eMedicine Specialties > Dermatology > Viral Infections

Herpes Simplex: Follow-up

Author: Gisela Torres, MD, Staff Physician, Department of Dermatology, University Hospitals of Cleveland; Senior Instructor in Dermatology, Case Western Reserve University
Coauthor(s): Malcolm Schinstine, MD, PhD, Staff Physician, Department of Pathology and Laboratory Medicine, Dartmouth College Hitchcock Medical Center; Paul Krusinski, MD, Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont; Stephen K Tyring, MD, PhD, MBA, Founder and Medical Director, Center for Clinical Studies, Clinical Professor, Departments of Dermatology, Microbiology, and Molecular Genetics, and Internal Medicine (Infectious Diseases), University of Texas Health Science Center at Houston
Contributor Information and Disclosures

Updated: Aug 25, 2009

Follow-up

Deterrence/Prevention

  • Herpes simplex virus (HSV) viral shedding is greatest during clinically evident outbreaks; however, transmission from individuals who are seropositive to their partners who are seronegative usually occurs during asymptomatic HSV shedding periods. Therefore, preventing transmission requires more than abstaining from intimate contact during outbreaks.
    • Barrier methods, such as condoms, confer 10-15% protection against the transmission of genital herpes, as transmission can occur to and from uncovered mucocutaneous surfaces or if the integrity of the barrier is compromised. Condoms have also been shown to be more effective in protecting women than men.
    • Various HSV vaccines have been and continue to be under investigation for the treatment and prevention of herpes genitalis, though most have not been shown to be effective. Recently, double-blind randomized trials of a glycoprotein D HSV-2 vaccine revealed that the vaccine conferred protection against the virus in women who were serologically negative for both HSV-1 and HSV-2. However, it did not prevent HSV infection in men despite their serostatus or in women who were positive for HSV-1 but negative for HSV-2.9
    • Long-term suppressive therapy for genital herpes has been shown to decrease asymptomatic HSV shedding, and long-term valacyclovir therapy significantly decreased HSV transmission to susceptible partners of individuals who were HSV-2 positive by 50-77%. Acyclovir and famciclovir have been shown to be as effective as valacyclovir for suppression of recurrences. Considerations for placing a patient on long-term suppressive therapy include frequent and/or severe outbreaks, infection in a patient who is immunocompromised, the patient’s sex, the patient’s HSV serostatus, and the reproductive capability of the patient’s partner.
    • HIV infection of an HSV patient or his or her seronegative partner should also be considered a possible indication for suppression, given the proposed increase in HIV viral load, although HSV suppressive therapy has not been shown to have an effect on HIV-1 viral shedding.
  • Women who are HSV-2 negative should be counseled to abstain from intercourse during the third trimester of pregnancy with partners that could be seropositive because primary HSV infection during this time places the fetus at highest risk of infection.
    • The most common approach in attempting to prevent vertical transmission is to have women with clinically apparent HSV lesions during labor undergo cesarean delivery. However, cesarean delivery does not prevent all cases of neonatal infection because in utero infection occurs and antepartum HSV cultures are not a good predictor of neonatal infections.
    • Use of acyclovir 400 mg PO tid during the third trimester of pregnancy has been proven to be safe and effective in preventing neonatal herpes and in eliminating the need for cesarean deliveries.

Complications

  • The most common complication of HSV infections is bacterial superinfection. In women with primary HSV-2 infection, aseptic meningitis is also common.
  • Significant complications, such as visceral and CNS dissemination and long-term sequelae, are rare and occur in patients who are immunocompromised or in cases of neonatal HSV.

    • Patients with AIDS who are treated with intravenous acyclovir may develop thymidine kinase–negative strains of HSV that are resistant to acyclovir. These patients may be successfully treated with intravenous foscarnet or topical cidofovir.
    • Babies born to mothers with genital HSV infection should be closely monitored for any signs of infection and promptly treated if signs of the disease develop. Neonatal HSV infection has a mortality rate of more than 80% if untreated and a mortality/significant morbidity rate of approximately 50% even when treated.

Prognosis

  • For most people, HSV infections are temporary and resolve without detrimental sequelae; however, recurrence is common.
  • Long-term sequelae (usually CNS) are more common with neonatal HSV infection than with other types of HSV infection. Scarring may occur from severe or superinfected lesions.

Patient Education

Miscellaneous

Special Concerns

  • Women who are pregnant or contemplating pregnancy should receive information regarding neonatal herpes simplex virus (HSV) transmission and the rationale for performing a cesarean delivery and/or for using antiviral therapy if active lesions are present.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.



More on Herpes Simplex

Overview: Herpes Simplex
Differential Diagnoses & Workup: Herpes Simplex
Treatment & Medication: Herpes Simplex
Follow-up: Herpes Simplex
Multimedia: Herpes Simplex
References
Further Reading
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References

  1. Margolis TP, Imai Y, Yang L, Vallas V, Krause PR. Herpes simplex virus type 2 (HSV-2) establishes latent infection in a different population of ganglionic neurons than HSV-1: role of latency-associated transcripts. J Virol. Feb 2007;81(4):1872-8. [Medline].

