Genital Herpes: A Review

 


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Am Fam Physician. 2016 Jun 1;93(11):928-934.

  Patient information: See related handout on genital herpes, written by the author of this article.

Author disclosure: No relevant financial affiliations.

Genital herpes is a common sexually transmitted disease, affecting more than 400 million persons worldwide. It is caused by herpes simplex virus (HSV) and characterized by lifelong infection and periodic reactivation. A visible outbreak consists of single or clustered vesicles on the genitalia, perineum, buttocks, upper thighs, or perianal areas that ulcerate before resolving. Symptoms of primary infection may include malaise, fever, or localized adenopathy. Subsequent outbreaks, caused by reactivation of latent virus, are usually milder. Asymptomatic shedding of transmissible virus is common. Although HSV-1 and HSV-2 are indistinguishable visually, they exhibit differences in behavior that may affect management. Patients with HSV-2 have a higher risk of acquiring human immunodeficiency virus (HIV) infection. Polymerase chain reaction assay is the preferred method of confirming HSV infection in patients with active lesions. Treatment of primary and subsequent outbreaks with nucleoside analogues is well tolerated and reduces duration, severity, and frequency of recurrences. In patients with HSV who are HIV-negative, treatment reduces transmission of HSV to uninfected partners. During pregnancy, antiviral prophylaxis with acyclovir is recommended from 36 weeks of gestation until delivery in women with a history of genital herpes. Elective cesarean delivery should be performed in laboring patients with active lesions to reduce the risk of neonatal herpes.

Genital herpes is a common sexually transmitted disease caused by herpes simplex virus (HSV) and characterized by lifelong infection and periodic reactivation. HSV, a DNA virus, is named from its protein coat as HSV-1 or HSV-2. HSV-1 is the chief cause of orolabial herpes. Until recently, genital herpes was more likely to be caused by HSV-2. However, the incidence of primary genital infection with HSV-1 is now as common or more common than HSV-2 in the United States.1

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Type-specific laboratory confirmation of HSV is recommended in patients with clinical disease to guide counseling and management.

C

1, 24, 29

Polymerase chain reaction assay is the preferred test for confirming HSV in clinically apparent lesions.

C

24, 26, 27, 29

Type-specific serologic testing should be offered to partners of patients with HSV infection to determine the risk of HSV acquisition.

C

15, 24, 29

Suppressive therapy reduces symptom severity, duration, and recurrence in patients with genital herpes. In HIV-negative patients, it is also effective in reducing transmission to at-risk partners.

A

24, 32

In persons with HIV and HSV-2 infections, suppressive therapy does not reduce the transmission of HSV-2 to at-risk partners.

B

24, 36


HIV = human immunodeficiency virus; HSV = herpes simplex virus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Type-specific laboratory confirmation of HSV is recommended in patients with clinical disease to guide counseling and management.

C

1, 24, 29

Polymerase chain reaction assay is the preferred test for confirming HSV in clinically apparent lesions.

C

24, 26, 27, 29

Type-specific serologic testing should be offered to partners of patients with HSV infection to determine the risk of HSV acquisition.

C

15, 24, 29

Suppressive therapy reduces symptom severity, duration, and recurrence in patients with genital herpes. In HIV-negative patients, it is also effective in reducing transmission to at-risk partners.

A

24, 32

In persons with HIV and HSV-2 infections, suppressive therapy does not reduce the transmission of HSV-2 to at-risk partners.

B

24, 36


HIV = human immunodeficiency virus; HSV = herpes simplex virus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Epidemiology

Worldwide, more than 400 million persons have genital herpes caused by HSV-2.2 In the United States, nearly one in five adults (approximately 50 million persons) has HSV-2 infection, with 1 million new infections occurring each year.35 Overall seroprevalence of HSV-1 is decreasing because of less childhood exposure to orolabial herpes; however, genital acquisition rates have increased simultaneously, with HSV-1 now representing

The Author

MARY JO GROVES, MD, is a clinical associate professor of family medicine at Wright State University Boonshoft School of Medicine, Dayton, Ohio.

Author disclosure: No relevant financial affiliations.

Address correspondence to Mary Jo Groves, MD, Wright State University Boonshoft School of Medicine, 3640 Colonel Glenn Hwy., Dayton, OH 45435. Reprints are not available from the author.

