What are the typical presentation and treatment of genital herpes in a sexually active adult?

Presentation of Genital Herpes

Genital herpes typically presents with painful vesicles that rapidly progress to ulcers on the genital mucosa or skin, often accompanied by a sensory prodrome of pain and pruritus, though most infected persons have mild, atypical lesions that go unrecognized. 1

Classic Clinical Manifestations

Primary (First Episode) Infection

• Lesion evolution: Papules → vesicles → ulcers → crusts on external surfaces 1
• Mucosal involvement: Only ulcerative stage visible on mucosal surfaces (vagina, cervix, urethra) 1
• Local symptoms: Sensory prodrome with pain and pruritus preceding lesions 1
• Associated findings: Dysuria, vaginal or urethral discharge, and inguinal lymphadenopathy (particularly common in primary infection) 1
• Systemic symptoms: Malaise, fever, and localized adenopathy may occur 2
• Duration: Untreated course is 7-10 days for orolabial lesions; genital lesions resolve over 15-21 days 1, 3
• Bilateral distribution: Multiple bilaterally located lesions are characteristic 3

Recurrent Episodes

• Milder presentation: Less severe than primary infection with fewer complications 4
• Shorter duration: Typically resolves more quickly than primary episodes 4
• Prodromal symptoms: May include localized pain or tingling before visible lesions appear 1

Atypical Presentations

Most persons with genital herpes have mild and atypical lesions that are not brought to medical attention and cannot be diagnosed by physical examination alone. 1

Common Atypical Forms

• Minimal lesions: Single small fissures or localized erythema 3
• Nonhealing ulcers: Particularly in immunocompromised patients 3
• Exophytic lesions: Verrucoid or nodular forms, mostly in HIV-infected patients 3
• Burning sensation: May occur without visible lesions 3

Severe/Complicated Presentations

• Immunocompromised patients: Extensive, deep, nonhealing ulcerations (most common with CD4+ counts <100 cells/µL) 1
• Rapid necrosis: Rare cases may progress to labial necrosis within 48 hours, requiring debridement 3
• Urinary retention: Can occur due to severe pain and dysuria 3
• Herpes proctitis: Presents with rectal pain and discharge 1

Viral Type Differences

• HSV-2: Most common cause of genital herpes; higher recurrence frequency (1-12 times per year) 1
• HSV-1: Causes 5-30% of first-episode genital herpes but recurs much less frequently than HSV-2 5
• Clinical indistinguishability: Episodes of genital HSV-1 are visually indistinguishable from HSV-2 1

Asymptomatic Viral Shedding

Regardless of clinical severity, reactivation on mucosal surfaces occurs intermittently and can result in transmission even without visible lesions. 1

• Frequency: More common with HSV-2 than HSV-1 and in patients with infection <12 months 5
• Transmission risk: Many cases are acquired from persons who don't know they have infection or were asymptomatic at time of contact 1

Diagnostic Approach

Laboratory confirmation should be pursued in all cases because mucosal HSV infections cannot be diagnosed accurately by clinical examination alone, especially in HIV-seropositive patients. 1

Preferred Diagnostic Methods

• PCR from lesion: Most sensitive method and gold standard for diagnosis 1, 3
• Viral culture: Less sensitive than PCR but widely available 1
• HSV antigen detection: Alternative when PCR unavailable 1
• Type-specific serology: Useful for asymptomatic persons or those with atypical lesions 1
• Tzanck smear: Shows multinucleated giant cells but less specific 3

Critical Diagnostic Considerations

• Virus typing is essential: HSV-1 recurs less frequently than HSV-2 in the genital area, which has prognostic importance for counseling 1, 5
• Routine type-specific serologic testing: Should be considered in persons seeking HIV care due to extensive interactions between HIV and HSV-2 1

Treatment Overview

First Clinical Episode

Antiviral therapy should be initiated within 72 hours of symptom onset and continued for 7-10 days or until clinical resolution. 1, 5

• Valacyclovir 1 g orally twice daily for 7-10 days 5
• Acyclovir 400 mg orally three times daily for 7-10 days 5
• Famciclovir 250 mg orally three times daily for 7-10 days 5
• Treatment may be extended if healing incomplete after 10 days 5

Recurrent Episodes

• Episodic therapy: Most effective when started during prodrome or within 1 day of lesion onset 5
• Valacyclovir 500 mg twice daily for 5 days 5
• Acyclovir 400 mg three times daily for 5 days 5

Suppressive Therapy

• Indicated for: Patients with ≥6 recurrences per year 5
• Reduces recurrence frequency by ≥75% 5
• Valacyclovir 1 g once daily or 500 mg once daily 5
• Reduces transmission: Daily valacyclovir 500 mg reduces HSV-2 acquisition by 48% 6

Severe Disease

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days for complications requiring hospitalization 5

Common Pitfalls

• Relying on clinical diagnosis alone: Poor sensitivity and specificity necessitate laboratory confirmation 1
• Topical acyclovir: Substantially less effective than oral therapy and should not be used 1, 5
• Missing atypical presentations: Most patients have mild, unrecognized disease 1
• Inadequate counseling: Patients must understand transmission risks, including asymptomatic shedding 5, 6
• Ignoring partner notification: Critical for preventing transmission 6