Genital herpes (GH) is a chronic, recurrent, intractable sexually transmitted disease caused by herpes simplex virus (HSV) infection of the genitourinary and perianal skin mucosa, mainly through sexual contact. The incidence of genital herpes has been increasing over the last 30 years and has become the leading cause of genital ulcers in many countries and regions.
I. Etiology and pathogenesis
There are two serotypes of HSV, HSV-1 and HSV-2, which are serologically cross-reactive. Genital herpes is predominantly an HSV-2 (about 90% of cases) infection. In recent years, the proportion of HSV-1 infection has increased significantly (10%-40%) due to oral-genital sex. HSV invades the body and first replicates in epidermal keratinocytes, causing primary infection, and then HSV-2 virus is latent in the sacral ganglion for a long time, and the latent virus can be activated and recurred by the lowered resistance of the body or certain triggering factors.
Second, the transmission route
HSV-2 is present in the exudate of skin lesions, semen, prostate fluid, cervical and vaginal secretions, and is mainly transmitted through sexual contact.
Clinical manifestations
Genital herpes occurs in sexually active men and women between the ages of 15 and 45. Genital herpes occurs in the genital and perineal areas. In males, it is more common in the foreskin, glans, coronal sulcus and penis. In women, it is more common in the labia majora and minora, the mons pubis, the clitoris, and the uterus. Less common sites are the perianal area, groin, femoral buttocks and scrotum. Anal and rectal involvement is common in male homosexuals. Genital herpes is clinically divided into three types: primary, recurrent and subclinical. The severity of clinical manifestations and frequency of recurrence are influenced by factors such as virus type and host immune status.
1. Primary genital herpes
Primary genital herpes is the first infection with HSV-2 or HSV-1. The incubation period is 2-14 days, with an average of 3-5 days. The lesions are clustered or scattered small blisters that break down after 2-4 days to form vesicles or ulcers, which later crust over and heal themselves.
Self-perceived pain. It is often accompanied by inguinal lymph node swelling, fever, headache, malaise and other systemic symptoms. The duration of the disease is usually 2-3 weeks.
2.Recurrent genital herpes
Recurrent genital herpes refers to the recurrence of the disease within 1-4 months after the primary genital herpes lesions have subsided, and the lesions usually appear at the original site. The recurrent genital herpes lesions are similar to primary genital herpes, but they are milder, have a shorter duration, and are often preceded by prodromal symptoms (such as a local burning sensation, pins and needles, or abnormal sensation).
The duration of the disease is usually 7-10 days. It may recur several times at intervals of 2-3 weeks or months. In male homosexuals, the anus and rectum can be involved, manifesting as local pain, constipation, urgency, perianal ulcers, etc. Sigmoidoscopy can reveal mucosal congestion, bleeding and ulcers in the lower rectum.
3. Subclinical genital herpes
Fifty percent of HSV-1-infected patients and 70%-80% of HSV-2-infected patients lack typical clinical manifestations and are subclinical genital herpes, which is the main source of genital herpes infection. The atypical lesions of subclinical genital herpes can be manifested as tiny fissures and ulcers in the genital area, which can easily be ignored.
4. Genital herpes during pregnancy
It can cause intrauterine growth retardation, miscarriage, premature birth and even stillbirth, and the birth canal can also cause fetal infection. Genital herpes can cause a series of complications such as disseminated HSV infection, viral meningitis and pelvic inflammatory disease. In HIV-endemic areas, genital herpes increases the risk of HIV infection, while HIV infection exacerbates the prevalence and condition of genital herpes. HSV-2 may play a synergistic role in the development of cervical cancer.
IV. Diagnosis and differential diagnosis
Genital herpes is diagnosed mainly based on medical history (history of sexual contact or spousal infection, etc.), typical clinical manifestations, and laboratory tests if necessary. Genital herpes should be differentiated from contact dermatitis, herpes zoster and leukoplakia.
V. Treatment plan
Patients with genital herpes should take rest and avoid alcohol consumption and excessive sexual activity. Sexual intercourse should be avoided when clinical manifestations appear. If genital herpes is active during pregnancy before delivery, a caesarean section should be performed.
1. Internal drug treatment
Nucleoside analogues are currently considered to be the most effective anti-HSV drugs.
Primary form
Acyclovir 200mg per dose, 5 times a day, or 400mg per dose, 3 times a day orally; or valacyclovir 1000mg per dose, 2 times a day orally; or famciclovir 250mg per dose, 3 times a day orally. The duration of treatment is 7-10 days.
Relapsing type
Intermittent therapy is used, preferably starting within 24 hours of the onset of prodromal symptoms or lesion appearance. Acyclovir 200mg 5 times a day or 400mg 3 times a day orally; or valacyclovir 500mg 1-2 times a day orally; or famciclovir 125mg twice a day orally. The course of treatment is usually 5 days.
Frequent relapses (more than 6 relapses in 1 year)
In order to reduce the number of relapses, daily suppressive therapy can be used, i.e. acyclovir 400mg orally 3 times daily, or famciclovir 500mg orally once daily, or famciclovir 250mg orally twice daily. Generally, 6-12 months of continuous oral dosing is required.
Severe symptoms of primary infection or extensive skin lesions
Acyclovir 5-10mg/(kg-d) in 3 doses. The course of treatment is usually 5-7 days.
2.Treatment with topical drugs
The affected area should be kept clean and dry. The lesions can be treated with topical 3% acyclovir ointment, 1% penciclovir cream and phthalamide cream, etc.