SIGNS AND SYMPTOMS 
- Local pain and itching
- Herpetic cervicitis, vaginitis, or urethritis may present with dysuria, urinary hesitance or retention, vaginal discharge, or pelvic pain
- Herpetic pharyngitis or gingivostomatitis may occur with oral acquisition
- Systemic symptoms like fever, headache, malaise, photophobia, anorexia, myalgias, and lymphadenopathy are more common with primary infection
History
- 1–2 day prodrome of local tingling, burning, itching, or pain prior to eruption (can mimic sciatica)
- Classically, lesions are noted on day 2 as macules and papules, then progress to vesicles, pustules, and then ulcerate by day 5
- Skin lesions crust over; mucosal membrane lesions heal without crusting
Physical Exam
- Lesions on vulva, vagina, cervix, perineum, buttocks; penile shaft or glans
- Grouped vesicles on an erythematous base
- On moist mucosal surfaces, ulcers may predominate
- Atypical features may include localized edema, erythema, crusts, or fissures
Pediatric Considerations
- Neonatal infections are often disseminated or involve the CNS with high morbidity and mortality
- Congenital HSV in the neonate without vesicles may mimic rubella, cytomegalovirus (CMV), or toxoplasmosis
- Consider sexual abuse in children with genital HSV; culture lesions and test for other STDs in suspected cases
ESSENTIAL WORKUP
Diagnosis based on history and physical exam
DIAGNOSIS TESTS & INTERPRETATION
Lab
- Viral load in lesions of primary infection are greater than those seen in recurrence
- Tzanck preparation and staining of fluid from lesions is insensitive and nonspecific
- Viral culture of vesicle fluid or ulcer base positive in 80–95% of cases, decreasing sensitivity as lesions crust and heal:
- PCR 1.5–4 times more sensitive than viral culture; test of choice for CSF analysis in suspected CNS infection
- Serologic tests not helpful in acute disease:
- Highly sensitive and specific; detect anti-gG1 and anti-gG2 antibodies
- Require 2 wk to > 3 mo to detect seroconversion
- Cannot distinguish acute from chronic disease
- HerpeSelect HSV-1/HSV-2 ELISA:
- Takes hour to days in lab
- POCkit HSV2, bedside results in 10 min
Imaging
No imaging generally indicated
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
Universal precautions should be maintained
INITIAL STABILIZATION/THERAPY
Rarely required unless associated with systemic symptoms requiring hospitalization:
ED TREATMENT/PROCEDURES
- Treatment partially controls symptoms and lesions; does not eradicate latent virus nor affect recurrences after drug is discontinued
- Episodic treatment of recurrences may shorten duration of lesions or ameliorate recurrences
- Daily suppressive therapy in patients with frequent recurrences (6 or more per year) reduces frequency of recurrences by 75%
- Famciclovir and valacyclovir are equally effective medications with less frequent dosing regimens, all interfere with viral DNA polymerase
- Resistance to acyclovir in immunocompromised individuals is 5–10%:
- Consider testing for concomitant STDs, those with an HSV outbreak are more likely to contract HIV
- Consider bladder catheterization, either indwelling or intermittent, for women with difficulty urinating due to possible sacral nerve involvement
Pregnancy Considerations
- Women with primary HSV infection during pregnancy should receive antiviral therapy:
- High rates of neonatal morbidity in both symptomatic and asymptomatic patients
- Suppressive antiviral therapy after 36 wk associated with decreased incidence of lesions at delivery:
- Decreased cesarean delivery rates
MEDICATION
- Systemic or severe infection requiring hospitalization:
- Acyclovir: 5–10 mg/kg IV over at least 1 hr q8h for 5–10 days
- Neonate/peds: 10–20 mg/kg IV over at least 1 hr q8h for 7–10 days
- 1st episode (7–10 day therapy; extend if not healed in 10 days):
- Acyclovir: 400 mg PO TID or 200 mg PO 5 times per day:
- Peds: 20 mg/kg PO TID or 5 mg/kg IV q8h.
- Famciclovir: 250 mg PO TID for 7–10 days
- Valacyclovir: 1,000 mg PO BID for 7–10 days
- Recurrent infection (5 day therapy):
- Must start within 1 day of appearance of lesion or during prodrome
- Acyclovir: 800 mg PO TID for 2 days or 800 mg PO BID for 5 days.
- Famciclovir: 1,000 mg PO BID for 1 day or 125 mg PO BID for 5 days.
- Valacyclovir: 500 mg PO BID for 3 days or 1,000 mg PO daily for 5 days.
- Suppressive therapy (daily):
- Acyclovir: 400 mg PO BID
- Famciclovir: 250 mg PO BID
- Valacyclovir: 500 mg PO daily or if > 10 recurrences yearly, 1,000 mg PO daily
- Treatment of patients with HIV coinfection:
- Recurrent infection (5–10 days therapy):
- Acyclovir: 400 mg PO TID
- Famciclovir: 500 mg PO BID for 5–10 days
- Valacyclovir: 1,000 mg PO BID
- Suppressive therapy:
- Acyclovir: 400–800 mg PO BID–TID
- Famciclovir: 500 mg PO BID
- Valacyclovir: 500 mg PO BID
[Outline]
- ACOG Committee on Practice Bulletins. ACOG Practice Bulletin No. 82: Management of herpes in pregnancy. Obstet Gynecol. 2007;109:1489–1498.
- Borhart J, Birnbaumer DM. Emergency department management of sexually transmitted infections. Emerg Med Clin North Am. 2011;29:587–603.
- Cernik C, Gallina K, Brodell RT. The treatment of herpes simplex infections: An evidence based review. Arch Intern Med. 2008;168:1137–1144.
- Corey L, Wald A. Maternal and neonatal herpes simplex virus infections. N Engl J Med. 2009;361:1376–1385.
- Roett MA, Mayor MT, Uduhiri KA. Diagnosis and management of genital ulcers. Am Fam Physician. 2012;85:254–262.
- Sexually transmitted diseases treatment guidelines 2010. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/std/treatment/2010/genital-ulcers.htm
See Also (Topic, Algorithm, Electronic Media Element)
Herpes Simplex