  2. Levett PN. Seroprevalence of HSV-1 and HSV-2 in Barbados. Med Microbiol Immunol. Jan 2005;194(1-2):105-7. [Medline].

  3. [Best Evidence] Baeten JM, Strick LB, Lucchetti A, Whittington WL, Sanchez J, Coombs RW, et al. Herpes simplex virus (HSV)-suppressive therapy decreases plasma and genital HIV-1 levels in HSV-2/HIV-1 coinfected women: a randomized, placebo-controlled, cross-over trial. J Infect Dis. Dec 15 2008;198(12):1804-8. [Medline].

  4. Xu F, Markowitz LE, Gottlieb SL, Berman SM. Seroprevalence of herpes simplex virus types 1 and 2 in pregnant women in the United States. Am J Obstet Gynecol. Jan 2007;196(1):43.e1-6. [Medline].

  5. Boivin G, Goyette N, Sergerie Y, Keays S, Booth T. Longitudinal evaluation of herpes simplex virus DNA load during episodes of herpes labialis. J Clin Virol. Dec 2006;37(4):248-51. [Medline].

  6. Foti C, Filotico R, Calvario A, Conserva A, Antelmi A, Angelini G. Relapsing herpes simplex-2 folliculitis in the beard area. Eur J Dermatol. Nov-Dec 2004;14(6):421-3. [Medline].

  7. Weinberg JM, Mysliwiec A, Turiansky GW, Redfield R, James WD. Viral folliculitis. Atypical presentations of herpes simplex, herpes zoster, and molluscum contagiosum. Arch Dermatol. Aug 1997;133(8):983-6. [Medline].

  8. Kaufman HE, Azcuy AM, Varnell ED, Sloop GD, Thompson HW, Hill JM. HSV-1 DNA in tears and saliva of normal adults. Invest Ophthalmol Vis Sci. Jan 2005;46(1):241-7. [Medline].

  9. Stanberry LR, Spruance SL, Cunningham AL, Bernstein DI, Mindel A, Sacks S, et al. Glycoprotein-D-adjuvant vaccine to prevent genital herpes. N Engl J Med. Nov 21 2002;347(21):1652-61. [Medline].

  10. Auslander BA, Biro FM, Rosenthal SL. Genital herpes in adolescents. Semin Pediatr Infect Dis. Jan 2005;16(1):24-30. [Medline].

  11. Balfour HH Jr. Antiviral drugs. N Engl J Med. Apr 22 1999;340(16):1255-68. [Medline].

  12. Barton S, Celum C, Shacker TW. The role of anti-HSV therapeutics in the HIV-infected host and in controlling the HIV epidemic. Herpes. Jun 2005;12(1):15-22. [Medline].

  13. Brown TJ, McCrary M, Tyring SK. Antiviral agents: Non-antiretroviral [correction of Nonantiviral] drugs. J Am Acad Dermatol. Oct 2002;47(4):581-99. [Medline].

  14. Celum C, Wald A, Hughes J, Sanchez J, Reid S, Delany-Moretlwe S, et al. Effect of aciclovir on HIV-1 acquisition in herpes simplex virus 2 seropositive women and men who have sex with men: a randomised, double-blind, placebo-controlled trial. Lancet. Jun 21 2008;371(9630):2109-19. [Medline].

  15. Gupta R, Wald A, Krantz E, Selke S, Warren T, Vargas-Cortes M, et al. Valacyclovir and acyclovir for suppression of shedding of herpes simplex virus in the genital tract. J Infect Dis. Oct 15 2004;190(8):1374-81Epub 2004 Sep 20. [Medline].

  16. Hellenbrand W, Thierfelder W, Müller-Pebody B, Hamouda O, Breuer T. Seroprevalence of herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) in former East and West Germany, 1997-1998. Eur J Clin Microbiol Infect Dis. Feb 2005;24(2):131-5. [Medline].

  17. Hosken NA. Development of a therapeutic vaccine for HSV-2. Vaccine. Mar 18 2005;23(17-18):2395-8. [Medline].

  18. Krusinski PA, Flowers FP. Common viral infections of the skin. Current Practice of Medicine. 1999;2:317-325.

  19. Lafferty WE, Coombs RW, Benedetti J, Critchlow C, Corey L. Recurrences after oral and genital herpes simplex virus infection. Influence of site of infection and viral type. N Engl J Med. Jun 4 1987;316(23):1444-9. [Medline].

  20. Langenberg AG, Corey L, Ashley RL, Leong WP, Straus SE. A prospective study of new infections with herpes simplex virus type 1 and type 2. Chiron HSV Vaccine Study Group. N Engl J Med. Nov 4 1999;341(19):1432-8. [Medline].

  21. Mayaud P, Legoff J, Weiss HA, Grésenguet G, Nzambi K, Bouhlal H, et al. Impact of acyclovir on genital and plasma HIV-1 RNA, genital herpes simplex virus type 2 DNA, and ulcer healing among HIV-1-infected African women with herpes ulcers: a randomized placebo-controlled trial. J Infect Dis. Jul 15 2009;200(2):216-26. [Medline].

