Herpes Simplex - Orolabial (1) and Genital Warts (2)

Herpes Simplex Virus (HSV) is a chronic, life-long viral infection characterized by periods of latency and periodic reactivation.

• Prodrome: A hallmark of HSV is the prodromal phase. Patients often report a "warning" sensation of tingling, itching, or burning at the site 6–24 hours before any visible sores appear.

• HSV-1 (Typically Oral): Patients report "cold sores" or "fever blisters" around the mouth or face. They may mention a history of childhood exposure or contact with someone with active lesions.

• HSV-2 (Typically Genital): Patients present with genital or anal sores and may report painful urination (dysuria) as urine touches the open ulcers.

• Triggers: Patients often identify specific triggers for recurrence, such as stress, illness (fever), UV light exposure, or hormonal changes (menstruation).

• Initial vs. Recurrent: The "primary" (first) outbreak is usually the most severe, often accompanied by flu-like symptoms, fever, and localized swelling of lymph nodes

Diagnosis is often made by the classic "grouped" arrangement of the lesions.

1. Vesicular Stage: Small, clear, fluid-filled blisters (vesicles) appearing in a "grouped" or "herpetiform" cluster on a red/inflamed base.

2. Ulcerative Stage: The vesicles are fragile and quickly rupture, leaving behind shallow, painful, "punched-out" erosions or ulcers.

3. Crusting Stage: Lesions eventually dry out, forming a yellowish or brownish crust (scab) before healing.

• Distribution: 

  • HSV-1: Lips (vermilion border), tongue, or perioral skin.

  • HSV-2: Penis, vulva, vagina, cervix, or perianal skin.

• Lymphadenopathy: Tender, swollen lymph nodes in the neck (for oral) or groin (for genital) are common during active outbreaks.

Crucial Note for Darker Skin Tones

• Erythema Presentation: The "red base" of the vesicles may not be obvious in darker skin; instead, the surrounding skin may look dark brown, violaceous, or simply swollen.

• Post-Inflammatory Changes: HSV outbreaks in darker skin often leave behind Post-Inflammatory Hyperpigmentation (PIH). These dark spots can be mistaken for active lesions or other skin conditions (like Fixed Drug Eruption).

• Differential Diagnosis:

  • Fixed Drug Eruption (FDE): Often presents as a single, circular, dark patch that recurs in the exact same spot after taking certain medications (like NSAIDs).

  • Syphilis (Chancre): Typically a painless, single ulcer, whereas HSV is usually multiple and painful.

While there is no cure, antiviral therapy significantly reduces the duration of outbreaks and the risk of transmission.

HSV  1:

The current recommendation is oral valacyclovir (2 grams twice daily for one day). If the patient has frequent outbreaks, chronic suppression is warranted. For chronic suppression of immunocompetent patients, oral valacyclovir 500 mg daily (for patients with less than ten outbreaks per year) or oral valacyclovir 1 gram by mouth daily (for patients with greater than 10 outbreaks a year) is recommended.

HSV  2:
Acyclovir:

• Primary herpes genitalis: 3 x 400 mg tablets PO daily for 7 to 10 days

• Severe primary herpes genitalis: 3 x 5 mg/kg IV daily for 5 to 7 days

• Recurrent herpes genitalis (less than 5 to 6 episodes/year): 400 mg PO twice a day for 3 days 

• Prophylaxis: 2 x 400 mg PO daily for 6 months

• Recurrent herpes genitalis (less than 5 to 6 episodes/year): 2 x 500 mg PO twice daily for 3 days, or

• 1 x 1000 mg tablet daily for 5 days 

For the treatment of eczema herpeticum, it is recommended to use 10 to 14 days of either acyclovir (15 mg/kg with a 400 mg maximum) 3 to 5 times daily or Valacyclovir 1 gram by mouth twice a day.

For immunocompromised patients with severe and chronic HSV, treatment is aimed at chronic suppression. For chronic suppression of immunocompromised patients, oral acyclovir 400 to 800 2 to 3 times daily, or oral valacyclovir 500 mg twice daily is recommended.

• Primary infections are very painful: analgesia is indicated.

• Lips: zinc oxide ointment or zinc oxide and castor oil; soothes and protects from sunlight.

• Antiseptic mouthwash e.g. chlorhexidine mouthwash 3-4 times daily and topical antiseptic or antibiotic e.g. betadine ointment or oxytetracycline ointment 3 times daily for bacterial superinfection.

• Use a lip cream / stick with a sunblocker daily to prevent recurrences.

• Genital herpes: Betadine or potassium permanganate solution sit baths 3 times daily. Zinc oxide and castor oil to soothe, or sulphur 5% in zinc oxide. Alternatively betadine ointment or oxytetracycline ointment 3 times daily.

• DermNet NZ – Herpes Simplex: https://dermnetnz.org/topics/herpes-simplex

• StatPearls – Herpes Simplex Virus (2024): https://www.ncbi.nlm.nih.gov/books/NBK482332/

• WHO – Herpes Simplex Virus Fact Sheet: https://www.who.int/news-room/fact-sheets/detail/herpes-simplex-virus