Can Herpes Simplex Be Painless?
Yes, herpes simplex virus infection can absolutely be painless—in fact, most HSV infections (80-90%) progress subclinically without symptoms, yet these asymptomatic individuals still shed virus and can transmit infection. 1, 2
The Spectrum of HSV Presentation
Asymptomatic and Subclinical Disease
- The majority of genital herpes cases (80-90%) are subclinical, meaning patients have no recognizable symptoms despite active infection and viral replication 1
- Most HSV-infected persons have unrecognized clinical infections, yet experience intermittent viral reactivation on mucosal surfaces that can result in transmission to others 1
- Subclinical presentations with asymptomatic viral shedding are likely responsible for most HSV transmission and contributed to the 30% increase in genital herpes prevalence in the United States 2
- Frequent viral shedding occurs from genital surfaces even in the complete absence of signs or symptoms of clinical disease 3
Atypical and Minimal Presentations
- HSV can present with subtle signs and symptoms that patients may not recognize as herpes infection 2
- Atypical clinical manifestations of HSV-1 can occur, including presentations that deviate from the classic vesicular pattern 4
- Some patients have mild and atypical lesions that are not brought to medical attention and cannot be diagnosed by physical examination alone 1
When HSV IS Painful: The Classic Presentation
Symptomatic Primary Infection
- Primary HSV gingivostomatitis in children characteristically presents with fever, irritability, tender submandibular lymphadenopathy, and superficial, painful ulcers in the gingival and oral mucosa 1, 5
- Classic genital herpes manifestations include a sensory prodrome consisting of pain and pruritis, followed by local symptoms with ulcerative lesions 1
- Primary infection is usually the most severe manifestation, particularly in HSV-seronegative individuals acquiring their first infection 1
Recurrent Episodes
- Recurrent herpes labialis episodes are characterized by itching, burning, and/or paresthesia (the prodrome) prior to visible lesions 1
- Recurrent episodes can be frequent, painful, long-lasting and disfiguring 1
Critical Clinical Pitfalls
The Diagnostic Challenge
- Laboratory confirmation should be pursued in all cases where diagnostic certainty is needed, because mucosal HSV infections cannot be diagnosed accurately without laboratory testing, especially in HIV-seropositive patients 1
- The CDC recommends obtaining viral cultures from skin vesicles, mouth, and other sites for definitive diagnosis 5
- Direct immunofluorescence from lesion scrapings can provide rapid HSV diagnosis 5
Immunocompromised Patients
- In profoundly immunocompromised patients (CD4+ counts <100 cells/µL), HSV can present as extensive, deep, nonhealing ulcerations that may be painless or have altered sensation 1, 6
- Immunocompromised children can develop severe local lesions or disseminated HSV with visceral involvement 1, 5
Public Health Implications
- The painless, asymptomatic nature of most HSV infections creates a major transmission risk, as infected individuals are unaware they can spread the virus 3, 2
- Approximately 70% of HIV-infected persons are HSV-2 seropositive, and HSV-2 reactivation increases HIV RNA levels in coinfected patients 1
- HSV-2 is a risk factor for HIV acquisition, and genital HSV shedding may be associated with genital tract inflammation 1, 3