  22. Nagot N, Ouedraogo A, Konate I, Weiss HA, Foulongne V, Defer MC, et al. Roles of clinical and subclinical reactivated herpes simplex virus type 2 infection and human immunodeficiency virus type 1 (HIV-1)-induced immunosuppression on genital and plasma HIV-1 levels. J Infect Dis. Jul 15 2008;198(2):241-9. [Medline].

  23. Ouedraogo A, Nagot N, Vergne L, Konate I, Weiss HA, Defer MC, et al. Impact of suppressive herpes therapy on genital HIV-1 RNA among women taking antiretroviral therapy: a randomized controlled trial. AIDS. Nov 28 2006;20(18):2305-13. [Medline].

  24. Paz-Bailey G, Ramaswamy M, Hawkes SJ. Herpes simplex virus type 2: epidemiology and management options in developing countries. Sex Transm Infect. Feb 2007;83(1):16-22. [Medline].

  25. Rana RK, Pimenta JM, Rosenberg DM, Tyring SK, Paavonen J, Cook SF, et al. Demographic, behavioral, and knowledge factors associated with herpes simplex virus type 2 infection among men whose current female partner has genital herpes. Sex Transm Dis. May 2005;32(5):308-13. [Medline].

  26. Sacks SL. Improving the management of genital herpes. Hosp Pract (Minneap). Feb 15 1999;34(2):41-9; quiz 139. [Medline].

  27. Sacks SL, Griffiths PD, Corey L, Cohen C, Cunningham A, Dusheiko GM, et al. HSV-2 transmission. Antiviral Res. Aug 2004;63 Suppl 1:S27-35. [Medline].

  28. Schacker T, Ryncarz AJ, Goddard J, Diem K, Shaughnessy M, Corey L. Frequent recovery of HIV-1 from genital herpes simplex virus lesions in HIV-1-infected men. JAMA. Jul 1 1998;280(1):61-6. [Medline].

  29. Scott LL, Hollier LM, McIntire D, Sanchez PJ, Jackson GL, Wendel GD. Acyclovir suppression to prevent clinical recurrences at delivery after first episode genital herpes in pregnancy: an open-label trial. Infect Dis Obstet Gynecol. 2001;9(2):75-80. [Medline].

  30. Severson JL, Tyring SK. Relation between herpes simplex viruses and human immunodeficiency virus infections. Arch Dermatol. Nov 1999;135(11):1393-7. [Medline].

  31. Singh AE, Romanowski B, Wong T, Gourishankar S, Myziuk L, Fenton J, et al. Herpes simplex virus seroprevalence and risk factors in 2 Canadian sexually transmitted disease clinics. Sex Transm Dis. Feb 2005;32(2):95-100. [Medline].

  32. Spruance SL, Tyring SK, Smith MH, Meng TC. Application of a topical immune response modifier, resiquimod gel, to modify the recurrence rate of recurrent genital herpes: a pilot study. J Infect Dis. Jul 15 2001;184(2):196-200. [Medline].

  33. Tyring SK, ed. Herpes simplex virus infections. Mucocutaneous Manifestations of Viral Diseases. New York, NY: Marcel Dekker Inc; 2002:69-144.

  34. Whitley RJ, Kimberlin DW, Roizman B. Herpes simplex viruses. Clin Infect Dis. Mar 1998;26(3):541-53; quiz 554-5. [Medline].

  35. [Guideline] Workowski KA, Levine WC. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep. May 10 2002;51(RR-6):1-78. [Medline].

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Keywords

herpes simplex virus, HSV, herpes genitalis, genital herpes, herpes labialis, orolabial herpes, HSV-1, HSV type 1, herpes simplex virus type 1, HSV-2, HSV type 2, herpes simplex virus type 2, localized eczema herpeticum, disseminated eczema herpeticum, Kaposi's varicelliform eruption, Kaposi varicelliform eruption, herpes whitlow, herpes gladiatorum, disseminated HSV infection, neonatal HSV infection, herpetic sycosis

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Contributor Information and Disclosures

Author

Gisela Torres, MD, Staff Physician, Department of Dermatology, University Hospitals of Cleveland; Senior Instructor in Dermatology, Case Western Reserve University
Gisela Torres, MD is a member of the following medical societies: American Academy of Dermatology and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Malcolm Schinstine, MD, PhD, Staff Physician, Department of Pathology and Laboratory Medicine, Dartmouth College Hitchcock Medical Center
Malcolm Schinstine, MD, PhD is a member of the following medical societies: American Society for Clinical Pathology, College of American Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Paul Krusinski, MD, Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont
Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Stephen K Tyring, MD, PhD, MBA, Founder and Medical Director, Center for Clinical Studies, Clinical Professor, Departments of Dermatology, Microbiology, and Molecular Genetics, and Internal Medicine (Infectious Diseases), University of Texas Health Science Center at Houston
Disclosure: Nothing to disclose.

Medical Editor

Sungnack Lee, MD, Vice President of Medical Affairs, Professor, Department of Dermatology, Ajou University School of Medicine, Korea
Sungnack Lee, MD is a member of the following medical societies: American Dermatological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Rosalie Elenitsas, MD, Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System
Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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