Herpes

HSV | genital herpes | herpes simplex |

Overview

  • Often acquired without symptoms
  • Initial episodes may be severe and prompt treatment is recommended
  • More than 50% of initial genital episodes are now caused by herpes simplex virus (HSV) type 1
  • Recurrences are usually mild or asymptomatic and may not require treatment
  • Symptomatic recurrences may be treated with suppressive or episodic therapy
  • Frequent recurrences should be managed with suppressive antiviral therapy.

Cause

Herpes simplex viruses (HSV) types 1 and 2.

Clinical presentation

Male Female
Symptoms
Initial episodes may be severe with extensive ulceration and systemic features Initial episodes may be severe with extensive ulceration and systemic features
Recurrent ano-genital ulcers or blisters Recurrent ano-genital ulcers or blisters
Recurrent skin splits – may be painful Recurrent skin splits – may be painful
Erythema with itching/tingling Erythema with itching/tingling
Urethritis Cervicitis often with visible ulcers in initial episodes
Proctitis  
Complications
Neuropathic bladder (initial episode) Neuropathic bladder (initial episode)
Psychosexual morbidity Psychosexual morbidity
Enhanced HIV transmission Enhanced HIV transmission
  Neonatal herpes (acquisition in last trimester of pregnancy)

See STI Atlas for images.

Special considerations

Severe complications are uncommon and usually limited to initial episodes. Recurrences are variable in severity of symptoms and frequency. Many recurrences are asymptomatic or have subtle features, such as redness, itch or fissures. Many initial recognised episodes are not from recent infection.

Diagnosis

TestSite/SpecimenConsideration
NAAT Swab of base of ulcer or de-roofed vesicle Requires visible lesions to be present
NAAT – Nucleic Acid Amplification Test

Investigations

NAATs are the most widely available tests and have greater sensitivity. Viral culture and direct immunofluorescence tests are insensitive, mostly have been superseded and only available in specialised laboratories.

Special considerations

  • Serological tests are available for herpes simplex viruses (HSV) and should only be used where results will provide meaningful clinical information (e.g. during pregnancy).
  • Screening asymptomatic individuals with serological tests for herpes is not recommended. Serological tests do not represent definitive microbiological diagnosis, and lack positive predictive value in low prevalence populations. There are no evidence-based interventions for asymptomatic individuals who have reactive serology and antibody results are not specific to anatomical sites of infection. Although genital herpes infection is associated with increased HIV transmission, intervention has not been shown to interrupt this.
  • Self-collection of NAAT specimens at first onset of recurrent symptoms may be useful to confirm diagnosis in patients who have failed to have confirmation when attending clinical services as viral shedding may only occur for short periods of time.

Management

Principal Treatment Options
SituationRecommendedAlternative
Initial episode Valaciclovir 500mg PO, BD for 5 days Aciclovir 400mg PO, TDS for 5 days
Recurrence: Episodic therapy Valaciclovir 500mg PO, BD for 3 days Famciclovir 1g PO, BD for 1 day
Recurrence: Suppressive therapy Valaciclovir 500mg PO, daily for 6 months Famciclovir 250mg PO, BD for 6 months

Treatment advice

  • Treatment should not be delayed for those presenting with severe episodes, particularly initial episodes.
  • Initial episodes may require a longer duration of treatment.
  • Limited evidence comparing other antiviral agents (aciclovir and famciclovir) with valaciclovir indicates that they are therapeutically equivalent. The ability for the patient to adhere to the recommended dosing frequency should be considered when selecting the appropriate treatment.
  • Choice of suppressive therapy, episodic therapy or no therapy depends on clinical features including frequency and severity of recurrences.
  • Review need for suppressive therapy six monthly as recurrences usually become less frequent and severe with time.
  • Those with very frequent recurrences or immunosuppression may require higher doses.
  • Ongoing symptoms, despite antiviral treatment, should prompt consideration of other causes of genital symptoms.

Other immediate management

  • Written information and support (e.g. Genital Herpes – The Facts)
  • Simple analgesia and antipyretics
  • Saline bathing
  • Topical lignocaine reduces pain from erosions
  • Urinating in a bath or shower relieves superficial dysuria
  • Neuropathic bladder requires catheterisation until resolution
  • Encourage condom use with ongoing partners
  • Herpes is not a notifiable condition.

Special treatment situations

Special considerations

  • Consider seeking specialist advice before treating any complicated presentation.
SituationRecommended
Pregnant women 
pregnancy
Aciclovir is the preferred agent in pregnancy. Although not licensed for this use, it has been used extensively in pregnancy without any significant reported adverse events.
Neonatal transmission may occur after the acquisition of herpes in the third trimester of pregnancy. Seek specialist advice in this circumstance.
Allergy to principal treatment choice Seek specialist advice
Regional/Remote

NAATs are better suited to storage and transport than viral culture and have replaced  the use of culture as the gold standard for testing
NAAT – Nucleic Acid Amplification Test

Contact tracing

  • Contact tracing is not recommended for genital herpes
  • Avoid risk of transmission to pregnant women in third trimester.

Follow up

Review in 1 week provides an opportunity to:

  • Undertake clinical evaluation of response to treatment
  • Complete sexual health screening if unable to do at time of initial presentation because of severity of symptoms
  • Provide further sexual health education and prevention counselling
  • Provide support and information as required
  • Obtain copies of results, if tested at another clinic, for use by the GP in order to be able to prescribe antiviral therapy for recurrent infection on PBS.

Test of Cure (TOC) and Retesting

Not required.

Special considerations

Psychosexual morbidity frequently outweighs physical manifestations. Distress around the diagnosis usually diminishes with time. Verbal and written information about herpes, addressing questions and specific counselling around individual circumstances is helpful. This can usually be done over 1-2 sessions. Some require more intensive counselling.

Auditable outcomes

  • 100% of patients presenting with initial episode of genital herpes should be offered treatment
  • 100% of those receiving ongoing antiviral medications should have microbiological confirmation of genital herpes infection by Nucleic Acid Amplification Test (NAAT).
Last Updated: Wednesday, 10 May 2017