This week we’re gonna talk about herpes. This is a topic that was asked by some of our listeners and its such a common thing that we wanted to really talk about this. It’s relatable to the entire population and is bothersome for many people to discuss. We all know about it, we’ve all seen what it looks like and some of us have mixed feelings about it. So we will dispel what it is, how you get infected, physical findings, treatment, etc. As well as, how to decrease the risk of spreading it to someone else
So lets start with some statistics >50% of people are infected with HSV I and > 15.5% of people in the US between 14-19 have HSV II
Most commonly we have seen them show as cold sores on the mouth and some people get it in their nose which can be really painful. Also we’ve all heard of genital herpes as well.
So there are two types: HSV1 and HSV2. HSV1 is oral herpes can also be a subtype known as herpetic labialis, HSV 2 is genital herpes
So how do you get infected?
- So this can be transmitted by: having HSV infection on your skin surface and you can easily give it to someone else via moist skin or mucous membranes (the mouth, anus and genitals) and can also spread through other areas of skin, as well as the eyes
- With that said it can occur in the following ways: having unprotected vaginal or anal sex, oral sex with a person who gets cold sores (increases the risk significantly), sharing sex toys, having genital contact with an infected person
- The virus can pass on just before the blister appears (so basically anytime from when it's invisible and until the blister is completely healed)
Note: HSV can be transmitted to another person when there are no signs of an outbreak but this is less likely
- This is particularly important when a woman is pregnant and has genital herpes. You have to look for active sores because if they are present during delivery there is a possibility that the infection will be passed on to the baby. Statistically, if you have an active vaginal infection then there is a 50% chance of transmission to the infant (which can lead to seizures, vesicles, respiratory distress, meningitis, and impaired neurological development in the baby). Symptoms for the baby include: vesicles on scalp, face, buttocks, can become irritable or lethargic with a fever and poor feeding. So if women have lesions or prodromal symptoms at the start of labor they will need a c-section to prevent transmissibility.
How it works? Well the virus penetrates through the skin down through your nerves where it lies dormant and then becomes reactivated in what typically is considered to be due to immunosuppression (the exact mechanism however we still don't know)
Physical exam findings: Most commonly it looks like grouped vesicles on a red base
Symptoms? May not experience any for months to years after getting infections, if you do get symptoms during the initial period you will usually notice them about 4 days after exposure (with that range being between 2-12 days)
Obviously we know herpes recurs. It is especially more frequent when you first become infected but with time your periods of remission get longer and less severe
1. Primary infections: the outbreak when a person is first infected
Signs or symptoms include:
- Blisters or ulceration on external genitalia, in vagina, or on the cervix
- Vaginal discharge
- Pain and itching
- Tender, enlarged lymph nodes
- Pain with urination
- Fever, malaise or feeling sick
- Cold sores around the mouth
- Red skin blisters, usually heals without any scarring
2. Recurrent infections: less severe, don’t last as long as the primary infection, will last no more than 10 days and are usually localized to tissues that are innervated by the involved nerve
Signs or symptoms include:
- Burning or tingling around genitals before blisters appear
- In women: blisters or ulcerations on the cervix
- Mouth cold sores
- Red blisters
HSV-1 in infancy can be severe with widespread gingivostomatitis and oral erosions (can sometimes be seen in adults as well), recurrence consists of the common “cold sore”. They can also sometimes present with keratoconjunctivitis, esophagitis, pharyngitis, and painful vesicular lesions
HSV-2 typically adults are affected and they get bilateral erosive vesicles on the genitals with associated swelling and painful lymph nodes (inguinal), recurrence is usually unilateral and appears like a cluster of blisters that are less painful than the initial infection. This can present with associated dysuria and fever.
Herpetic whitlow: is a fun fact here as it presents as a skin lesion on the hand that can be caused by either HSV I or II. It is most commonly seen in health care workers who come in contact with oral secretions like dentists or respiratory therapists.
Herpetic labialis: a type of recurrent herpes. It can be found over the vermillion border of lips or mucosa of hard palate. It may be preceded by a prodrome of itching, tingling or burning.
- Clinical and history based, can confirm with a PCR test or a smear
- Sometimes you need to do further testing if you want to differentiate shingles from herpes because they look similar on the smear but you can also sometimes differentiate that on physical findings by its distribution pattern
- Other things to consider: contact dermatitis like poison ivy, molluscum, genital warts, pemphigoid disorders, aphthous ulcers (not preceded by vesicles only seen on nonkeratinized mucosal surfaces like the inner surface of the lips and buccal mucosa), chancre when compared to HSV2 (they will have tested positive for syphilis) and chancroid (known for being painful and by the bacterium H. ducreyi)
- Different treatment options and effectiveness of treatment varies from person to person. Note there is no cure so no drug will get rid of it but you can improve symptoms and decrease recurrence
- At home remedies include: painkillers (Tylenol or ibuprofen), bathing in lightly salted water helps relieve symptoms, soaking in a warm sitz bath, applying petroleum jelly to affected area, avoid tight clothing around that area, wash hands thoroughly especially after touching the affected area, refraining from sexual activity until symptoms have gone, and with painful urination can apply cream or lotion to the urethra (such as, lidocaine)
- Some people report alleviation of symptoms with ice packs but make sure wrap it in a towel or cloth first
- Drugs: antivirals (acyclovir) prevent the virus from multiplying, they help reduce severity of symptoms and will help the outbreak clear up faster
- Usually medications are prescribed for an initial outbreak but recurrent ones are milder and may not even need treatment however this varies as mentioned before. Some people require episodic treatment or prophylactic treatment to try and prevent these outbreaks.
