Emergency Department Care

ED care consists of diagnosis and appropriate treatment. The concern for possible infection is the basis of initiating treatment. Most patients may be treated in the outpatient setting. Pregnant patients also need to be educated on the importance of follow-up to reduce transmission to the fetus.^[14]Identification of patients who need inpatient treatment (ie, encephalitis) and initiation of antiviral and supportive therapy is imperative.^[5]

Consultations

Ophthalmologist for keratoconjunctivitis

Obstetrician for active genital herpes in a near-term pregnancy

Outpatient dermatologist for differentiation of skin infections

Infectious disease specialist for disseminated disease and encephalitis

The psychological effect of HSV diagnosis may require patients to seek further evaluation.^[4]

Prevention

Patients should be counseled on barrier protection methods to prevent HSV transmission to others. A discussion regarding daily prophylaxis can be conducted outside of the emergency department.

HSV-2 is an STD. Patients and all sexual contacts should be tested and treated for accompanying STDs.

Practice abstinence when lesions are present.

Always use condoms because of the potential for asymptomatic viral shedding.

Health care personnel (especially medical, dental) should use universal precautions (eg, gloves) to prevent herpetic whitlow.

Experimental vaccines are currently in clinical trials.

Use sunscreen to decrease herpes labialis recurrences.

Further Outpatient Care

Pregnant patients need to be closely monitored by their obstetricians to reduce the risk of an outbreak at the time of delivery.

Patients with herpetic keratitis should be monitored by an ophthalmologist to evaluate for permanent damage (eg, blindness).

Any patient with genital herpes may need referral to a psychologist because of the emotional effect of a permanent and socially stigmatizing disease.

Further Inpatient Care

Admission for patients with herpes simplex is necessary in the following instances:

Encephalitis, hepatitis, or pneumonitis
Severe gingivostomatitis causing decreased ability to tolerate oral fluids
Immunocompromised patients with severe or disseminated diseases