REFERENCES

show all references

1. Bernstein DI, Bellamy AR, Hook EW III, et al. Epidemiology, clinical presentation, and antibody response to primary infection with herpes simplex virus type 1 and type 2 in young women. Clin Infect Dis. 2013;56(3):344–351....

2. Looker KJ, Magaret AS, Turner KM, Vickerman P, Gottlieb SL, Newman LM. Global estimates of prevalent and incident herpes simplex virus type 2 infections in 2012 [published correction appears in PLoS One. 2015;10(5):e0128615]. PLoS One. 2015;10(1):e114989.

3. Centers for Disease Control and Prevention (CDC). Seroprevalence of herpes simplex virus type 2 among persons aged 14–49 years—United States, 2005–2008. MMWR Morb Mortal Wkly Rep. 2010;59(15):456–459.

4. Satterwhite CL, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis. 2013;40(3):187–193.

5. Bradley H, et al. Seroprevalence of herpes simplex virus types 1 and 2—United States, 1999–2010. J Infect Dis. 2014;209(3):325–333.

6. Xu F, Sternberg MR, Kottiri BJ, et al. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. JAMA. 2006;296(8):964–973.

7. Gupta R, Warren T, Wald A. Genital herpes. Lancet. 2007;370(9605):2127–2137.

8. Corey L, Wald A. Genital herpes. In: Holmes KK, Sparling PF, Stamm WE, et al. Sexually Transmitted Diseases. 4th ed. New York, NY: McGraw Hill Medical; 2008:399–438.

9. Halpern-Felsher BL, Cornell JL, Kropp RY, Tschann JM. Oral versus vaginal sex among adolescents: perceptions, attitudes, and behavior. Pediatrics. 2005;115(4):845–851.

10. Cherpes TL, et al. Genital tract shedding of herpes simplex virus type 2 in women: effects of hormonal contraception, bacterial vaginosis, and vaginal group B Streptococcus colonization. Clin Infect Dis. 2005;40(10):1422–1428.

11. Tata S, Johnston C, Huang ML, et al. Overlapping reactivations of herpes simplex virus type 2 in the genital and perianal mucosa. J Infect Dis. 2010;201(4):499–504.

12. Beauman JG. Genital herpes: a review. Am Fam Physician. 2005;72(8):1527–1534.

13. Schillinger JA, McKinney CM, Garg R, et al. Seroprevalence of herpes simplex virus type 2 and characteristics associated with undiagnosed infection: New York City, 2004. Sex Transm Dis. 2008;35(6):599–606.

14. Tronstein E, et al. Genital shedding of herpes simplex virus among symptomatic and asymptomatic persons with HSV-2 infection. JAMA. 2011;305(14):1441–1449.

15. Engelberg R, Carrell D, Krantz E, Corey L, Wald A. Natural history of genital herpes simplex virus type 1 infection. Sex Transm Dis. 2003;30(2):174–177.

16. Phipps W, Saracino M, Magaret A, et al. Persistent genital herpes simplex virus-2 shedding years following the first clinical episode. J Infect Dis. 2011;203(2):180–187.

17. Diamond C, et al. Clinical course of patients with serologic evidence of recurrent genital herpes presenting with signs and symptoms of first episode disease. Sex Transm Dis. 1999;26(4):221–225.

18. Freeman EE, et al. Herpes simplex virus 2 infection increases HIV acquisition in men and women: systematic review and meta-analysis of longitudinal studies. AIDS. 2006;20(1):73–83.

19. Corey L. Synergistic copathogens—HIV-1 and HSV-2 [published correction appears in N Engl J Med. 2007; 356(14):1487]. N Engl J Med. 2007;356(8):854–856.

20. Leeyaphan C, et al. Clinical characteristics of hypertrophic herpes simplex genitalis and treatment outcomes of imiquimod: a retrospective observational study. Int J Infect Dis. 2015;33:165–170.

21. Tan DH, Kaul R, Walsmley S. Left out but not forgotten: should closer attention be paid to coinfection with herpes simplex virus type 1 and HIV? Can J Infect Dis Med Microbiol. 2009;20(1):e1–e7.

