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Genital herpes simplex virus (HSV) diagnosis and management

Last updated: June 2013

Diagnosis

Clinical

Typical herpetic genital lesions and/or symptoms such as prodrome (for example burning, itching, or tingling at site where lesions occur), paraesthesia, vesicles, followed by single/multiple and painful shallow ulcers, and healing with crusting scabs.

Atypical lesions are common and a high clinical suspicion should be maintained followed by appropriate testing.

Confirmed

Both HSV type 1 and type 2 can infect the genitals and testing should be type specific.

Nucleic Acid Amplification Test

Note: NAAT refers to Nucleic Acid Amplification Test, such as PCR

  • swab specimen from an infected site
  • type specific PCR.

HSV Serology

  • HSV serology for IgM and IgG is routinely available
  • IgM is unreliable
  • the sensitivity and specificity of IgG may be between 95 to 97% depending on the specific assay
  • screening with serology is not routinely recommended
  • use of this test may be indicated in certain clinical settings such as
    • recurrent genital symptoms without diagnosis
    • partners of HSV infected persons wishing to know.

HSV viral culture

Not routinely available.

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Treatment

No treatment is available to eradicate the virus.

First episode

The following points are to be considered:

  • antiviral therapy should be commenced at time of clinical presentation, prior to result availability and within 72 hours of most recent symptom onset
  • there may be value in starting therapy even if lesions have been present for more than 48 to 72 hours if new lesions are developing
  • higher dose therapy may be required in patients with moderate to severe symptoms
  • a first episode may have systemic symptoms and new lesions may develop after initial consultation
  • a first episode may take longer to resolve and treatment should be sufficient duration.

Standard therapy

Famciclovir 250 mg orally 8 hourly for 7 to 14 days (B1)

OR

Valaciclovir 500 or 1000 mg orally 12 hourly for 7 to 14 days (B3).

Treatment should be extended until healing is complete.

Recurrent herpes

Episodic therapy

The following points are to be considered:

  • episodic therapy can decrease the duration and severity of symptoms
  • early treatment during prodrome may abort an attack
  • treatment should be instituted as soon as possible after symptom onset
  • short course therapy (1 to 3 days) is preferred.

Standard therapy

Famciclovir 500 mg orally stat followed by 250 mg 12 hourly for a further three doses (B1)

OR

Valaciclovir 500 mg orally 12 hourly for 3 days (B3)

OR

Famciclovir 1000 mg orally 12 hourly for 2 doses (B1)

In human immunodeficiency virus (HIV) infection

Famciclovir 500 mg orally 12 hourly for 5 to 10 days (B1)

OR

Valaciclovir 1000 mg orally 12 hourly for 5 to 10 days (B3)

Suppressive therapy and transmission risk reduction

The following points are to be considered:

  • suppressive therapy aims to prevent episode recurrence
  • is appropriate for patients who experience distress or problematic symptoms with each episode
  • suppressive therapy with valaciclovir has been shown to reduce the risk of transmission to sero-negative partners by 50% by reducing recurrences and asymptomatic viral shedding
  • suppressive therapy may be considered in HIV and HSV2 sero-discordant couples, and in HSV2 positive patients with an HSV2 negative pregnant partner
  • therapy should be reviewed every 6 to 12 months for efficacy and ongoing need
  • suppressive therapy does not alter the long term recurrence rate and severity of episodes once off treatment
  • is safe if taken in the long term.

Standard therapy

Valaciclovir 500 mg orally daily (B3)

OR

Famciclovir 250 mg orally 12 hourly (B1)

Valaciclovir is superior in reducing viral shedding.
Failure to control recurrence on standard therapy may be overcome by doubling the dose.

In HIV infection

Valaciclovir 500 mg orally 12 hourly (B3)

OR

Famciclovir 500 mg orally 12 hourly (B1).

Adjunct therapy

The following therapies can supplement antiviral treatment:

  • topical antiseptic agents such as betadine and dilute salt water will assist in preventing secondary bacterial infection
  • oral analgesia such as paracetamol with or without codeine
  • topical anaesthetic agents such as lignocaine gel may be used in the short term with a small risk of sensitisation

Hospitalisation may be required for management of pain or complications.

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Patient education

Patient education is often complex and patients should be referred to a health advisor for counselling at first or follow up visits.

HSV is common with an approximate prevalence of 80 to 90% for type 1, and 12 to 80% (depending upon the population tested) for type 2. Recent seroprevalence data found 1 in 8 Australian adults are infected with HSV 2.

Type 1 HSV in the genitals is more common than type 2 HSV in the younger population and will recur much less frequently than type 2 HSV in the genitals.

Up to 80% of people infected with HSV type 2 are not aware that they are infected as they are asymptomatic or have not had their symptoms of HSV diagnosed. In serodiscordant relationships, the risk of acquiring HSV 2 from an infected male to a non infected female is about 10% and infected female to non infected male about 5% per annum.

The following points should be covered:

  • HSV type 1 and 2 infections are common in the community
  • the natural history of HSV infection including greater severity of initial attack, decreasing frequency and severity of recurrences with time
  • treatment options including suppressive therapy
  • methods of transmission and treatment options to reduce risk of transmission
  • nature of asymptomatic viral shedding during which time transmission may occur
  • identification of prodromal symptoms which may assist in early recognition and treatment of recurrences
  • avoidance of sex during outbreaks and optional use of condoms at other times which may decrease transmission
  • a pregnant women should inform her treating doctor if she or her partner has HSV infection
  • infection with HSV type 2 in the genitals can increase the risk of HIV acquisition or transmission.

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Follow up

  • Provide test results. Attempts should be made to inform patients who do not attend for results of positive herpes tests, as patient awareness of infection may reduce onward transmission.
  • As the infection is life-long, giving the patient a copy of positive herpes tests can be helpful for future management by other doctors.
  • False negative swab results can occur and do not exclude herpes in individuals with characteristic clinical signs.
  • Record clinical progress, complications such as neuropathic signs and symptoms, and perceived value of the therapeutic measures used.
  • Some first episodes require prolonged courses of treatment until resolution.
  • Enquire about any anxieties or further questions the patient may have and arrange further counselling as appropriate.
  • Offer review at the time of next symptoms to confirm recurrence rate.
  • Discuss long term management options, including suppressive therapy for frequent recurrences.
  • Offer one standby course of antiviral medication to be initiated at first sign of recurrence.

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Further information

For further information on the diagnosis and management of HSV contact Clinic 275.

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Disclaimer

These guidelines are based on review of current literature, current recommendations of the United States Centers for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV and local expert opinion.

They are written primarily for use by Clinic 275 staff and some flexibility is required in applying them to certain private practice situations.

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