sex with partners who have or you suspect have genital herpes.
  • Consider asking your obstetrician about HSV antibody testing

Fever Blister Information - Fever Blisters & Cold Sores

Cold sores or fever blisters are common skin conditions that affect 15 percent to 30 percent of the U.S. population. Cold sores are actually caused by the herpes simplex virus (HSV) and are the most common manifestation of a herpes simplex virus infection.

Fever Blisters and the Herpes Simplex Virus

Fever blisters are caused more often by the herpes simplex virus type 1 (HSV-1) than herpes simplex virus type 2 (HSV-2). As a matter of fact, more than 85 percent of the world's population has been infected with HSV-1. These infections follow the usual course of herpes simplex virus infections in that the first outbreak is usually more painful and lasts longer than recurrent infections.

Fever Blisters - Primary Infection

The first time the skin in or around the mouth comes in contact with the herpes simplex virus; the outbreak occurs inside the mouth -- on the gums, tongue, and throat. This is called gingivostomatitis. This first infection occurs most often in childhood, and the highest incidence of infection occurs between 6 months and three years of age. Children get pain, fever, swollen lymph nodes, and may have difficulty swallowing. These symptoms last for about a week and resolve spontaneously. Children with gingivostomatitis are at risk for dehydration if the pain keeps them from drinking fluids. Water-based popsicles are sometimes used to provide hydration and pain relief.

The finger is actually a common place to get a herpes infection, common enough to have its own name - herpetic whitlow. This picture shows the early vesicular stage of the infection. Because the skin on the fingers is thicker, the vesicles aren't as fragile and may not ulcerate quickly.

 

This picture shows a herpetic whitlow (herpes infection of the finger) that has vesicles and ulcerations.

Fever Blisters - Recurrent Infection

Once a person has been exposed to the herpes simplex virus, the virus remains in certain cells in the body and can reactivate at any time. Reactivation can be triggered by trauma to the skin, menstruation, sun exposure, stress, fever, and other causes. This reactivation produces the lesions we know as cold sores or fever blisters. Fever blisters are most often seen on the border of the lip and consist of three to five vesicles. Over the next three to five days, the vesicles become pustular, ulcerative, and then crust over. Symptoms are usually most severe 8 hours after the outbreak. Most people have about 2 outbreaks per year, but 5 percent to 10 percent have greater than 6 outbreaks per year.

Fever Blisters - Prodrome

Recurrent infections are often preceded by a prodrome, symptoms that appear before the outbreak occurs. Common prodromal symptoms for fever blisters are pain, tingling, and burning. A herpes prodrome can last from 2 hours to 2 days.

Spread of Fever Blisters

Fever blisters are contagious and spread by direct contact with infected saliva or droplets in the breath, or by skin to skin contact. The herpes simplex virus can be reactivated in response to various stimuli including UV radiation (sun exposure), stress, a cold, illness, or dental work.

Genital Herpes Treatments

There are medications available to treat genital herpes infections and prevent recurrent infections. However, none of the drugs get rid of the virus. Herpes cannot be "cured." The decision to use one treatment over another for genital herpes depends on many factors that must be discussed with your health-care provider.

Initial or Recurrent Genital Herpes Outbreaks

One of the major factors determining treatment is whether a person has had a genital herpes outbreak in the past. The first episode of genital herpes is usually the worst and includes general symptoms that make a person feel unwell. Recurrent episodes of genital herpes are generally not as painful and do not last as long. Frequency of Genital Herpes Outbreaks

People who have more than 6 outbreaks per year should discuss suppressive therapy with their health-care provider. With suppressive therapy, a person takes medication every day to reduce the number of outbreaks. Over time, the frequency of outbreaks decreases in many people; therefore, people on suppressive therapy should periodically discuss the risks and benefits of stopping daily medication with their health care provider.

If a Person Is Sexually Active

A discordant couple (one partner with herpes and the other does not) requires special considreration. Suppressive therapy to prevent transmission to a known negative partner may be recommended. Studies have shown that the risk of transmitting to a herpes-negative partner is lower if the herpes-positive person is on therapy.

Genital Herpes and a Weakened Immune System

People with weakened immune systems because of HIV/AIDS, leukemia, transplantation, and long-term corticosteroid use are at risk for more severe herpes infections. The herpes simplex virus in these people may be resistant to older antiviral treatments or more difficult to treat; therefore, other medications than the ones listed here or medications at higher doses may be required.

Genital Herpes and Pregnancy

Women who have a herpes outbreak in the third trimester or at delivery are at greater risk of transmitting the herpes simplex virus to their babies. Certain antiviral drugs are considered safe to use in pregnancy while the safety of others has not been determined. Any woman who is pregnant should report to her health-care provider current or past symptoms that she feels may be herpes.

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