Diagnosis & Management:

• Introduction

• Contents

• Disclaimer
  Please read before using the guidelines

• Clinical assessment guidelines

Download for printing (pdf format)

Genital Herpes Contents

Essential Facts

More Information

Diagnosis and management
(includes clinical photographs)

Herpes WWW Links

Reading Material

Pamphlet
(pdf format)

Genital Herpes
Diagnosis and management

Diagnosis

Management

Patient education

Follow-up

Diagnosis

Presumptive

Specimen from genital lesion demonstrates typical HSV morphology by electron microscopy

or

Evidence of HSV on Pap smear 

 Confirmed

Isolation of herpes simplex virus (HSV) in cell culture or detection of HSV DNA by a Nucleic Acid Amplification Test (PCR) in a specimen from the cervix, urethra or a genital or perianal lesion. Ideally, the specimen should be taken within 72 hours of the appearance of a suspicious lesion.

Note:  HSV serology using EIA is not recommended because of defects in both sensitivity and specificity

Clinical

Typical herpetic genital lesions (pre-emergent paraesthesia ,blisters, or multiple, painful shallow ulcers)

Management

Treatment

No treatment is available to eradicate the virus.

 First episode

Antiviral agents reduce viral shedding from lesions, hasten healing and reduce the risk of recurrence while being administered.  In the STD clinic valaciclovir is used with the aim of avoiding hospitalisation and/or reducing severe patient distress in acute first episode infection.

Standard therapy

valaciclovir 500 mg orally 12 hourly for 5 days (ADEC B3)

The patient should be reviewed after 5 days for resolution of symptoms A further 5 days of valaciclovir may be indicated.

For HSV proctitis  

valaciclovir 1000mg orally 12 hourly for 7 to 10 days (ADEC B3)

 Recurrent herpes

Intermittent therapy

Most immunocompetent patients with recurrent disease do not benefit from intermittent antiviral therapy. If indicated, treatment should be instituted during the prodrome or within 2 days of onset of lesions.

 valaciclovir 500 mg orally 12 hourly for 5 days 

                                          or

famciclovir 125 mg orally 12 hourly for 5 days (ADEC B3)

Suppressive therapy

In patients with frequent or severe recurrences, daily suppressive therapy reduces the frequency of recurrences, although it does not totally eliminate symptomatic or asymptomatic viral shedding.  Suppressive therapy with valaciclovir has  also been shown to reduce the risk of transmission to sero-negative partners in monogamous relationships.

Standard therapy

valaciclovir 500 mg orally daily for a minimum of 6 to 12 months 
(this dose may be increased to 500 mg twice daily if the patient has recurrences 
while on suppressive therapy)

or

famciclovir 250 mg orally 12 hourly for a minimum of 6 to 12 months

After 6 to 12 months, medication should be discontinued to allow evaluation of the rate and severity of recurrences.

 Adjunct therapy

The primary aim is supportive treatment by keeping lesions as clean and dry as possible while spontaneous healing occurs.  This may be achieved by saline bathing (or other cleansing) of the ulcerated area, drying with tissues, application of Betadine paint and/or exposing the ulcers to air or the warmth of a reading light (a fan or hair dryer may be useful) for 10 to 15 minutes several times a day, particularly after urination (for women).  Topical lignocaine, antiseptics and zinc creams should not be used.

Analgesics by mouth are often useful, particularly at night time.

Hospitalisation should be considered for patients who are in obvious distress from the physical effects of their lesions, particularly when pain is aggravated by walking or leads to urinary retention.  This pattern occurs mainly in first attacks involving widespread ulceration of the vulval or perineal area.

Patient education

Patient education is often complex.  HSV is common with an approximate prevalence of 80-90% for type 1 and 20-30% for type 2.  Up to 60-70% of people with HSV type 2 are not aware that they are infected. The risk of acquiring herpes from male to female is about 10% and female to male about 5% per annum in a serodiscordant relationship.  The following points should be covered:

•  The nature of HSV infection including greater severity of initial attack, decreasing frequency and severity of recurrences with time

• HSV type 1 and 2 infections are common in the community

• Treatment options

• Method of transmission

• Nature of asymptomatic viral shedding during which time transmission may occur

• Avoidance of sex during outbreaks and optional use of condoms at other times which may decrease transmission

• For a pregnant woman to inform her treating doctor of her HSV infection.

• Provide the patient with or recommend literature on genital herpes.

Follow-up

• Provide test results

• False negative results are common and do not exclude herpes in individuals with characteristic clinical signs.  Patients with recurrent ulceration where HSV has not been isolated should be reviewed by a sexual health physician

• Record clinical progress and perceived value of the therapeutic measures used

• Enquire about any anxieties or further questions the patient may have.

Top of Page