Guidelines 2016 – Genital Herpes Simplex
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Genital herpes simplex is a chronic, lifelong, recurrent viral infection of the skin and mucous membranes of the genitalia, characterized by eruptions on a lightly raised erythematous base.
II. ETIOLOGY
A. Herpes simplex virus (HSV). There are two HSV strains.
1. HSV type 1 (HSV-1): commonly causes herpes labialis (cold sores) and herpes keratitis; increasingly, the cause of anogenital herpetic infections
a. Usually seen in childhood (as acute gingivostomatitis)
b. May be seen in adults who engage in oral sex, kissing
c. Incubation period: 3 to 7 days, course 1 to 3 weeks
d. May be recurrent and has no cure
e. Offers no protection against getting HSV type 2 (HSV-2) but makes HSV-2 more likely to be subclinical
2. HSV type 2
a. Genital counterpart of acute gingivostomatitis; primarily sexually transmitted
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b. Incubation period: 4 to 7 days up to 4 weeks, course may last 2 to 3 weeks
c. HSV-2 remains dormant in dorsal nerve ganglia, may be recurrent, and has no cure
d. May be present for many years with no symptoms or no recognizable symptoms
e. HSV-2 does provide immunity against HSV-1
f. 25% of population has HSV-2
3. Both HSV-1 (10%) and HSV-2 (90%) have been implicated in genital infections, but rarely is HSV-2 found orally
III. HISTORY
A. Genital herpes
1. Primary infection (may actually be caused by HSV-1 or HSV-2); mean duration of 12 days
a. Multiple lesions
i. Male: penis, buttocks, thighs
ii. Female: labia, fourchette, cervix, buttocks, thigh, nipples
b. Myalgia
c. Arthralgia
d. Malaise
e. Fever, lymphadenopathy
f. Dysuria, male and female (urinary retention may occur, especially in women with lesions close to meatus)
g. Dyspareunia
h. Headache (can be sign of herpes meningitis)
2. Recurrent genital lesions
a. Lesions less painful
b. Less or no systemic symptoms
c. Unilateral
d. Prodromal symptoms (itching, burning, and/or tingling at site where lesions then appear)
B. Additional information to be considered
1. Genital herpes: primary infection
a. Known exposure
b. Sexual preference
c. Recent participation in oral sex with partner who has herpes labialis
2. Genital herpes: recurrent infection
a. History of recent exposure to reactivating factors: physical trauma, exposure to sunlight, stress, menses
b. Prodrome
i. Pruritus
ii. Burning at site of previous lesion(s)
iii. Tingling at site of previous lesion(s)
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iv. Symptoms as in A and B across nerve tract serving site of previous lesion(s) (i.e., sciatic pain with lesion on labia)
IV. PHYSICAL EXAMINATION
A. Genital herpes
1. Primary infection
a. Temperature, blood pressure
b. Examination of genitalia: vesicular lesions containing cloudy liquid on erythematous base. Vesicles break, lesions coalesce to form ulcerative lesions with irregular borders, macerated if in moist areas.
i. Female: lesions (painful), examination will be difficult; use of speculum may be impossible. Lesions present as described in Genital Herpes Simplex, History, III.A. Cervicitis may be present.
ii. Male: lesions (painful) present in areas previously described in Genital Herpes Simplex, History, III.A. Urethral discharge may be present.
c. Groin: Inguinal adenopathy may be present.
d. Abdomen: Bladder distension, secondary to urinary retention, may be present; more common in women.
e. Check for atypical presentation as cystitis, meningitis, encephalitis, urethritis, ocular lesions
2. Recurrent infection genital herpes
a. As previously mentioned (Genital Herpes Simplex, History, III.B.2), but clinical picture less severe
V. LABORATORY EXAMINATION (BOTH NONSENSITIVE AND NONSPECIFIC)
A. May include HSV-1 and HSV-2. Scrape lesion for samples for:
1. Virology culture with typing (within 7 days of first episode, 2 days of recurrence)—low sensitivity especially for recurrent lesions
2. Genital lesions: consider GC culture, serology test for syphilis, Chlamydia test (may need to wait until follow-up visit if infection is severe)
3. Herpes can be diagnosed through tissue culture, blood test, or antigen detection (swab or scrape a lesion).
4. HerpeSelect type-specific glycoprotein (gG) test for HSV-1 and HSV-2 can differentiate between the two types.
B. Consider HIV testing
VI. DIFFERENTIAL DIAGNOSIS
A. Syphilis
B. Chancroid
C. Lymphogranuloma inguinale
D. Granuloma inguinale
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VII. TREATMENT
A. General therapy
1. Consider immune status of patient with frequent outbreaks and/or long-duration outbreaks, plus the degree of systemic involvement
2. Consider also the potential for asymptomatic shedding
3. Comfort measures
a. Tepid water sitz baths, plain or with Betadine solution; dry carefully with cool-air hair dryer, making sure to hold it away from body
b. If voiding over lesions is painful, instruct patient to void while sitting in water in a bathtub
c. Stress avoidance of tight, restricting clothing. The vulva should be exposed to airflow as much as possible (patient may wear a skirt or robe without underpants when at home).
