Herpes simplex virus (HSV)
Questionnaire/history:
Oral herpes simplex?
- Pain?
- Burning?
- Paraesthesia?
Anogenital herpes?
- Dysuria?
- Vaginal discharge?
- Urethral discharge?
- Lymphadenitis (30%)?
Systemic symptoms (more common in primary infection)?
- Malaise?
- Myalgia?
- Fever?
Past medical history?
Current medication?
Known drug allergies?
Examination:
Oral herpes simplex?
Crops of vesicles?
- Ruptured?
- Crusted over?
Location?
- Around lips?
- Cheeks?
- Nose?
Anogenital herpes?
Blistering?
Ulceration?
Location?
- External genitalia?
- Perianal region?
Management:
Oral HSV:
Referral:
Consider seeking advice or referring if:
- Immunocompromised and troublesome recurrent infections
- Pregnant and near term
Do not routinely prescribe topical/oral antivirals - topical antivirals can be bought over-the-counter
Consider prescribing oral antivirals if the infection is severe, persistent or recurrent or if immunocompromised and presentation within 5 days of vesicles forming:
Antivirals:
Acute treatment: aciclovir 400 mg TDS (double dose if immunocompromised) until lesions have healed (minimum 5 days), valaciclovir is an alternative 2nd line
Suppressive treatment (if frequent, severe and predictable triggers): aciclovir 400mg BD for 5-7 days (ideally started as soon as prodromal symptoms appear)
Advised:
Usually, a mild and self-limiting illness
HSV type 1 accounts for > 90% of cases
Anogenital HSV:
Referral:
Ideally, all people with suspected genital herpes should be referred to a specialist GUM clinic for diagnosis, virus detection/typing, treatment, screening for other STIs, counselling and follow-up
Essential to refer if:
- Pregnant women
- Immunocompromised individuals
- Herpetic proctitis
Antivirals:
First episode (5 days): aciclovir 400 mg TDS (or valaciclovir 500mg BD)
Recurrent episodes:
- Short course aciclovir 800 mg TDS for 2 days (or valaciclovir 500 mg BD for 3 days)
- 5-day course aciclovir 200 mg 5x daily (or valaciclovir 500 mg BD)
Advised:
Vaseline or topical local anaesthetic (eg 5% lidocaine) especially before micturition if dysuria
Avoid all sexual contact until follow-up or lesions have cleared
HSV type 1 most common cause, but type 2 more common in recurrent disease
Resource(s):