Living Sphere :: About HSV2

Genital Herpes: A Medical Perspective
by Dr Stuart Aitken

Genital herpes is a condition affecting the genital skin of many people.

The diagnosis of genital herpes can be stressful, but getting factual information can help people and their partners put herpes in perspective and get on with their lives.

If you or your partner has genital herpes, it is worthwhile arming yourself with the knowledge you need to make the choices that are right for you. Read widely, ask questions, and don't be afraid to be critical of the information you come across. Talking about genital herpes with someone who understands can help. Your general practitioner or a sexual health clinic is often a good place to start. Check out the links and articles section of this site for other useful resources.

What is genital herpes?

Genital herpes is a skin condition caused by the Herpes Simplex Viruses. Most of us are familiar with the appearance of 'cold sores': those sores that appear around the mouth or nose during times of stress, when people get run down, or have a cold or flu. 'Classic' genital herpes is a similar concept: recurrent blisters, splits or sores, that occur on genital skin, rather than around the lips.

What causes genital herpes?

Genital herpes is caused by the Herpes Simplex Viruses, conveniently abbreviated to HSV.

These viruses come from a larger family of viruses, the herpes viruses. The herpes family of viruses contains some other well-known viruses, such as the virus that causes chicken pox and shingles, and the virus that causes glandular fever. Throughout our lives, most humans will come into contact with some of these viruses from the herpes family.

There are two types of HSV: Herpes Simplex Virus Type One (HSV-1) is the virus that commonly causes cold sores around the mouth or nose. Herpes Simplex Virus Type Two (HSV-2) usually affects the genital area. However, either of these viruses can affect either site. That is, HSV-1 can cause genital herpes, and (less commonly) HSV-2 can cause cold-sores around the mouth.

What are the symptoms of genital herpes?

Classic outbreaks of genital herpes occur as a series of skin changes over seven to ten days. Tingling, numbness or itching is the first sign of an outbreak for some people, and the skin overlying the area often looks normal. A group of small, painful blisters then appears on the skin, and the surrounding skin will often become red. The blisters often join up and burst, leaving an ulcer or sore. These ulcers become crusted over with a scab. When the crust falls away from the skin, there is often a patch of redness which fades over a few days.

During recurrences, people may experience pain around the site. Sometimes the skin might feel numb or prickly (like when you get 'pins and needles'). Occasionally, there may be more unusual symptoms, such as back pain, or flu-like symptoms.

When herpes presents with the 'classic' symptoms described above, the diagnosis is usually straightforward. However, we now know that only one out of every five people who have the genital herpes virus will experience these classic symptoms. Another twenty percent will have absolutely no symptoms at all! For the remaining sixty percent, recurrences will be 'atypical'. These atypical symptoms can vary widely. They can include itch, pain passing urine, painless ulcers, splits in the skin, patches of redness, numbness or tingling. These are symptoms that can be very easily confused with other skin conditions.

In other words, the majority of people who have herpes virus on their genitals will have either no symptoms or very minor symptoms. It is not surprising that most people who have the virus that causes genital herpes don't realise that they have it.

In general, the first episode of herpes is the most severe. During this time, a person may experience fevers, chills, muscle or joint aches, headache, or tiredness. These flu-like symptoms are common to many other infections. The blisters and ulcers of the first episode are sometimes severe, and passing urine can be quite painful, especially for women.

Recurrences of herpes tend to get milder, shorter and less frequent over time. While most people will get virus shedding from the skin at different times, not everyone will get obvious recurrent episodes of herpes. Flu-like symptoms and severe ulcers are not usually seen in recurrences of herpes.

How common is genital herpes?

About 80 percent of Australian adults acquire HSV-1. Some of those people will know that they have the virus because they come out with 'cold sores' around the lips or nose. For the rest of those who have the virus, there is little or no hint that the virus is there. It is safe to say that acquiring HSV-1 is pretty much a normal part of being a human being!

About twelve percent or about one in eight Australian adults have HSV-2. Most people who have herpes virus on their genitals are unaware that they have the virus. Most studies tend to agree that of all those who have evidence of exposure to genital herpes, only about one in five will know that they have the virus.

How is it transmitted?

Herpes simplex viruses are transmitted from one person to another during skin to skin contact. These viruses are very fragile, so they don't survive in the environment for significant periods of time. Consequently, herpes is unlikely to be transmitted through clothing, bedclothes, toilet seats, and so on. If you have been infected with one type of herpes simplex virus, your body's immune reaction prevents you from getting that same virus again. In other words, if you get cold sores around your lips from HSV-1, you are extremely unlikely to get HSV-1 on any other part of your body, including the genitals. You may, however, still be susceptible to acquiring the other herpes simplex virus, HSV-2.

While the virus is definitely present at the time of recurrences, it can be shed from the skin at other times too, even if the skin looks and feels completely normal. This shedding of virus is called 'asymptomatic shedding'.

As the majority of people who have HSV don't actually know that they carry the virus, and the virus can be spread from skin which looks and feels normal, it can be very difficult to know exactly where a person has acquired their infection. It is not surprising that most people who pass the virus on to a partner don't know that they have herpes themselves. This can be difficult to accept for partners in a relationship, and it is important to avoid blaming one another.

