Vulva Herpes Simplex Virus

Herpes simplex virus (HSV)

Herpes simplex viral infection is the most common sexually transmitted disease in the world and the commonest cause of vulvar ulcers.

Both herpes simplex virus I and II can cause vulvar infections; HSV II is the usual cause. HSV I, usually an oral infection, is now not uncommonly found in the genital area. Herpes simplex II is predominantly sexually transmitted and present in 20% of the population over 12 years of age in the United States. Spread is usually from contact with an asymptomatic partner. Women are more susceptible to infection than men. The recurrence rate for HSV II is 89% and for HSV I is 45%.

91% of HSV II positive women carriers are unaware of their infection. 80% of these women have symptoms, self-misdiagnosed as yeast infection? vaginitis, clothing irritation, urinary tract infection (cystitis), soap allergy, poor lubrication, and hemorrhoids.

Most women present with recurrent HSV and no primary HSV history.

Clinically HSV infection can present three ways: i. The classic primary pattern shows a red swollen vulva and extensive groups of vesicles that rapidly become pustular and break down leaving open, tender, red erosions. This will last 14-16 days. It can be anywhere on the labia, vaginal vestibule, perineum, vagina or cervix. The less common primary pattern onsets with fever, malaise, bilateral extensive generalized vesicles and ulcers with severe pain and dysuria. It can be so uncomfortable that catheterization is necessary. Fever, chills and myalgia may accompany this eruption and the duration can be two weeks.

ii. Recurrent HSV infection of the vulva usually involves a prodrome with itching and tingling. Less frequently, pain and burning precedes the onset of shallow blisters that rapidly break down leaving small groups of erosions. Small fissures may be the only manifestation. Duration is about 5 days. Recurrence with menstrual periods may occur.

iii. Immunosuppressed patients with HSV present with atypical large, open, non-healing eroded or ulcerated areas that are necrotic, painful and indolent, and may last many months.

Diagnosis is made by culture; smear for direct immunofluorescence, type specific serology or, less commonly, polymerase chain reaction (PCR).

Treatment involves emotional support. For primary HSV: Valacyclovir 1g bid for 7 days or Famciclovir 500 mg bid for 7 days. For recurrent HSV: Valacyclovir 500 mg bid for 3 days or valacyclovir 2g STAT, repeated once in 12 hours or famciclovir 125 mg bid for 5 days For chronic HSV or to stop asymptomatic viral shedding :Valacyclovir 1g daily or Valtrex 500 qd, or Famciclovir 250 mg bid. Always rule out other sexually transmitted diseases.