Guidelines

Mell HK. Management of oral and genital herpes in the emergency department. Emerg Med Clin North Am. 2008 May. 26(2):457-73, x. [QxMD MEDLINE Link].
Tronstein E, Johnston C, Huang ML, Selke S, Magaret A, Warren T, et al. Genital shedding of herpes simplex virus among symptomatic and asymptomatic persons with HSV-2 infection. JAMA. 2011 Apr 13. 305 (14):1441-9. [QxMD MEDLINE Link].
Fanfair RN, Zaidi A, Taylor LD, Xu F, Gottlieb S, Markowitz L. Trends in seroprevalence of herpes simplex virus type 2 among non-Hispanic blacks and non-Hispanic whites aged 14 to 49 years--United States, 1988 to 2010. Sex Transm Dis. 2013 Nov. 40 (11):860-4. [QxMD MEDLINE Link].
Wald A, Corey L. Persistence in the population: epidemiology, transmission. Arvin A, Campadelli-Fiume G, Mocarski E, Moore PS, Roizman B, Whitley R, Yamanishi K, eds. Human Herpesviruses: Biology, Therapy, and Immunoprophylaxis. Cambridge, MA: Cambridge University Press; 2007.
World Health Organization. Herpes simplex virus. Available at http://www.who.int/mediacentre/factsheets/fs400/en/. Jan 2017; Accessed: April 2017.
Porter D. Herpes Keratitis. American Academy of Ophthalmology Herpes Keratitis. Available at https://www.aao.org/eye-health/diseases/herpes-keratitis. April 25, 2018; Accessed: July 9, 2019.
Biggs WS, Williams RM. Common gynecologic infections. Prim Care. 2009 Mar. 36(1):33-51, viii. [QxMD MEDLINE Link].
Ahmad FA, Storch GA, Miller AS. Impact of an Institutional Guideline on the Care of Neonates at Risk for Herpes Simplex Virus in the Emergency Department. Pediatr Emerg Care. 2015 Aug 21. [QxMD MEDLINE Link].
Amel Jamehdar S, Mammouri G, Sharifi Hoseini MR, Nomani H, Afzalaghaee M, Boskabadi H, et al. Herpes simplex virus infection in neonates and young infants with sepsis. Iran Red Crescent Med J. 2014 Feb. 16 (2):e14310. [QxMD MEDLINE Link].
Bernstein DI, Bellamy AR, Hook EW 3rd, Levin MJ, Wald A, Ewell MG, et al. Epidemiology, clinical presentation, and antibody response to primary infection with herpes simplex virus type 1 and type 2 in young women. Clin Infect Dis. 2013 Feb. 56 (3):344-51. [QxMD MEDLINE Link].
Tronstein E, Johnston C, Huang ML, Selke S, Magaret A, Warren T, et al. Genital shedding of herpes simplex virus among symptomatic and asymptomatic persons with HSV-2 infection. JAMA. 2011 Apr 13. 305(14):1441-9. [QxMD MEDLINE Link].
Corey L, Wald A. Genital Herpes. Holmes KK, Sparling PF, Stamm WE, et al. Sexually Transmitted Diseases. 4th ed. New York: McGraw-Hill; 2008. 399-437.
Singh A, Preiksaitis J, Ferenczy A, Romanowski B. The laboratory diagnosis of herpes simplex virus infections. Can J Infect Dis Med Microbiol. 2005 Mar. 16 (2):92-8. [QxMD MEDLINE Link].
Brown ZA, Wald A, Morrow RA, Selke S, Zeh J, Corey L. Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. JAMA. 2003 Jan 8. 289 (2):203-9. [QxMD MEDLINE Link].
Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5. 64 (RR-03):1-137. [QxMD MEDLINE Link].
World Health Organization. WHO Guidelines for the treatment of Genital Herpes Simplex Virus. Geneva, Switzerland: World Health Organization; 2016. [Full Text].
Gnann JW Jr, Whitley RJ. CLINICAL PRACTICE. Genital Herpes. N Engl J Med. 2016 Aug 18. 375 (7):666-74. [QxMD MEDLINE Link].
Frenkl TL, Potts J. Sexually transmitted infections. Urol Clin North Am. 2008 Feb. 35(1):33-46; vi. [QxMD MEDLINE Link].
Bucher J, Koyfman A. What Is the Most Effective Treatment of Herpes Simplex Keratitis?. Ann Emerg Med. 2016 Jul. 68 (1):26-7. [QxMD MEDLINE Link].
Pasternak B, Hviid A. Use of acyclovir, valacyclovir, and famciclovir in the first trimester of pregnancy and the risk of birth defects. JAMA. 2010 Aug 25. 304(8):859-66. [QxMD MEDLINE Link].
Kaminester LH, Pariser RJ, Pariser DM, Weiss JS, Shavin JS, Landsman L, et al. A double-blind, placebo-controlled study of topical tetracaine in the treatment of herpes labialis. J Am Acad Dermatol. 1999 Dec. 41 (6):996-1001. [QxMD MEDLINE Link].
[Guideline] Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006 Aug 4. 55:1-94. [QxMD MEDLINE Link].
Johnson R. Herpes gladiatorum and other skin diseases. Clin Sports Med. 2004 Jul. 23(3):473-84, x. [QxMD MEDLINE Link].
Benedetti J, Corey L, Ashley R. Recurrence rates in genital herpes after symptomatic first-episode infection. Ann Intern Med. 1994 Dec 1. 121(11):847-54. [QxMD MEDLINE Link].
Clark JL, Tatum NO, Noble SL. Management of genital herpes. Am Fam Physician. 1995 Jan. 51(1):175-82, 187-8. [QxMD MEDLINE Link].
Cockerell C. Diagnosis and treatment of cutaneous herpes simplex virus infections. West J Med. 1996 Jun. 164(6):518-20. [QxMD MEDLINE Link].
Hill J, Roberts S. Herpes simplex virus in pregnancy: new concepts in prevention and management. Clin Perinatol. 2005 Sep. 32(3):657-70. [QxMD MEDLINE Link].
Hirsch MS. Herpes simplex virus. Mandell GL, ed. Mandell, Douglas, and Bennet's Principles and Practice of Infectious Diseases. 4th ed. Churchill Livingstone; 1995. 1336-45.
Holland-Hall C. Sexually transmitted infections: screening, syndromes, and symptoms. Prim Care. 2006 Jun. 33(2):433-54. [QxMD MEDLINE Link].
Patel R, Rompalo A. Managing patients with genital herpes and their sexual partners. Infect Dis Clin North Am. 2005 Jun. 19(2):427-38, x. [QxMD MEDLINE Link].
Rooney JF, Straus SE, Mannix ML. Oral acyclovir to suppress frequently recurrent herpes labialis. A double-blind, placebo-controlled trial. Ann Intern Med. 1993 Feb 15. 118(4):268-72. [QxMD MEDLINE Link].
Whitley RJ, Gnann JW Jr. Acyclovir: a decade later. N Engl J Med. 1992 Sep 10. 327(11):782-9. [QxMD MEDLINE Link].
Wu JJ, Pang KR, Huang DB. Advances in antiviral therapy. Dermatol Clin. 2005 Apr. 23(2):313-22. [QxMD MEDLINE Link].
Patel EU, Frank MA, Hsieh YH, Rothman RE, Baker AE, Kraus CK, et al. Prevalence and factors associated with herpes simplex virus type 2 infection in patients attending a Baltimore City emergency department. PLoS One. 2014. 9 (7):e102422. [QxMD MEDLINE Link].

Media Gallery

Cutaneous vesicles characteristic of herpes simplex virus infection.
Herpes labialis.
Penile infection with herpes simplex virus type 2.
Tzanck smear showing a multinucleated giant cell.
Herpes simplex virus dendritic ulcer with fluorescein staining.
Genital herpes infection.

of 6

Author

Melissa Kohn, MD, MS, FACEP, EMT-PHP Clinical Instructor of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University; Emergency Medicine/EMS Physician, Director of EMS Resident Education, Medical Command Facility Director, Einstein Medical Center

Melissa Kohn, MD, MS, FACEP, EMT-PHP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Lawrence C Brilliant, MD Clinical Assistant Professor, Department of Primary Care and Community Services, MCP Hahnemann University; Attending Physician, Department of Emergency Medicine, Doylestown Hospital

Lawrence C Brilliant, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Robin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Rahul Sharma, MD, MBA, FACEP Medical Director and Associate Chief of Service, NYU Langone Medical Center, Tisch Hospital Emergency Department; Assistant Professor of Emergency Medicine, New York University School of Medicine

Rahul Sharma, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Association for Physician Leadership, Phi Beta Kappa, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.