Genital herpes is a sexually transmitted disease caused by herpes simplex virus infection of the mucous membrane of the genital skin of the vulva and anus. The herpes simplex viruses that cause genital herpes are HSV-1 and HSV-2. HSV can cause genital herpes, but it can also be transmitted to the newborn through the birth canal during delivery, causing HSV infection in the newborn.
I. Diagnosis
1. Epidemiological history: history of unsafe sex, multiple sexual partners or sexual partner infection.
2, clinical manifestations.
(1) Primary genital herpes: It refers to the first appearance of clinical manifestations of genital herpes. Primary genital herpes can be a primary genital herpes or a non-primary infection.
(2) Recurrent genital herpes: the first recurrence occurs mostly 1-4 months after the primary infection. The frequency of recurrence varies widely among individuals, with an average of 3-4 times per year and up to 10 times per year. Most of them have prodromal symptoms a few hours to 5 d before the onset of the rash, manifested as local itching, burning, tingling, vague pain, numbness and perineal swelling. The lesions are small in number and are clusters of small blisters that quickly break down to form vesicles or superficial ulcers with asymmetric distribution and mild local pain, itching, and burning sensation. The duration of the disease is often 6-10 d, and the lesions mostly heal within 4-5 d. Systemic symptoms are rare, and there is no inguinal lymph node enlargement.
(3) Subclinical infection: HSV infection without clinical signs and symptoms. However, asymptomatic detoxification exists and may be infectious.
(4) Atypical or unrecognized genital herpes: atypical lesions may be nonspecific erythema, fissures, sclerosis (or boils), folliculitis, skin abrasions, and erythematous foreskin ooze.
(5) Special types of genital herpes.
3. Laboratory tests.
(1) Culture method: positive cell culture for HSV.
(ii) antigen detection: enzyme-linked immunosorbent assay or immunofluorescence test for positive HSV antigen.
③Nucleic acid detection: PCR and other tests for positive HSV nucleic acid. Nucleic acid testing should be carried out in laboratories accredited by relevant institutions.
(iv) Antibody testing: positive HSV-2 type-specific serum antibody test. In addition, type-specific serologic diagnostic tests can detect serum antibodies to different HSV types and can be used as an aid in the diagnosis of the lesion-free phase in patients with recurrent genital herpes, as well as in the determination of the HSV infection status of the patient’s sexual partners and as an aid in the diagnosis of atypical genital herpes. The detection of IgM antibodies of different types in the serum indicates a first infection with that type of HSV, and only in the presence of recent infection. In contrast, IgG antibodies persist for a longer period of time and their positivity is more suggestive of HSV infection, especially as an aid to diagnosis in patients without obvious skin lesions. However, the sensitivity and specificity of different reagents vary greatly, and the test results cannot be used as a basis for confirming the diagnosis of cases at present.
4.Diagnostic classification: clinical diagnosis cases: consistent with clinical manifestations, with or without epidemiological history. Confirmed cases: meet both the requirements of clinical diagnosis and any 1 of the laboratory tests.
II. Treatment
(i) General principles: Asymptomatic or subclinical genital HSV infection usually does not require drug treatment. Treatment for symptomatic patients includes both systemic treatment and local management. Systemic treatment is mainly antiviral therapy and treatment of co-infection, while local treatment includes cleaning the wound and preventing secondary infection. As genital herpes is very prone to recurrence, it often brings psychological stress to patients, causing tension, depression or anxiety, which in turn can affect the natural course of the disease. Therefore, comprehensive treatment measures such as medical counseling, psychosocial counseling, and medication should be given in the early stages of the disease in order to reduce recurrence of the disease. All patients infected with genital herpes should be tested for syphilis and HIV.
(ii) Treatment options.
1.Systematic antiviral therapy.
(1) Recommended regimen for primary genital herpes: oral acyclovir 200mg 5 times daily for 7-10d; or acyclovir 400mg 3 times daily for 7-10d; or valacyclovir 500mg twice daily for 7-10d; or famciclovir 250mg 3 times daily for 7-10d.
(2) Herpetic proctitis, stomatitis or pharyngitis: increase the dose or extend the course of treatment to 10-14d as appropriate.
(3) Disseminated HSV infection: Acyclovir 5-10mg/kg intravenously every 8 hours for 5-7d or until clinical manifestations disappear. In patients with impaired renal function, the dosage of acyclovir should be adjusted according to the degree of renal damage.
