Cutaneous HSV infections present as grouped vesicles on an erythematous base with burning pain, evolving to erosions and crusts. HSV-1 commonly affects orolabial areas; HSV-2 is more often genital, though sites overlap due to changing epidemiology. Primary infection may be systemic; recurrences are milder and triggered by stress, illness, UV, or procedures. Antivirals shorten duration and reduce transmission; suppressive therapy benefits frequent recurrences and certain high-risk contexts.
Epidemiology and Transmission
- HSV-1 seroprevalence remains high; increasing role in genital herpes in many regions.
- Transmission via contact with infected secretions/lesions; asymptomatic shedding common.
- Occupational exposures: wrestlers (herpes gladiatorum), healthcare workers (herpetic whitlow historically).
Clinical Syndromes
- Orolabial HSV: herpes labialis (cold sores) at vermilion border; prodrome of tingling/burning followed by vesicles that crust in 7–10 days.
- Primary gingivostomatitis (children): diffuse oral ulcers, fever, lymphadenopathy.
- Genital HSV: painful vesicles/ulcers, dysuria, tender inguinal nodes; recurrent outbreaks at same site.
- Extragenital:
- Herpes gladiatorum: clustered lesions on face/neck/torso in contact athletes.
- Herpetic whitlow: painful vesicles on fingers; healthcare or autoinoculation.
- Eczema herpeticum (Kaposi varicelliform eruption): disseminated HSV in patients with atopic dermatitis or barrier disorders—emergency; requires systemic antivirals.
- Herpes keratitis: ocular pain, photophobia, dendritic ulcers—ophthalmology emergency.
Differential Diagnosis
- Aphthous ulcers, impetigo, varicella/zoster, syphilis chancre, chancroid, fixed drug eruption, hand-foot-mouth disease, contact dermatitis.
Diagnosis
- Clinical for typical recurrent lesions.
- Confirm with PCR/NAAT from swab of fresh lesion; culture less sensitive; type-specific serology for epidemiology/counseling when lesions absent.
Management
- Episodic therapy (start at prodrome or within 24 hours)
- Orolabial:
- Acyclovir 400 mg five times daily × 5 days, or
- Valacyclovir 2 g twice in one day (12 hours apart), or
- Famciclovir 1500 mg single dose.
- Genital:
- Acyclovir 400 mg tid × 5–10 days (primary), 800 mg bid × 5 days (recurrent), or
- Valacyclovir 1 g bid × 7–10 days (primary), 500 mg bid × 3 days (recurrent), or
- Famciclovir regimens (e.g., 1 g bid × 1 day for recurrent).
- Suppressive therapy (frequent recurrences, severe disease, transmission reduction)
- Genital HSV:
- Acyclovir 400 mg bid, or valacyclovir 500 mg qd (less frequent) to 1 g qd, or famciclovir 250 mg bid.
- Valacyclovir 500 mg daily reduces transmission in discordant couples.
- Orolabial: consider in frequent outbreaks or occupational risk (athletes).
- Severe/complicated disease
- Eczema herpeticum, immunocompromised, severe mucocutaneous disease: oral or IV acyclovir depending on severity; admit if extensive or systemic.
- Acyclovir resistance (immunocompromised): suspect with progression on therapy; use foscarnet or cidofovir per specialist.
- Adjuncts and prevention
- Analgesics; topical anesthetics for oral pain; maintain hydration in children.
- Avoid contact during active lesions; condoms reduce but do not eliminate transmission; daily suppressive therapy lowers shedding.
- Triggers: minimize UV exposure, stress management; consider prophylaxis around procedures (e.g., cosmetic lasers) with valacyclovir.
- Special populations
- Pregnancy:
- Primary genital HSV in late pregnancy poses high neonatal risk; obstetric management includes antivirals and consideration of cesarean delivery with active lesions.
- Suppressive acyclovir/valacyclovir from 36 weeks reduces outbreaks at delivery.
- Neonatal HSV: presents with skin/eye/mouth disease, CNS, or disseminated infection—urgent IV acyclovir.
References (recent guidelines and reviews)
- CDC STI Treatment Guidelines and updates, 2021–2024.
- RCTs of high-dose single-day valacyclovir/famciclovir for orolabial/genital HSV, 2021–2024.
- Eczema herpeticum and immunocompromised HSV management reviews, 2022–2024.
- Transmission reduction with suppressive valacyclovir studies, updates through 2024.