Both HSV-1 and HSV-2 may cause genital herpes, although HSV-2 is more frequently the cause of genital lesions. HSV-2 is more common for females than males comprising 65% of all individuals with active infection. Usually the acquirement of HSV-2 infection is associated with the onset of sexual activity as the virus may be transmitted via sexual intercourse. Women are likely to experience more severe primary infections than men and tend to develop various complications.
The incubation period of primary genital herpes may last from 2 and up to 14 days. Primary genital herpes tends to have a prolonged symptom duration. It is considered that those who experienced a symptomatic primary herpes genitalis will have a disease recurrence within 1 year. The labia minora, labia majora, and perineum are the most frequently affected.
The first episode of genital herpes manifests with fever, headache, general malaise, and muscular pain. Pain, itching, burning sensation, and the painful enlargement of the local lymph nodes are characteristic. These symptoms occur between day 7 and 11 of the illness. Pain persists for about 10 days.
The lesions persist for approximately 21 days and develop gradually. As the infected cells die the blisters that contain pus or not, after about a week the vesicles disrupt, leaving a painful ulcer. Later the surface of the ulcer crusts and the lesion heals. The lesions appear on the two sides of the vulva. A clear mucoid discharge and dysuria (painful urination) may also be present.
Herpetic lesions can involve the vagina, cervix, bladder, anus, and rectum.The cervix and urethra are involved in more than 80% of women with first-episode HSV. Cervicitis commonly develops.
Recurrent herpes genitalis usually lasts less than the primary infection with the duration of 7 to 10 days and the rash is not so abundant. Itching, burning, tingling, or tenderness at the affected site precede the lesion formation.
Related risks in pregnancy
- Increased risks of miscarriage and pre-term labor if the primary infection is acquired in the last trimester. The primary infection is more dangerous than the recurrent disease as the virus shedding in the first episode is relatively higher.
- Transplacental infection is not common. Mother-to-child transmission occurs during vaginal delivery due to virus shedding in the cervix or the lower genital tract, in case of primary infection – in 50% of cases, if recurrent – in 5%.
- The neonate may suffer from central nervous system infection.
- Cesarean section (before the rupture of the membranes) is indicated when the primary genital herpes is detected at the due time of delivery. When the diagnosis is confirmed, it is recommended for the pregnant woman to take acyclovir 400 mg three times daily for five days. Prophylactic acyclovir (400 mg twice daily) is administered for pregnant women who tend to have recurrent infections, especially near the due date.
30% of neonatal HSV occur due to HSV-1 and 70% to HSV-2.
Neonatal infection may be disseminated (in 25% of cases), localized (45%) or it may be asymptomatic. In 30% of cases, hepatic encephalitis occurs. The disease may also manifest as chorioretinitis, microcephaly, mental retardation, seizures and may result in death.
Neonatal HSV infection requires treatment with intravenous acyclovir. Neonatal mortality is high. 65% of neonates die as a result of HSV infection if not treated.
Breastfeeding is allowed when the mother is able to avoid any contact between her lesions, her hands and the baby.
Women with genital herpes should abstain from sexual intercourse with healthy partners when the lesions are present or the woman experiences prodrome symptoms. Condom use may be helpful to avoid the transmission of HSV.
The treatment should be initiated within 1 day after the lesions appear or when a woman detects the symptoms which precede the lesion development.
- First episode
- Acyclovir 400 mg three times daily for 7–10 days or
- Acyclovir 200 mg five times daily for 7–10 days or
- Famciclovir 250 mg three times daily for 7–10 days or
- Valacyclovir 1 g twice daily for 7–10 days
- Therapy for recurrent disease
- Acyclovir 400 mg three times daily for 5 days or
- Acyclovir 800 mg twice daily for 5 days or
- Acyclovir 800 mg three times daily for 2 days or
- Famciclovir 125 mg twice daily for 5 days or
- Famciclovir 1 g twice daily for 1 day or
- Famciclovir 500 mg once, then 250 mg twice daily for 2 days or
- Valacyclovir 500 mg twice daily for 3 days or
- Valacyclovir 1 g once daily for 5 days
- Suppressive therapy
- Acyclovir 400 mg twice daily or
- Famciclovir 250 mg twice daily or
- Valacyclovir 0.5 or 1 g once daily