What is recurrent genital herpes in a sexually active adult with a history of previous genital herpes outbreaks?

What is Recurrent Genital Herpes?

Recurrent genital herpes is a lifelong viral infection characterized by periodic reactivation of latent herpes simplex virus (HSV-1 or HSV-2) from the sacral ganglia, causing episodic outbreaks of genital lesions that typically occur with varying frequency—from once every few years to several times per month. 1

Pathophysiology and Natural History

Recurrent genital herpes results from reactivation of latent virus that persists in a non-multiplying episomal form in the nuclei of neurons in the sacral ganglia following primary infection. 1 After the initial infection resolves, the virus establishes latency and can reactivate unpredictably throughout the patient's lifetime. 1

• The localization of recurrent lesions usually coincides with the site of primary infection. 1
• Most cases of genital herpes (80-90%) progress subclinically but may become symptomatic at any time. 1
• HSV-2 causes approximately 94% of recurrent genital herpes cases, while HSV-1 accounts for only about 6%. 2
• HSV-1-induced genital herpes recurrences are significantly less frequent than HSV-2. 3

Clinical Presentation

Each recurrent episode classically presents with a prodrome followed by a patch of redness, then localized papular and vesicular rash containing clear fluid with thousands of infectious viral particles. 1

Typical Episode Progression:

• Prodromal symptoms may occur before visible lesions appear. 1
• Vesicles develop containing clear fluid with high viral particle concentrations. 1
• Vesicles burst to form shallow ulcers or erosions. 1
• Lesions crust and heal spontaneously without leaving scars. 1
• Episodes typically last less than 10 days (mean 10.1 days), though may be prolonged by secondary bacterial infection or immunosuppression. 1, 4

Severity Compared to Primary Infection:

• Recurrent episodes are much milder than primary infection. 5
• Systemic symptoms are uncommon in recurrent episodes (compared to 67% in primary infection). 4
• Lesions are typically small, vesicular or ulcerative, and unilaterally distributed. 4
• Approximately 25% of recurrent episodes are completely asymptomatic. 4

Frequency and Pattern of Recurrences

The frequency of recurrences varies widely among individuals, ranging from once every few years to several times per month. 1

• In many patients, the number of recurrences does not decrease significantly between the first year and subsequent years. 2
• The frequency of recurrences may decrease over time in some patients. 1
• Patients with HSV-2 experience more frequent recurrences than those with HSV-1. 1
• Asymptomatic viral shedding occurs more frequently in patients with HSV-2 infection and in those who have had genital herpes for less than 12 months. 1

Transmission Risk

Sexual transmission of HSV can occur during asymptomatic periods through asymptomatic viral shedding, which occurs more frequently with HSV-2 infection. 1

• Many cases of genital herpes are acquired from persons who do not know they have a genital infection or who were asymptomatic at the time of sexual contact. 1
• In one study, more than half of steady partners of patients with genital HSV-2 had HSV-2 antibodies, indicating subclinical infection. 2
• Duration of relationship or condom use did not significantly influence transmission frequency, suggesting individual susceptibility factors. 2
• About 64% of patients are not aware of asymptomatic shedding and the risk of sexual transmission without clinical symptoms. 2

Psychological Impact

The major concerns of patients with recurrent genital herpes are the frequency of recurrences and fear of transmitting infection to partners or infants. 4

• Recurrent genital herpes results in significant psychological stress and has a tremendous negative impact on quality of life. 6
• The infectious potential to sexual partners contributes substantially to psychological distress. 6

Diagnostic Considerations

Laboratory confirmation should be pursued in all cases because clinical diagnosis alone is unreliable, particularly for distinguishing recurrent episodes from other causes of genital ulceration. 7

Indications for Testing:

• Males: History of recurrent vesicular and ulcerative genital skin lesions. 1
• Females: History of recurrent vesicular and/or ulcerative genital skin lesions on the genitals, thighs, buttocks, or perineum. 1

Common Diagnostic Pitfalls:

• Herpes zoster in the genital region may be misdiagnosed as recurrent genital herpes. 8
• Most persons with genital herpes have mild and atypical lesions that cannot be diagnosed by physical examination alone. 7
• In immunocompromised patients, herpes can present as extensive, deep, nonhealing ulcerations rather than typical vesicles. 7

Treatment Implications

Genital herpes is a lifelong infection with no cure; treatment focuses on managing symptoms and reducing transmission risk. 1

• Episodic antiviral therapy during recurrent episodes may shorten the duration of lesions when initiated during prodrome or within 1 day of onset. 1
• Daily suppressive therapy reduces the frequency of recurrences by at least 75% in patients with frequent recurrences (≥6 per year). 1
• Valacyclovir is FDA-approved for treatment of recurrent episodes and chronic suppressive therapy in immunocompetent and HIV-1-infected adults. 9
• Suppressive therapy reduces but does not eliminate asymptomatic viral shedding or the potential for transmission. 1