08.09.2007

The antiviral agent Valtrex significantly reduces asymptomatic viral shedding in genital herpes according to new data presented today ... More Info

22.08.2007

A shorter course (3 days) of therapy of the antiviral for treating recurrent episodes of genital herpes. Previously, a 5-day ... More Info

September, 2007
Up to 50% of first episode genital herpes in the United Kingdom is attributable to herpes simplex type 1 virus, although recurrences are far more likely after infection with herpes simplex type 2 virus.

Many patients and clinicians are unaware that oral sex is a common route of transmission of genital herpes infections.

Transmission from asymptomatic individuals in monogamous relationships can occur after several years, causing severe psychological distress.

The majority of patients with genital herpes simplex virus infections have symptoms and signs unrecognized by either themselves or their clinicians.

Oral antiviral treatment, Valtrex, should be given for primary or first episode genital herpes, and long term oral suppressive antiviral treatment is highly effective in reducing recurrences of symptoms in selected patients.

More than 28 000 cases of genital herpes were reported from clinics dealing with sexually transmitted diseases in England last year, and sero prevalence studies suggest that there are many more unrecognized infections. Patients often present having had frequent painful attacks of genital ulceration for many years, although effective antiviral drugs are available that dramatically reduce morbidity if used appropriately. In addition patients often believe that they are infectious only during symptomatic episodes, despite evidence that most transmission occurs from asymptomatic shedding of the virus.[This poor understanding may result in unnecessary morbidity for patients and their partners and inhibits efforts to reduce the spread of genital herpes. We have concentrated on the clinical management of genital herpes. Sources of information included the UK national guidelines, relevant references from Medline, data from recent international meetings, and personal experience of treating patients with genital herpes.

Clinical Course of Genital Herpes
Herpes simplex virus is classified into types 1 and 2. Herpes simplex virus type 1 is widespread in the population and is the cause of herpes labialis; nevertheless, most infected individuals remain asymptomatic. Herpes simplex virus type 2 is mostly acquired sexually. Genital herpes can result from infection with either viral type.

After initial infection both types establish latency in the dorsal root ganglion, which innervates the affected epithelium. Latent virus is never cleared and is not affected by antiviral treatment. Reactivation results in either symptomatic disease or asymptomatic shedding of the virus. The initial infection may or may not cause symptoms and it is followed by sero conversion, with type specific antibodies becoming detectable 4-6 weeks after infection. The proportion of first episode genital herpes in the United Kingdom due to herpes simplex virus type 1 is increasing (up to 50% in some centres. Possible reasons for this are a falling rate of orally acquired herpes simplex virus type 1 infection in childhood leading to increased susceptibility in sexually active adolescents, and an increase in the practice of oral sex by young people. Recurrent episodes of genital herpes simplex virus type 1 are much less frequent than those experienced by patients infected with herpes simplex virus type 2, who account for 95% of recurrent cases.

Clinical Spectrum of Genital Herpes
Primary or first episode genital herpes classically presents with blisters and sores, with local tingling and discomfort . Some patients also report dysthesia or neuralgic type pain in the buttocks or legs and malaise with fever. Recent data, however, suggest that only 37% of patients who acquire herpes simplex virus type 2 have symptoms, although overt disease may follow.

Recurrences are generally milder than primary infection. It now seems that the clinical spectrum of disease can include atypical rashes, fissuring, excoriation and discomfort of the anogenital area, cervical lesions, urinary symptoms, and extragenital lesions. Additionally, the common occurrence of asymptomatic shedding of the virus has been reported. This refers to the presence of the virus on epithelial surfaces in the absence of signs or symptoms and it occurs intermittently in most people infected with herpes simplex virus type In a prospective study of women with herpes simplex virus type 2 monitored by daily self swabbing, shedding of the virus was found on 28% of days by the sensitive technique of polymerase chain reaction and 8.1% of days by virus isolation. The days on which shedding occurs cluster together and are more common in women with frequent recurrences of symptoms, especially in the first year of infection. The rate of shedding is much lower for infections caused by herpes simplex virus type 1.