(4) Intermittent therapy for recurrent genital herpes: It is used in case of recurrence to reduce the severity of the disease, shorten the duration of recurrence and reduce virus excretion. Intermittent therapy is best used when the patient has prodromal symptoms or within 24 h of the onset of symptoms. Recommended regimen: oral acyclovir 200 mg five times daily for 5 d; or acyclovir 400 mg three times daily for 5 d; or valacyclovir 500 mg twice daily for 5 d; or famciclovir 250 mg three times daily for 5 d.
(5) Frequent recurrence of genital herpes (more than 6 recurrences per year): long-term suppressive therapy can be used. Recommended regimen: oral acyclovir 400mg twice daily; or valacyclovir 500mg once daily; or famciclovir 250mg twice daily. Long-term continuous dosing is required, and the duration of treatment is usually 4-12 months.
(6) Genital herpes in pregnancy: In pregnant women, the safety of drugs such as acyclovir has not been clarified, and if they are to be used, the pros and cons should be weighed and the patient’s informed consent should be obtained. It is currently believed that acyclovir can be given orally in pregnant women with first-episode genital herpes; in those with complications, acyclovir should be administered intravenously. In pregnant patients with frequent recurrent or recent genital herpes infections, the rate of cesarean delivery can be reduced by continuous acyclovir treatment during the last 4 weeks of pregnancy to reduce the appearance of active damage. Acyclovir treatment may be dispensed with in pregnant women with a previous history of recurrent genital herpes and no signs of recurrence at the time of the last full term. In pregnant women with active lesions or prodromal symptoms, cesarean section may be performed before rupture of membranes, provided there are no contraindications, but cesarean section does not completely prevent neonatal herpes. Pregnant patients without active lesions may be delivered vaginally, but their newborns are closely monitored after delivery for fever, lethargy, sucking power during breastfeeding, convulsions, or occurrence of lesions for prompt management. The chance of mother-to-child transmission of primary genital herpes at the end of pregnancy is 10 times greater than that of recurrent genital herpes; therefore, prevention of primary genital herpes infection at the end of pregnancy should be performed in pregnant women who are serologically negative, i.e., who have never been infected with herpes virus. Preventive measures include abstaining from sexual intercourse in late pregnancy, avoiding oral sex, or using condoms throughout sexual intercourse.
2, local treatment: local lesions can be cleaned with physiological sodium chloride solution or 3% boric acid solution, to keep the affected area clean and dry. Topical application of 3% acyclovir cream or 1% penciclovir cream, etc., but the efficacy of local treatment alone is far inferior to the systemic use of drugs.
3, follow-up and prognosis: for patients with initial genital herpes, after treatment, systemic symptoms disappear, lesions recede, local pain, abnormal sensation and lymph node enlargement disappears, that is, clinical cure. However, the disease is prone to recurrence, especially within 1 year after the initial infection, which is more frequent. Genital HSV-2 infection is more likely to recur than HSV-1 infection. There is a tendency for recurrence to decrease as the course of the disease is delayed. Patients with clinical episodes have subclinical or asymptomatic detoxification, and most sexual and vertical transmission of genital herpes occurs during subclinical or asymptomatic detoxification. Recurrence of genital herpes is associated with a number of triggering factors; alcohol consumption, spicy food, fatigue, cold, anxiety, stress, sexual intercourse, and menstruation are common triggers. Regular lifestyle habits, proper physical exercise, good psychological status and avoidance of triggering factors are important measures to reduce and prevent recurrence. The purpose of follow-up visit is to provide further health education and consultation to patients, and the next treatment medication can be considered to be provided to patients at the follow-up visit so that they can take the medication within 24h of prodromal symptoms or attacks.
(iii) Prevention.
1. Health education.
(1) Emphasize informing their sexual partners of their condition, obtaining their understanding and cooperation, and avoiding sexual contact at the time of recurrent prodromal symptoms or the appearance of skin lesions, or better still, using barrier contraception to reduce the risk of HSV transmission to sexual partners.
(2) Promote barrier contraception such as condoms, which can reduce the risk of genital herpes transmission, but sexual intercourse at the time of lesion appearance may occur with HSV transmission even with condoms.
(3) Changing sexual behavior, avoiding non-marital sex, and eliminating multiple sexual partners are the fundamental measures to prevent genital herpes.