Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Herpes Simplex Type 2
HERPES SIMPLEX TYPE 2
One of the most common sexually transmitted diseases characterized by painful vesicular lesions of the genitals. It represents an acute infection or reactivation of latent herpes.
I. Etiology
A. Herpesvirus hominis type 2 (HSV-2); occasionally type 1 (HSV-1), especially in primary infections
B. Although either can be found at either site, 75% of type 1 (HSV-1) infections involve the face and skin above the waist; 75% of type 2 (HSV-2) infections involve the genitalia and skin below the waist.
C. HSV-2 persists in a latent form following infection. Reactivation occurs in about 80% of cases with variable and unpredictable frequency. Recurrence rates are higher for genital herpes after primary HSV-2 genital herpes than after HSV-1. Recurrence rate generally decreases after the first year.
II. Incidence
A. Primarily seen beyond the age of puberty
B. One of the most common sexually transmitted diseases
C. Twenty-two percent of adults in USA have HSV-2 antibodies.
III. Incubation
A. 3–12 days following exposure. Maximum may be as long as several weeks; minimum is 32 hours.
B. Recurrent herpes: 24 hours following precipitating cause
IV. Communicability
A. Primary infection: 15 to 42 days
B. Recurrent infection: 6 days
C. Virus is present in the lesions during the prodromal period and is highly contagious during prodrome. Asymptomatic shedding is a major epidemiologic problem.
V. Subjective data
A. Primary infection
1. Tenderness of genital area prior to appearance of lesions
2. Lesions on vulva or penis
3. Severe pain in genital area
4. Swollen glands
5. Fever may be present with associated symptoms of headache, malaise, and myalgia.
6. Discharge from lesions of vulva or penis
7. Inability to void or burning and stinging on urination
8. May have lesions or “sores” at other sites
B. Recurrent infection
1. Burning or tingling sensation of several hours duration prior to appearance of lesions
2. Lesions are less painful than in primary infection; may be pruritic
3. Urethral or vaginal discharge
4. Lesions are fewer in number than in primary infection and are generally external.
VI. Objective data
A. Primary herpes
1. Edema, erythema, and exquisite tenderness of vulva or penis. Uncircumcised males may present with more severe involvement.
2. Multiple discrete or grouped vesicular lesions with subsequent erosion in 1 to 3 days, producing gray-white ulcerations
3. Lesions are found on the labia, vagina, and cervix in females and external genitalia in males.
4. Lesions may occur at other sites from autoinoculation: On buttocks, thighs, fingers, pharynx, conjunctiva.
5. Malodorous discharge from vagina or penis
6. Tender inguinal adenopathy
7. Bladder may be distended.
8. Presence of yellow or golden crust on older lesions suggests bacterial infection.
B. Recurrent herpes
1. Discrete or clustered vesicles on an erythematous base; lesions are generally external.
2. Mucoid discharge in cervical, vaginal, or urethral involvement
3. Inguinal adenopathy not a significant finding
VII. Assessment
A. Diagnosis is generally made from the history and typical appearance of the lesions. There may be a history of exposure. If diagnosis is in doubt, a culture of the vesicle fluid may be done.
B. Differential diagnosis
1. Traumatic lesions
2. Scabies
3. Chancroid
VIII. Plan
A. There is no prophylaxis or cure for herpes simplex type 2; treatment is aimed at pain control and prevention of new lesions.
B. Topical: 5% acyclovir ointment (Zovirax) 6 times a day for 1 week. Begin therapy within 6 days of onset.
C. Sitz baths; cool Burow’s solution compresses 10 minutes qid.
D. Dry heat (hair dryer)
E. With urinary retention, advise females they may void with less pain while in the tub. (Catheterization may be necessary.)
F. Topical anesthetics
1. Benzocaine aerosol as needed or
2. Lidocaine jelly 2% qid
G. Betadine 1% tid–qid; apply with cotton balls.
H. Zovirax capsules: For primary herpes or to shorten duration of recurrent episodes
1. Primary herpes: 200-mg capsule 5 times a day every 4 hours for 10 days
2. Recurrent herpes: 200-mg capsule 5 times a day every 4 hours for 5 days. Initiate therapy at first sign of recurrence.
3. Chronic suppressive therapy for recurrent herpes: 400-mg capsule bid for up to 12 months
a. Decreases duration of lesions and viral shedding.
b. Increases rate of aborted recurrences.
4. Dosages are for children over 40 kg. or
I. Valtrex
1. Primary herpes: 1 g every 12 hours for 10 days
2. Recurrent herpes: 500 mg every 12 hours for 5 days
3. Chronic suppressive therapy for recurrent herpes: 500 mg every 24 hours
4. Check current recommendations. Dosage must be adjusted according to patient’s creatinine clearance.
J. Analgesics: Tylenol or NSAIDs may not be adequate for pain control. Opiates may be indicated for first 24 to 72 hours.
1. Tylenol 3: 1 to 2 tablets every 4 hours prn or
2. Ultram 50 mg: 50 to 100 mg every 4 to 6 hours (maximum 400 mg/d)
K. Mupirocin or bacitracin to prevent bacterial superinfection.
L. Treatment should include evaluation for other sexually transmitted diseases.
IX. Education
A. Avoid indiscriminate sexual practices.
B. Avoid sexual contact with person with active lesions. Genital ulcers are of particular concern because they provide a portal of entry for the HIV virus.
C. Virus is shed during prodrome and can also be shed when entirely asymptomatic.
D. There is no prevention (other than safe sex) or cure for herpes simplex type 2.
E. Zovirax ointment will help decrease healing time and in some cases, decrease the duration of viral shedding and duration of pain. It will not prevent transmission of the virus to other people or prevent recurrences.
F. Oral Zovirax shortens the viral shedding time. In some patients, it may decrease the duration of pain and new lesion formation. With frequent recurrences (six or more episodes a year), administration of Zovirax may prevent or reduce severity or frequency of recurrences.
G. Side effects from Zovirax are generally mild and include nausea, diarrhea, headache, and rash.
H. Although benzocaine aerosol may be used frequently for comfort, caution patient that it may be a skin sensitizer.
I. If herpes simplex type 1 caused initial attack, recurrences are unlikely to occur in genital area.
J. Pap smear should be done yearly because of increased incidence of dysplasia and carcinoma of cervix.
X. Complications
A. Secondary infection
B. Urinary retention
C. Constipation with anorectal infection.
XI. Follow-up
A. Call stat if unable to void.
B. Return if question of secondary infection.
C. Annual Pap smears
XII. Referral
A. Pregnant woman
B. Patient with urinary retention
C. Immunocompromised patient.
D. Ocular involvement