Recurrent Herpes Simplex on Mons Pubis
Recurrent herpes simplex on the mons pubis is caused by reactivation of latent herpes simplex virus (HSV-1 or HSV-2) that remains dormant in the sacral nerve ganglia following the initial genital infection. 1
Mechanism of Recurrence
The fundamental cause is viral reactivation from latency rather than reinfection. After the primary genital infection resolves, the virus establishes lifelong latency by remaining in a non-multiplying episomal form within the nuclei of neurons in the sacral ganglia. 1 Recurrences arise when this dormant virus reactivates and travels back down the nerve to the original site of infection—in this case, the mons pubis. 1
The localization of recurrent lesions typically coincides with the site of the primary infection, which is why the mons pubis continues to be affected if that was the initial site. 1
Viral Type Matters Significantly
The specific HSV type dramatically influences recurrence patterns:
- HSV-2 genital infections recur approximately 95% of the time with a mean frequency of 0.33 recurrences per month (roughly 4 times per year). 2, 3
- HSV-1 genital infections recur only about 50% of the time with a much lower frequency of 0.020 recurrences per month. 2, 3
- HSV-2 recurs in the genital area much more frequently than HSV-1, making viral typing clinically important for counseling about expected recurrence patterns. 4, 3
Most genital herpes is caused by HSV-2, though HSV-1 now accounts for approximately half of new genital herpes cases in developed countries due to changing sexual practices. 4, 5
Recurrence Frequency and Patterns
Recurrence frequency varies considerably:
- Episodes can occur anywhere from once every few years to several times per month. 1
- In the first year after initial HSV-2 infection, patients experience a median of 5 recurrences per year. 6
- Recurrence rates typically decrease over time—patients with HSV-2 followed for more than 4 years showed a median decrease of 2 recurrences between years 1 and 5. 6
- However, 25% of patients may actually experience an increase in recurrences even after 5 years, illustrating significant individual variability. 6
Clinical Presentation of Recurrences
Each recurrent episode follows a characteristic pattern:
- Begins with a patch of redness at the site (prodrome)
- Progresses to localized papules, then vesicles containing clear fluid with thousands of infectious viral particles
- Vesicles burst to form shallow ulcers or erosions
- Lesions eventually crust and heal spontaneously without scarring
- Episodes typically last less than 10 days but may be prolonged by secondary bacterial infection or immunosuppression 1
Important Clinical Caveats
Laboratory confirmation should always be sought because clinical diagnosis alone is neither sensitive nor specific. 1, 5 The mons pubis location can make differentiation from other causes of genital ulceration difficult, including:
- Syphilis (Treponema pallidum)—HSV and syphilis can occasionally coexist in the same lesion 1
- Chancroid (Haemophilus ducreyi) 1
- Non-infectious causes: Behçet syndrome, Crohn disease, fixed drug eruption 1
- Herpes zoster (shingles) in the genital region, which can mimic HSV but is caused by varicella-zoster virus 7
Most genital herpes (80-90%) progresses subclinically, meaning patients may have asymptomatic viral shedding and recurrences without recognizing symptoms. 1, 4 This has major implications for transmission risk and counseling.