Knowing how to decrease the risk of transmission to partners is important for people with genital herpes. There are several ways of decreasing transmission, but none of them is one hundred per cent effective:

Avoiding all sexual contact during outbreaks
Using condoms each time there is sexual contact, even if there are no symptoms
Taking suppressive treatment with valaciclovir (the role of the other drugs in preventing transmission has not yet been fully evaluated).

How is herpes diagnosed?

Herpes is best diagnosed by identifying the virus in the laboratory with a swab test. This is a fairly simple test, and involves your doctor or sexual health nurse rubbing a suspicious area of skin with a swab (like a cotton bud). This method of diagnosis makes it possible to match up the virus with changes that are happening in the skin. A positive test tells you and your doctor:

Which virus is responsible for the lesions (HSV-1 or HSV-2)
Which part of your body the virus is affecting
Confirm what sort of symptoms your herpes is causing

Blood tests for herpes are available, but they need to be used with caution. Routine blood testing for herpes is not recommended, as interpretation of the tests can be complex, and in some circumstances these tests are not particularly accurate. Furthermore, positive blood test results do not give any information about which part of the body is affected, or whether or not the symptoms a person is experiencing are definitely due to the virus rather than another cause. In Australia, a positive blood test without swab confirmation is not sufficient evidence to access subsidised treatments through the Pharmaceutical Benefits Scheme.

However, the blood tests are of use in some special situations. Probably the most important situation is when a woman is pregnant, and her partner has genital herpes. Great care should be taken to avoid acquiring herpes in the later stages of pregnancy, as the chances of transmitting herpes to the baby are higher in this situation.

The implications of a positive test require some careful thought. If a positive test would make a person feel bad about themselves, but not change their sex lives or make them eligible for treatment, one wonders if there is a point to doing the test at all. It is always worthwhile taking the time to seriously think about the consequences before agreeing to a test. For some people, taking the plunge and getting the blood test is the right thing to do, but for others it might do more harm than good.

Are there any serious complications of herpes?

Fortunately, serious complications of genital herpes are rare. In fact, most people with genital herpes will either get no symptoms, or only very minor symptoms.

Perhaps the most serious consequence of genital herpes is transmission of herpes from pregnant mother to the newborn baby. As newborn infants only have weak immune systems, herpes infections can be severe or even life-threatening. Fortunately, this is a very rare occurrence in Australia, and seems to be restricted to women who acquire herpes in the last part (the third trimester) of pregnancy. For women with a longer history of herpes, there will be transfer of antibodies which provide immunity from the mother's blood stream to the baby through the placenta, and the baby will thus be protected. For women with herpes who are pregnant, or intend to fall pregnant, it is worthwhile talking to your health care provider about your management. For pregnant women with genital herpes, or who have a partner with genital herpes, letting your health care provider know this so they can give you the best advice about managing your pregnancy.

For adults with herpes, serious consequences are rare. Sometimes severe initial herpes can affect the nerves which supply the bladder. When this happens, the bladder does not function properly and cannot empty. If the bladder becomes over-stretched there may be long term damage, so prompt medical attention should be sought.

There are a few other potentially serious problems that are almost always related to the first episode of herpes, but they are very uncommon.

How is genital herpes managed?

The most effective tool for managing herpes is knowledge. Most experts agree that the psychological consequences of genital herpes present a much greater problem than the physical consequences for most people. In strictly biomedical terms, genital herpes is usually a minor, recurrent skin condition that just happens to affect the genitals. Psychological reactions to a diagnosis of genital herpes can include feelings of guilt or shame, anger, fear and sadness. Many people go through a period of low self-esteem after the diagnosis. These feelings usually improve with time, and are helped by gaining information about herpes and being able to talk about the condition and what it means for you. People often find that their feelings about having herpes change with time as they start to develop a different perspective on herpes. Sometimes the help of a counsellor can assist with the psychological part of the healing process, especially if there is a severe psychological reaction to the diagnosis, or if the negative feelings last for a long time and aren't improving. Your general practitioner or sexual health clinic can provide information about options for counselling.

There are three medications available in Australia for the treatment of genital herpes: aciclovir, valaciclovir and famciclovir. These medications all work in the same way: they stop HSV from reproducing itself. Medications are particularly useful in the first episode of herpes, when symptoms are most severe. For people with many recurrences, the medications can be taken regularly to prevent outbreaks (suppressive therapy). For those with infrequent or mild recurrences, the medications can be used during the outbreak (episodic therapy). Not all people with herpes require treatment with medication. Your doctor can provide you with advice about medication that is tailored to your individual circumstances.

During outbreaks, the affected areas can be quite sore. Some useful tips for managing symptoms are listed below:

Simple pain-relieving medications, like paracetamol, can be quite effective, especially for people with their first episode who are getting lots of aches and pains or fevers.
Some people experience pain when passing urine: this can be lessened by passing urine in the bath or shower. A water bottle squeezed over the area while urinating can be an effective alternative if it is impractical to have a shower or bath. Avoiding dehydration helps to keep urine dilute, and less likely to cause pain on broken skin.
Gently cleansing the affected area with some warm, salty water (one teaspoonful in a litre of tap water) twice a day can help to keep the area clean.
After showering, avoid vigorous towelling of the area. Many find that using a hair-dryer on the cool setting is a gentle alternative for drying the skin. Carefully blotting the area with a soft towel or tissue is another strategy.
Local anaesthetic creams or gels can also be effective at decreasing pain from ulcers.

Please contact Dr Stuart Aitken / Living Sphere for permission to republish this article.