Diagnosis of Genital Herpes
Genital herpes infection can be diagnosed by using virus culture, antigen detection, and polymerase chain reaction. Virus culture is the test of choice since it is relatively rapid (results within seven days), allows typing of the isolate (which is important for prognosis), and is widely available. Antigen detection with commercial assays is rapid, but kits cannot discriminate between the two viral types and this method has reduced specificity and sensitivity compared with virus isolation. All patients with genital herpes should have at least one virologically confirmed diagnosis. Type specific antibody tests may help identify those infected (with or without symptoms) with either virus type or both, but the limitations and role of these assays in diagnosis and management of genital herpes are not fully established.[13] The assays may, however, be complementary to virus culture for investigating patients with undiagnosed recurrent genital ulceration, demonstrating sero conversion in pregnancy, and investigating asymptomatic partners.[14]

Genital Herpes Treatment
Patients presenting with first episode genital herpes often have widespread anogenital ulceration and severe pain, occasionally with retention of urine. The antiviral agents Valtrex hasl been shown to be effective in reducing the severity and duration of symptoms. Most patients with severe genital herpes feel depressed and tearful, even when ignorant of their diagnosis. Reassurance about the self limiting nature of the initial attack and support about future management is extremely effective in reducing distress. Information about the clinical course of the infection needs to be given early, but follow up for screening for other sexually transmitted infections, and ongoing counseling when patients have recovered, are required.

Recurrent Genital Herpes
After genital herpes has been diagnosed, patients (particularly those with herpes simplex virus type 2 infection) should be asked to keep a diary of recurrences and offered an appointment for long term follow up. Most recurrent attacks are much less severe than a first episode or primary attack. The options for treatment are bathing in saline, short courses of antiviral treatment for individual recurrences (episodic treatment), or Valtrex suppressive antiviral treatment. The treatment modality depends on the severity and frequency of attacks and should be decided between the patient and doctor. Episodic treatment reduces symptoms and needs to be started as soon as possible after onset of symptoms. Ideally, patients should hold a stock of antiviral drugs for self treatment.

Addressing Patients' Concerns About Genital Herpes
When patients are told they have genital herpes they commonly ask several questions--namely, how did I get this, how long have I had it, has my partner been unfaithful, is it incurable, and am I infectious?

It is helpful to discuss the possibility that infection can have been present without recognizable signs in them or their partners, so that recent infidelity is not necessarily implied. Positive strategies for treatment should be emphasized. Knowledge that the tendency is for attacks to decrease with time (even if they are frequent initially) is often reassuring, as is information on the frequency of the infection in the population.

One of the most difficult areas is how to discuss the diagnosis with present or future partners. It should be emphasized again that a current partner may already have the virus, although they may be unaware of this. If this is so (type specific antibody testing may be helpful in this situation) super infection is not thought to occur, and therefore safer sex precautions are probably not required unless otherwise indicated. For uninfected partners or those whose status is not known, methods to reduce the likelihood of passing on infection should be advised whether partners are aware of the diagnosis or not. This should include the avoidance of sexual contact during periods when any suggestive symptoms are present, and it is our practice to advise the use of condoms, although good data on their efficacy are lacking. Patients need reassurance that genital herpes is not transmitted by non-sexual contact and that no special precautions need be taken within the family other than normal hygiene measures.

As the ramifications of genital herpes are complex, the subject may need to be discussed on several occasions in a calm unhurried way and written information and sources of further support provided.

Genital Herpes Treatment Conclusions
Genital herpes is a common infection that is frequently unrecognized or misdiagnosed. In our experience patients diagnosed with genital herpes often have received suboptimal treatment and poor advice concerning transmission. Many patients feel stigmatized and psychologically distressed as well as being in considerable pain. Effective counseling and adequate antiviral treatment (including Valtrex suppressive treatment) can make a major difference to their quality of life:

• All patients with primary or first episode genital herpes should receive oral antiviral and supportive treatment, preferably Valtrex.
• Suppressive Valtrex, antiviral treatment should be considered for those patients with more than three attacks a year
• Oral Valtrex is an effective agent for both first episode genital herpes and suppressive treatment
• Clear written information should be given to all patients infected with herpes simplex virus
• All patients should receive counselling on prevention of transmission and implications of infection with herpes simplex virus during pregnancy