Herpes simplex virus infection

Last reviewed: February 2020

Last updated: November 2019

Summary

Symptoms of genital herpes range from asymptomatic to tingling and burning without lesions, to recurrent genital ulcerations.

Symptoms of herpes labialis include tingling and burning followed by development of vesicular then ulcerative lesions involving the oropharynx and perioral mucosa.

Acyclovir, famciclovir, and valacyclovir are effective at shortening the duration and severity of an outbreak.

Daily suppressive therapy reduces recurrences by 80% and reduces transmission risk by approximately 50%.

Glycoprotein G-based type-specific serology testing is used to diagnose infection with or without lesions and distinguish between type 1 and 2.

Definition

The major clinical manifestations of infection with herpes simplex virus (HSV) type 1 (HSV-1) or HSV type 2 (HSV-2) are oral, genital, and ocular ulcers. Less commonly, primary or recurrent HSV infections may also present at other sites with neurologic, ocular, hepatic, or respiratory complications. The primary episode occurs during initial infection with HSV, in which the host lacks an antibody response.

Herpes labialis (oral herpes) is infection of the mouth area and lips, most commonly with HSV-1. If symptomatic, fever, sore throat, and pharyngeal edema may occur. Painful ulcers can appear a few days later on the pharyngeal and oral mucosa, and fever and mouth pain may last for several days. Recurrent infections can occur and typically recurrences are in the same site. Recurrences last from 6 to 48 hours; pain, burning, or tingling starts, and then vesicles form. Systemic manifestations do not typically occur and the lesions will crust and heal in about 10 days.

Genital herpes is caused by infection with either HSV-1 or HSV-2. The first clinical episode of genital ulceration may represent either new acquisition of the virus or newly recognized disease with remote acquisition of the virus. Sexual contact passes infection to the patient. Women may have genital pain, discharge, and dysuria with ulcerative lesions on the vulva, perineum, buttocks, cervix, and vagina. During primary infection, women tend to have systemic symptoms including fever, neuralgia, and constipation, whereas men have a milder primary course. Men may have vesicles on the penis shaft or glans with urethritis. Proctitis may occur with discharge, rectal pain, tenesmus, constipation, impotence, and urinary retention after anorectal intercourse. About 90% have recurrent episodes within the first year, with recurrences becoming less frequent and severe over time.[1][2]

For both HSV-1 and HSV-2, asymptomatic shedding may occur in the absence of lesions; transmission of the virus may occur during asymptomatic shedding. HSV establishes latency in neuronal ganglia and periodically reactivates. Most reactivations are asymptomatic but can result in transmission of the virus. The classic clinical presentation of vesicles progressing to painful ulcers is unusual; atypical and mild symptoms are common, and most people have unrecognized disease.

For details of management of ophthalmic HSV infection, please refer to the Uveitis and Keratitis topics. For details of management of suspected HSV encephalitis, please refer to the Encephalitis topic.