Can Herpes Simplex Virus 2 (HSV-2) cause skin tenderness in areas beyond the groin?

HSV-2 Can Cause Skin Tenderness Beyond the Groin

Yes, HSV-2 can absolutely cause skin tenderness and lesions in areas beyond the groin, including the buttocks, thighs, perianal region, and potentially any cutaneous surface of the body. 1

Anatomical Distribution of HSV-2 Lesions

While HSV-2 predominantly affects genital regions, the virus is not anatomically restricted:

• Common extragenital sites include the buttocks, thighs, and perianal skin, which are explicitly recognized as typical HSV-2 presentation sites in both males and females 1
• Any body location can be affected through direct inoculation, with cutaneous lesions occurring anywhere on the body surface 2
• The perigenital region and areas adjacent to primary genital sites are frequently involved during both primary and recurrent infections 1

Clinical Presentation and Prodromal Symptoms

Skin tenderness often precedes visible lesions and represents a characteristic prodromal phase:

• The classic progression includes a sensory prodrome (which includes tenderness) followed by papule → vesicle → ulcer → crust stages 3
• This prodromal tenderness occurs as the virus reactivates from latent infection in the sacral ganglia and travels along nerve pathways to the skin 1
• Tenderness may be present even when visible lesions are minimal or absent, particularly during subclinical shedding episodes 1

Recurrent Infection Patterns

The localization of recurrent lesions typically coincides with the primary infection site, but can extend to adjacent dermatomes:

• Recurrences arise from viral reactivation in ganglia, with the virus traveling along sensory nerves to reach the skin 1
• Both the buttocks and thighs are specifically listed as common recurrence sites for genital HSV-2 in females 1
• The frequency of recurrences varies from once every few years to several times per month 1

Important Clinical Caveats

Laboratory confirmation is essential because clinical examination alone cannot reliably diagnose HSV-2 or distinguish it from other conditions:

• HSV-2 lesions are clinically indistinguishable from HSV-1 lesions in appearance 3
• Other causes of skin tenderness and ulceration (including syphilis, chancroid, inflammatory bowel disease, Behçet syndrome, and fixed drug eruption) must be excluded 1
• Viral culture, HSV DNA PCR, or HSV antigen detection with viral typing should be performed, as typing has prognostic implications for recurrence frequency 3

Atypical and Widespread Presentations

In certain clinical contexts, HSV-2 can cause more extensive cutaneous involvement:

• Immunocompromised patients may develop chronic progressive mucocutaneous herpes with large non-healing ulcers or acute widespread dissemination 2
• Dermatological conditions (especially atopic eczema) can lead to widespread cutaneous dissemination known as Kaposi's varicelliform eruption 2
• Herpetic lesions involve the dermis and represent partial-thickness wounds, which explains the associated tenderness and potential for scarring in severe cases 4

Bottom line: Skin tenderness in areas beyond the groin is a recognized manifestation of HSV-2 infection, occurring both as prodromal symptoms before visible lesions and as part of the active infection in extragenital sites, particularly the buttocks, thighs, and perianal region. 1, 2