- Episodic treatment is usually for those who have < 6 recurrences in a year and you receive a 5 day course once symptoms appear
- Suppressive treatment if for persons who have >6 recurrences in a year or are immunosuppressed
- Sometimes you will take a daily antiviral treatment forever. With this, the goal is to prevent recurrence and it also significantly reduces the risk of passing HSV to a partner (even though the risk is still always present)
- Acyclovir can be given PO or IV but all medications come with side effects. For example, they all can affect kidney function
- Acyclovir ointment: used in addition to first line therapy is effective in reducing duration of viral shedding but does not prevent recurrence
- Acyclovir has been used for suppressive therapy or for those with Erythema multiforme in which cases you would take it daily
- Other antivirals include famciclovir or valacyclovir and these are also indicated for immunocompromised individuals
- For people with active genital lesions while pregnant you can receive treatment at 36 weeks gestation to reduce viral shedding and recurrent lesions at onset of labor. This is an example of prophylactic medication use.
- Topical options include: acyclovir, penciclovir and docosanol cream
Prevention (basically avoid direct contact with active shedding lesions on infected people)
- Use condoms during sex
- Do not have sex while symptoms are present (genital, anal, or skin to skin)
- Do not kiss when there is a cold sore around the mouth
- Do not have many sexual partners
- It has been noted that some people that have emotional stress, are tired, ill, experience skin friction, are immunodeficient, menstruating, exposed to the sun, had trigeminal nerve manipulation, or dental extractions may trigger a recurrence of symptoms. So you should be able to find ways to identify these triggers and attempt to avoid them to help reduce recurrence.
- Associated conditions: HSV encephalitis, bells palsy, erythema multiforme, eczema herpeticum and esophagitis
- HSV can persist in AIDs patients (when present for >1 month this needs to be considered), with antiviral resistance
- HSV encephalitis, pneumonitis, esophagitis - seen with HSV-1
- Neonatal herpes, disseminated vesicular rash - seen with HSV-2
You cannot get genital herpes from the toilet seat!
You cannot become infected with HSV by touching an object, work surface, or towel that has been touched by an infected person!
- Warm compress - to minimize pain and swelling
- Cold compress - to reduce swelling as well
- Baking soda or cornstarch paste - helps dry out lesions and relieve itching
- Topical garlic - has presumed “antiviral properties”
- Topical apple cider vinegar - has antiinflammatory and anti-viral properties but needs to be diluted with water
- You want to boost your immune system by eating antioxidant rich veggies like cauliflower, spinach, kale, and tomatoes. Note lysine is important in suppressing herpes and these foods are rich in that amino acid
- Omega 3 fatty acids can help fight chronic inflammatory conditions so you should eat more salmon, mackerel, chia seeds, and flax seeds
- Maintain a high protein diet with low saturated fats like almonds, eggs, and oats
- Vitamin C can help heal herpes outbreaks and may prolong the time between outbreaks. So eat more bell peppers, oranges, strawberries, mangoes, and papaya
- Zinc may reduce the amount of outbreaks and may decrease time to recurrence like vitamin C. For Zinc you can eat more wheat germ, chick peas, lamb, and pork
- Vitamin B complex can boost your immune response and you can get it from green beans, eggs, spinach, and broccoli
- People have considered a number of topical oils: aloe vera, tea tree, witch hazel, manuka honey, goat milk, chamomile essential oil, ginger essential oil, thyme essential oil, greek sage oil, eucalyptus oil, mexican oregano oil, lemon balm extract, combined sage and rhubarb extract, licorice extract, echinacea extract, neem extract. These do not have any FDA approval or definitive scientific evidence behind their use and some of these products need to be diluted before direct application. With that said, consult your physician before use with any of these
Avoid: acidic foods, L-arginine or foods that have high levels of it like chocolate, added sugar, processed or food preservatives, and alcohol because it is broken down like sugar and high sugar consumption is linked to decreasing white blood cells
These home remedies can help in addition to the treatments mentioned but should not be the sole treatment basis if treatment is required
1. Got a cold sore? Throw out your toothbrush and get a new one!
2. Use a hypoallergenic clear lip balm to protect your skin from sun, cold, and wind
3. Don’t share cups or drinks during your outbreak
4. Please don’t pick or try to pop them you will only make it worse and potentially breed a bacterial infection on top of it. Plus, don't forget the scarring potential!
5. Got genital herpes? Wear cotton underwear and loose clothing, keep the area dry, enjoy a long warm shower and don’t soak in a bath. Avoid sex because you can transmit the infection even with condom use
That's all for this week, don't forget to leave us feedback, rate, review, subscribe and send in your questions so we can continue to improve as well as, provide you high quality content!
Disclaimer: The Content on our podcast/website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.