d. Peri-irrigation for comfort
4. Patient education
a. Explain the disease process and route of transmission to the patient (i.e., oral/genital sex during outbreaks)
i. 90% of those infected do not know they are infected
ii. Most transmissions occur without symptoms in the infected person
iii. Viral shedding occurs 5% to 70% of day
iv. Condom use protects women, not men
b. Patients should be advised to abstain from sexual activity while lesions are present
c. Explain the dangers associated with herpes during pregnancy
d. Discuss possible factors involved with recurrences
e. Discuss need for yearly Pap smear
f. Support group: alt.support.herpes (Usenet newsgroup)
B. Medication
1. Initial genital outbreak
a. Acyclovir 400 mg orally three times a day for 7 to 10 days or
b. Acyclovir 200 mg orally five times a day for 7 to 10 days or
c. Famciclovir (Famvir) 250 mg orally three times a day for 7 to 10 days or
d. Valacyclovir (Valtrex) 1 g orally twice a day for 7 to 10 days
e. Comfort measures: Xylocaine 2% gel or cream; apply three to four times daily (do not use around urethra) for comfort measure or bacitracin ointment, apply locally, for secondary infection only two to five times a day or add gramicidin, a topical antibiotic, to suppress replication of HSV-1 and HSV-2
2. Episodic therapy for recurrent infection—therapy should be initiated within 1 day of lesion onset or during prodrome
a. Acyclovir 400 mg orally three times a day for 5 days or
b. Acyclovir 800 mg orally twice a day for 5 days or
c. Acyclovir 800 mg orally three times a day for 2 days or
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d. Famciclovir 125 mg orally twice daily for 5 days or
e. Famciclovir 1,000 mg orally twice daily for 1 day or
f. Famciclovir 500 mg orally once followed by 250 mg twice daily for 2 days or
g. Valacyclovir 500 mg orally twice a day for 3 days or
h. Valacyclovir 1 g orally once a day for 5 days
3. Suppressive therapy for recurrent genital herpes: Evidence is growing showing benefits of beginning suppressive therapy with the first episode, not waiting for chronic outbreaks to be established. Safety and efficacy have been established for as long as 6 years with acyclovir and 1 year for valacyclovir or famciclovir. Early intervention will decrease recurrences during the first year when outbreaks are the most frequent as well as decrease the likelihood of viral shedding.
a. Acyclovir 400 mg orally twice a day or
b. Famciclovir 250 mg orally twice a day or
c. Valacyclovir 500 mg orally daily for persons with fewer than nine outbreaks per year or
d. Valacyclovir 1 g orally daily for persons with fewer than 10 outbreaks per year
4. Recommended regimens for daily suppressive therapy in persons with HIV
a. Acyclovir 400 to 800 mg orally two to three times a day or
b. Famciclovir 500 mg orally twice a day for 5 to 10 days or
c. Valacyclovir 1 g orally twice a day for 5 to 10 days
5. Recommended regimens for episodic infection in persons with HIV
a. Acyclovir 400 mg orally three times a day for 5 to 10 days or
b. Famciclovir 500 mg orally twice a day or
c. Valacyclovir 500 mg orally twice a day
6. Suppressive therapy in persons infected with HIV
a. Acyclovir 400 to 800 mg orally twice to three times a day or
b. Famciclovir 500 mg orally twice a day or
c. Valacyclovir 500 mg twice a day
7. In pregnancy (see CDC guidelines, 2015)
a. For first clinical episode or severe recurrent, treat with oral acyclovir
b. In life-threatening, severe maternal HSV infection, treat with intravenous acyclovir
8. Unresolved herpes are herpes outbreaks lasting several weeks or more
a. Immunologic status should be evaluated with physician consultation
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VIII. COMPLICATIONS
A. Secondary infection of lesion
B. Keratitis (keep fingers away from eyes)
C. Generalized herpetic skin eruptions
D. Meningitis
E. Encephalitis
F. Pneumonitis
G. Hepatitis
H. Fetal–neonatal infection
I. Spread to other persons at risk for developing disseminated herpes
1. Immunosuppressed or deficient individuals, including persons with HIV
2. Patients with open skin lesions (e.g., burns, atopic dermatitis)
3. Infants, small children
IX. CONSULTATION/REFERRAL
A. Secondary infections
B. Urinary retention if unable to void in bathtub
C. Suspected ocular lesion
D. Severe primary episode
E. Poor fluid intake associated with severe primary episode
F. Persistent headache, nausea, vomiting, photophobia, convulsions, pain in upper right quadrant, chest pain, shortness of breath
G. Unresolved outbreaks lasting several weeks or more
H. Life-threatening episode in pregnant women
X. FOLLOW-UP
As needed or see Appendix I for information, which you may want to photocopy or adapt for your patients.
See Bibliographies.
Websites: www.herpes.com; American Social Health Association (ASHA) booklets, books, handouts; The Helper, 800-230-6039; ASHA patient herpes hotline, 919-361-8488; www.cdc.gov/std/tg2015