Genital herpes

This term covers both primary infections and recurrent infections caused by herpes simplex viruses in the genital area. Several clinical pictures fall under it:

• vulvovaginitis herpetica
• Balanitis (Balanoposthitis) herpetica
• proctitis herpetica
• urethritis herpetica

HSV-2 accounts for the majority of infections (80-90%). Infections with HSV-1 are increasing (Mathew R et al 2018). The most common manifestations are vulvovaginitis herpetica and balanitis (balanoposthitis) herpetica.

Primary genital herpes infections are asymptomatic in 2/3 of cases. In a symptomatic course, after a short prodromal stage, there is an acute clinical picture with general symptoms: malaise, fever, moderately painful regional lymphadenitis. At the site of infection, painful grouped vesicles develop on an erythematous base. The vesicles burst or they become cloudy with pus. In the skin area, crusting and healing subsequently occur. No crusts develop in the mucosal area. Healing occurs via erosive lesions that epithelialize without scarring.

Primary vulvovaginitis herpetica is not infrequently manifested by dysuria and micturition difficulties!

Recurrent genital herpes progresses clinically much more easily than the primary infection, often unnoticed. Patients with HSV-2 induced viral infection develop recurrences more frequently than HSV-1 infected individuals (5xyr/1xyr).

Mild prodromal symptoms, as in an intercurrent flu-like infection, may occur. Many women do not notice the recurrence at all. Grouped vesicles are accompanied by mild burning pain symptoms. Lymphadenitis may be present but may also be absent. Women with documented recurrent genital herpes simplex have asymptomatic viral shedding in a high percentage.

In HIV-infected individuals, HSV-2 infection can lead to coinfection with cytomegaloviruses. Clinically, such dual infections manifest themselves in therapy-resistant ulcers in the genital area (Rawre J et al.2018).

Primary infection:

• In severe cases, systemic therapy with aciclovir (Zovirax 200) 5 times/day 1 tbl. every for 5-10 days. Oral therapy is usually sufficient (Milpied B et al. 2019).
• Alternative: Aciclovir 400mg p.o. 3x daily for 7-10 days.
• Alternative: If necessary, intravenous therapy with aciclovir can be considered (aciclovir 5 mg/kg bw 3 times/day every 8 hours for 5 days).
• Alternative: Valciclovir: 500-1000mg p.o./2x/day for 5-10 days.
• Famciclovir: 250mg p.o. 3x/day for 5-10 days.
• Patients with immunosuppression: Aciclovir 400mg 4x/day or Zovirax 800mg 5 times/day.

Recurrence:

• Systemic therapy with aciclovir (Zovirax 200) 2 times/day 1 tbl. for 5-10 days. Oral therapy is usually sufficient.
• Alternative: Aciclovir 800mg p.o. 3 times/day for 2 days.
• Alternative: Valciclovir: 500mg p.o./2x/day for 3-5 days (Milpied B et al. 2019).
• Famciclovir: 125mg p.o. 2x/day once.

Relapse prophylaxis:

• Systemic therapy with aciclovir (Zovirax 400) 2 times/day.
• Alternative: Valciclovir: 500mg p.o./1x/day
• Famciclovir: 250mg p.o. 2x/day
• Usually, relapse prophylaxis is given for months to years. It is successful in 80% of patients, the recurrences are significantly reduced. Periodic therapy breaks are necessary to control the recurrence.

Prophylactic therapy during pregnancy:

• Women with a primary infection or redive infection during pregnancy can be treated prophylactically from the 36th WA (weeks' amenorrhea) until birth:
• Aciclovir: 400mg/day p.o.
• Alternative: Valciclovir 500mg/day p.o.

Note: Not proven a positive effect of suppressive continuous therapy with nucleoside analogues on the risk of the infant to develop neonatal herpes (Milpied B et al. 2019).

Recommended approach in pregnancy:

Primary infection:

• 3 x 400 mg aciclovir for 10 days.

Primary infection 1st + 2nd trimester:

• From 32nd SSW vulvovaginal smears (PCR). In case of negative smear without lesions vag. delivery.
• In case of a positive smear or lesions, sectio.

Primary infection > 34th SSW:

• 3 x 400 mg aciclovir/d until delivery, primary sectio.

Recurrences:

• Dosage for prophylaxis from 36th SSW is 3 x 400mg aciclovir/d.
• Vulvovaginal smears around ET (PCR); if negative: vaginal delivery. If positive or lesions: primary sectio.

1. Harfouche M et al. (2019) Herpes simplex virus type 1 epidemiology in Africa: Systematic review, meta-analyses, and meta-regressions.J Infect pii: S0163 4453.
2. Itzhaki RF (2017) Herpes simplex virus type 1 and Alzheimer's disease: possible mechanisms and signposts. FASEB J 31:3216-3226. https://www.ncbi.nlm.nih.gov/pubmed/28765170
3. Mathew R et al. (2018) Herpes Simplex Virus 1 and 2 in Herpes Genitalis: A Polymerase Chain Reaction-Based Study from Kerala.Indian J Dermatol 63:475-478.
4. Milpied B et al. (2019) Diagnostic and therapeutic recommendations for sexually transmitted diseases: Genital herpes.Ann Dermatol Venereol 146:31-36.
5. Rawre J et al.(2018) Herpes simplex virus type 2 and cytomegalovirus perigenital ulcer in an HIV infected woman.Indian J Med Microbiol 36:441-443.