22. Dunphy K. Herpes genitalis and the philosopher's stance. J Med Ethics. 2014;40(12):793–797.

23. Gilbert LK, Omisore F. Common questions about herpes: analysis of chat-room transcripts. Herpes. 2009;15(3):57–61.

24. Centers for Disease Control and Prevention. 2015 sexually transmitted diseases treatment guidelines: genital HSV infections. http://www.cdc.gov/std/tg2015/herpes.htm. Accessed March 1, 2016.

25. Johnston C, Morrow RA, Moreland A, Wald A. Genital herpes. In: Morse SA, Ballard RC, Holmes KK, Moreland AA, eds. Atlas of Sexually Transmitted Diseases and AIDS. 4th ed. London, UK: Saunders Elsevier; 2010:169–185.

26. Scoular A, Gillespie G, Carman WF. Polymerase chain reaction for diagnosis of genital herpes in a genitourinary medicine clinic. Sex Transm Infect. 2002;78(1):21–25.

27. Wald A, et al. Polymerase chain reaction for detection of herpes simplex virus (HSV) DNA on mucosal surfaces: comparison with HSV isolation in cell culture. J Infect Dis. 2003;188(9):1345–1351.

28. Wald A, Ashley-Morrow R. Serological testing for herpes simplex virus (HSV)-1 and HSV-2 infection. Clin Infect Dis. 2002;35(suppl 2):S173–S182.

29. Scoular A. Using the evidence base on genital herpes: optimising the use of diagnostic tests and information provision. Sex Transm Infect. 2002;78(3):160–165.

30. U.S. Preventive Services Task Force. Final update summary: Genital herpes: Screening. March 2005. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/genital-herpes-screening. Accessed October 7, 2015.

31. Centers for Disease Control and Prevention. Genital herpes—CDC fact sheet (detailed). http://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm. Accessed March 1, 2016.

32. Hollier LM, Eppes C. Genital herpes: Oral antiviral treatments. BMJ Clin Evid. 2015;2015:1603.

33. Corey L, et al. An update on short-course episodic and prevention therapies for herpes genitalis. Herpes. 2007;14(suppl 1):5A–11A.

34. Lebrun-Vignes B, et al. A meta-analysis to assess the efficacy of oral antiviral treatment to prevent genital herpes outbreaks. J Am Acad Dermatol. 2007;57(2):238–246.

35. Cernik C, Gallina K, Brodell RT. The treatment of herpes simplex infections: an evidence-based review. Arch Intern Med. 2008;168(11):1137–1144.

36. Mujugira A, Magaret AS, Celum C, et al.; Partners in Prevention HSV/HIV Transmission Study Team. Daily acyclovir to decrease herpes simplex virus type 2 (HSV-2) transmission from HSV-2/HIV-1 coinfected persons: a randomized controlled trial. J Infect Dis. 2013;208(9):1366–1374.

37. Celum C, Wald A, Hughes J, et al.; HPTN 039 Protocol Team. Effect of aciclovir on HIV-1 acquisition in herpes simplex virus 2 seropositive women and men who have sex with men: a randomised, double-blind, placebo-controlled trial. Lancet. 2008;371(9630):2109–2119.

38. Abudalu M, Tyring S, Koltun W, Bodsworth N, Hamed K. Single-day, patient-initiated famciclovir therapy versus 3-day valacyclovir regimen for recurrent genital herpes: a randomized, double-blind, comparative trial. Clin Infect Dis. 2008;47(5):651–658.

39. Reyes M, Shaik NS, Graber JM, et al.; Task Force on Herpes Simplex Virus Resistance. Acyclovir-resistant genital herpes among persons attending sexually transmitted disease and human immunodeficiency virus clinics. Arch Intern Med. 2003;163(1):76–80.

40. Kinghorn GR, Turner EB, Barton IG, Potter CW, Burke CA, Fiddian AP. Efficacy of topical acyclovir cream in first and recurrent episodes of genital herpes. Antiviral Res. 1983;3(5–6):291–301.

41. Xu F, Markowitz LE, Gottlieb SL, Berman SM. Seroprevalence of herpes simplex virus types 1 and 2 in pregnant women in the united states. Am J Obstet Gynecol. 2007;196(1):43.e1–e6.

42. Stephenson-Famy A, Gardella C. Herpes simplex virus infection during pregnancy. Obstet Gynecol Clin North Am. 2014;41(4):601–614.



 

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