Genital herpes simplex virus (HSV) diagnosis and management
Last updated: June 2013
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.
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 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.
No treatment is available to eradicate the virus.
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.
Famciclovir 250 mg orally 8 hourly for 7 to 14 days (B1)
Valaciclovir 500 or 1000 mg orally 12 hourly for 7 to 14 days (B3).
Treatment should be extended until healing is complete.
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.
Famciclovir 500 mg orally stat followed by 250 mg 12 hourly for a further three doses (B1)
Valaciclovir 500 mg orally 12 hourly for 3 days (B3)
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)
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
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.
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.
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.
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 Adelaide Sexual
Health Centre staff and some flexibility is required in applying them to certain private practice situations.
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Genital herpes - what to expect if you are diagnosed with genital herpes, inluding treatment options and recurrent outbreaks
British Association for Sexual Health and HIV
Adelaide Sexual Health Centre
Adelaide Sexual Health Centre provides free, confidential, specialist sexual health services. Get advice, testing and treatment for all sexually transmitted infections.
Genital herpes - including symptoms, treatment and prevention
Genital herpes is an infection of the skin and mucous membranes in the genital area caused by the herpes simplex type 1 or 2 viruses
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