Types
- HSV type 1 (HSV-1) is mainly transmitted by oral-to-oral contact and causes oral herpes/cold sores. HSV-1 is also an increasingly common cause of genital herpes.
- HSV type 2 (HSV-2) is primarily an STIthat causes genital and ano-rectal herpes. HSV-2 is uncommonly associated with oral herpes.
Causes
- Genital HSV infection may be acquired from either symptomatic or asymptomatic partners, and from either anogenital or oral contact.
- Most infections are caused by HSV-2 but an increasing number of genital infections are due to HSV-1.
Clinical presentation
- Most HSV infections are asymptomatic.
- Clinical manifestations depend on site of viral entry and host immune status.
- Manifestations of newly acquired (primary) infection may be severe in HSV naive hosts and can include systemic signs or symptoms.
- Common manifestations include recurrent genital ulceration, gingivostomatitis, urethritis, cervicitis and proctitis.
- Less common presentations that require specialist assessment include keratitis, sacral radiculopathy, hepatitis, central nervous system involvement and neonatal HSV infection.
Diagnosis
| Test | Site/ Specimen | Comments |
|---|---|---|
| PCR |
Swab of lesion OR Rectal swab (if proctitis) |
HSV is usually a clinical diagnosis accompanied by a swab for HSV PCR. Co-testing: Syphilis PCR should be performed for all genital ulcers. Consider Mpox PCR based on risk assessment. |
| HSV serology | Blood |
Serology should not be used in screening and only ordered when there are clear individual clinical indications (e.g. in an HSV naive asymptomatic pregnant patient with a partner who has been newly diagnosed with HSV). The practitioner who orders HSV serology should have a clear understanding of the positive and negative predictive values of the test result. |
Management
| Condition | Recommended | Extra comments |
|---|---|---|
| Primary HSV or initial presentation |
Valaciclovir 500 mg PO, twice daily for 7-10 days OR Aciclovir 400 mg PO, 3 times a day for 7-10 days |
Treatment is most effective when started within 5 days of symptom onset, but there are benefits with initiating treatment after this. Topical antivirals and antibiotics are ineffective. |
| Recurrent HSV (episodic therapy) |
Valaciclovir 500 mg PO, twice daily for 3-5 days OR Famciclovir 1g PO stat and repeat 1g PO in 12 hours OR Aciclovir 800 mg PO, three times a day for 2 days |
Viral replication during recurrent episodes lasts for only 1-2 days, so episodic therapy should be commenced within 24 hours of symptom onset and the earlier the better. 1-day antiviral courses are as effective as longer courses. Valaciclovir 2g PO stat and repeated in 12 hours has been shown to be effective but is not PBS approved in Australia. |
| Recurrent HSV (suppressive therapy) |
Valaciclovir 500 mg PO, daily OR Famciclovir 250 mg PO, twice a day OR Aciclovir 400 mg PO, twice a day |
Patients with proven genital herpes who have > 6 episodes annually are likely to experience substantial reduction in frequency of outbreaks on suppressive therapy. Patients who have frequent recurrences (10 or more per year) may require valaciclovir 500 mg tablets bd or 1g daily. |
| People living with HIV with normal CD4 counts | Antiviral doses and duration is the same as for those without HIV. | |
| People living with HIV who have moderate to severe immunosuppression |
Initial or primary infections should be treated with twice the usual dose. If new lesions continue to develop 3-5 days after treatment has started, a further increase in dose may be necessary. Treatment should be continued until re-epithelialisation has occurred, which may exceed 10 days. For episodic treatment of recurrences not responding to standard doses, use twice the usual dose and continue treatment for 5 days or longer, depending on clinical response. Suppressive therapy should be given at least twice daily. The usual doses are usually effective, but may be doubled if recurrences are not satisfactorily controlled. Non-healing lesions may be seen in both severe immunodeficiency and as part of an immune reconstitution inflammatory syndrome following commencement of antiretroviral therapy. Such lesions require referral for further virological assessment and topical and/or intravenous therapy. |
|
| Herpes in Pregnancy | New Zealand Herpes Foundation STIEF | |
Supportive care
- Offer lignocaine 2% jelly or LMX4 cream topically. Exercise caution with topical anaesthetic agents as they may cause sensitisation with prolonged use.
- Offer paracetamol +/- codeine for pain relief.
- Passing urine in the bath or shower can alleviate urinary discomfort.
- Salt baths can ease discomfort and aid healing of ano-genital lesions.Treat comorbid thrush with ananti-fungal, ideally an oral formulation.
- Consider oral antibiotics if secondary bacterial infection is suspected.
Other management
- Offer routine STI screening
- Provide written resources to all patients diagnosed with HSV.
- Discuss red flags including urinary retention, persistence of lesions despite treatment
- Advise patients to abstain from sexual activity whilst during symptomatic episodes.
- Educate patients on other strategies to reduce transmission risk including barrier protection and lubrication.
- Suppressive therapy (see above) should be discussed with all patients newly diagnosed with genital HSV an option to reduce the frequency and severity of symptomatic flares as well as reduce the risk of transmission.
Follow up
Consider the psychosocial effects of the diagnosis, offer education, counselling and consider the need for referral for psychological supportFollow-up
Patients treated presumptively for HSV should be reviewed to assess response to treatment, confirm results, provide further education and discuss long-term management strategies (episodic vs. suppressive therapy). The need for additional psychosocial support should also be assessed.
Contact tracing & partner management
Contact tracing is not recommended for HSV-1 or HSV-2. Symptomatic partners should be tested with PCR. Asymptomatic partners generally should not be tested.
Disclaimer
We recognise that gender identity is fluid. In our treatment guidelines, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines.
The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.