Management guidelines for herpes simplex

• Herpes Viruses Association •

Diagnosis

• Typical appearance of blisters or sores on the affected area of the body may permit clinical diagnosis in obvious cases
• To confirm diagnosis of herpes simplex, a swab may be taken for cell culture or, for increased detection rates, use PCR
• Since other conditions may be present, refer patients with genital symptoms to a department of genitourinary medicine for full testing
• Studies have shown that primary symptoms are equally caused by herpes simplex type 1 (HSV1) and type 2 (HSV2)

Drug treatment

First episode

• Depending on the severity of symptoms, the following may be prescribed/advised:
  • topical anaesthetic such as lidocaine 5% ointment, or lidocaine 10% spray
  • systemic analgesics
  • antipyretics if flu-like symptoms are a concern
  • antiviral tablets (aciclovir, famciclovir or valaciclovir) are most effective if given within 72 hours of symptom onset. They may limit the duration of severe cases
• Topical antiviral therapy offers little benefit
• Treatment guidelines including therapy for immunocompromised patients can be found at www.bashh.org/guidelines

Recurrent symptoms

• Recurrent symptoms are more likely in genital cases where infection is caused by HSV2
  
• The use of antiviral treatment for recurrent symptoms is the patient's subjective decision
  
• Suppressive therapy should be offered to patients having outbreaks every two months or more frequently, or who are having psychological or relationship problems because of this virus
  
• Episodic treatment should begin as soon as symptoms or prodromes start. Therefore the patient should have tablets or a prescription ready in advance of symptoms reappearing
  
• A 2-day course of 800 mg aciclovir three times a day has been demonstrated as safe and effective in treating recurrences. It may abort lesions. This regimen is IHMF category 1 recommendation
  
• Topical anaesthetics and systemic analgesics are effective in alleviating the symptoms
  
• Patients may like to self-manage symptoms—see 'self-help advice' below

Prophylactic treatments

• When the patient has what he or she considers to be unacceptably frequent episodes, antiviral treatment may be prescribed for a period of months
  
• To aid self dosing and since aciclovir is speedily excreted, 200 mg tablets, to be taken more frequently, may be prescribed in preference to 400 mg tablets
• Famciclovir and valaciclovir remain in the body longer and so can be taken less frequently. These drugs are, or will soon be, available in generic versions, which will reduce the cost of long-term therapy

Self-help advice

• For treating symptoms:
  
  • OTC topical anaesthetic such as lidocaine 5% ointment, or lidocaine 10% spray
  • a well wrapped ice-bag applied for an hour may abort the outbreak as well as ease soreness or alleviate itch
  • if micturition is painful, women may pour water over the urethra, urinate in a bath or into a bottle
    
• Prophylactic self-help suggestions:
  • the Herpes Viruses Association (HVA) has run successful trials on adaptogens and natural compounds: Eleutherococcus senticosus (2 g standardised extract) and olive leaf extract (400 mg 20% oleuropein). Clinical trials have not shown extra L-lysine to be effective, although this is suggested by many complementary therapists
    
  • many other tips are available from the HVA—send SAE for details or see www.herpes.org.uk

Complications

• Autonomic neuropathy, resulting in urinary retention (primary genital infection)
  
• Gingivostomatitis with resultant difficulty in eating/drinking (primary facial infection)
  
• Eczema herpeticum: individuals with atopic dermatitis may acquire herpes simplex over a wider area with more severe symptoms
  
• Central nervous system infections, caused equally by type 1 or 2, either with primary infection or long after. Such infections are diagnosed by PCR of cerebrospinal fluid:
  
  • aseptic meningitis is quite common but does not cause any long term problems
    
  • herpes encephalitis is rare (200 cases a year). Symptoms are lowered (or altered) consciousness, also confusion, drowsiness, seizures and coma

Counselling

• Depending on what the patient has previously heard about herpes simplex, s/he may need counselling. BASHH guidelines state that patients who are anxious benefit from talking to and learning from other people with the condition. Ask the Herpes Viruses Association (contact details at the end of this guideline summary) for free True or False leaflets for your patient
• Perception:
  • a patient who has been exposed to inaccurate media reports and jokes may be distressed by the diagnosis
  • someone to whom herpes simplex is merely the medical term for cold sores may be less concerned
• Epidemiology:
  • a worried patient may derive considerable comfort from being informed that >65% of adults carry the virus, most of whom will be unaware of this as they are asymptomatic
• Transmission:
  • diagnosed patients should be counselled not to have skin-to-skin contact with the affected area when symptoms are present, or suspected i.e. when prodromal symptoms occur, unless their partners also have the same virus in which case reinfection is unlikely
  • prodromal symptoms will vary: an itch at the site of the sore, a 'scalded skin' sensation, deep aches, or sharp twinges
  • herpes simplex lies dormant in the nerve ganglion so appearance of symptoms in a relationship may not be a recent infection or evidence of infidelity
  • mild symptomatic infection often goes unrecognised, so that a high proportion of people contract the virus from a partner who 'doesn't have anything', but in fact has minor, undiagnosed symptoms
  • asymptomatic shedding occurs mainly in newly infected patients, mostly just before or just after an outbreak. This lessens over time, so that after two years it is very rare
  • the high level of unrecognised infection with consequent antibody protection means that when no symptoms are present diagnosed patients need take no more than usual precautions when kissing or having sex
  • once infected, the virus cannot be spread to a new site on the patient's body, unless immunocompromised
• Pregnancy and cervical cancer:
  • media representation of these two aspects of simplex infection worries many women
  • herpes simplex if contracted in the first trimester may lead to miscarriage, or in the third trimester lead to early labour and danger that the baby may be infected during birth
  • a full-term baby with normal development of the immune system whose mother had herpes simplex prior to conception will have transplacental protection; she can normally be delivered vaginally even if genital sores are present (see NICE algorithm for Caesarean Section)
  • herpes simplex is no longer considered to be a causal factor for cervical cancer

full guidelines available from…
Herpes Viruses Association, 41 North Road, London N7 9DP (Tel – 020 7607 9661, patient helpline – 0845 123 2305)
http://www.link.com/

The Herpes Viruses Association. Management guidelines for herpes simplex. Updated August 2011