Topic Tuesday: HSV-2

By June 10, 2014 Topic Tuesday No Comments

Herpes is a common and usually mild recurrent skin condition caused by a virus: the herpes simplex virus (HSV). Here’s some good news: herpes is not life-threatening nor does it destroy your immune system

HSV is in a family of viruses called “herpesviruses.” There are eight human herpesviruses. (I know it looks like a typo, but actually medical texts refer to herpesvirus as one word.) Also, every animal species that has been studied has its own herpesvirus: cat, carp, elephant, horse. What these viruses all have in common is the ability to hide in the body without causing symptoms, and then reappear at a later time.

The human herpesvirus family includes the Epstein-Barr virus, often abbreviated to EBV (the cause of mono), the varicella virus (the cause of chicken pox) and zoster (the cause of shingles).

Although there are several viruses in the herpesvirus family, each is a separate virus and each is different. Having one virus does not mean you will have another.

There are two types of herpes simplex viruses: herpes simplex virus type-1 (HSV-1) and herpes simplex virus type-2 (HSV-2).

The majority of oral herpes cases are caused by HSV-1 and the majority of genital herpes cases are caused by HSV-2; however, type-1 or type-2 can occur in either the genital or oral area.

Genital Herpes

Genital herpes is a sexually transmitted disease. It can cause sores in the genital area and is transmitted through vaginal, oral or anal sex, especially from unprotected sex when infected skin touches the vaginal, oral or anal area. Occasionally, it can cause sores in the mouth and can be spread by secretions in saliva. Because the virus does not live outside the body for long, you cannot catch genital herpes from an object, such as a toilet seat.

How Do You “Catch” It?

HSV-2 is spread by direct skin-to-skin contact, including vaginal, anal and oral sex. The virus can be passed whenever it is present on the skin, even right before an outbreak when no symptoms are present. Simplex-1 can be passed to the genitals and simplex-2 can be passed to the mouth during oral sex.

What Are the Signs and Symptoms of Genital Herpes?

While some people realize that they have genital herpes, many do not. It is estimated that one in five people in the United States has genital herpes; however, as many as 90% are unaware that they have the virus. This is because many people have very mild symptoms that go unrecognized or are mistaken for another condition or no symptoms at all.

A person may show symptoms within days after contracting genital herpes or it may take weeks, months or years. Some people may have a severe outbreak within days after contracting the virus while others may have a first outbreak so mild that they do not notice it. Because of these possibilities, it can be difficult for people to know when and from whom they may have contracted the virus.

Someone with genital herpes may first notice itching, tingling or burning and pain or soreness in the buttocks, legs and groin areas. This is followed by small red bumps that appear at or near where the virus entered the body. These bumps turn into blisters or open sores a few hours to a few days later. The “classic” symptoms that most people associate with genital herpes are these sores, vesicles, or ulcers – all of which can also be called “lesions.” (The scientific literature on herpes uses the term “lesion” to describe any break or irregularity in the skin.) These classic lesions of genital herpes often resemble small pimples or blisters that eventually crust over and finally scab like a small cut. These lesions may take anywhere from two to four weeks to heal fully. Here’s the good news: they eventually do scab over and heal without leaving any scars.

The sores, which may appear on the vagina, penis, scrotum, buttocks or anus, start out as red bumps that soon turn into red, watery blisters. The sores might make it very painful to urinate. They may may open up, ooze fluid or bleed. The entire genital area may feel very tender or painful and there may be flu-like symptoms including fever, headache and swollen lymph nodes.

More good news:

If future outbreaks occur, they tend to be less severe and shorter in duration, with sores healing faster. The future outbreak can also include swollen glands, muscle aches, headache, fever, painful or difficult urination and nausea. Although symptoms can be so mild that people do not notice their future outbreaks at all.

For many people, herpes lesions can so mild that they may be mistaken for:

  • insect bites
  • abrasions
  • yeast infection
  • “jock itch” and other conditions
How Long Until Symptoms Appear?

When a person is first infected, the immune response is not well developed and the virus is able to multiply more rapidly and in more places than it can later. Signs and symptoms during a first episode can be quite pronounced. Someone who has been exposed to genital herpes will notice genital itching and/or pain about 2 to 20 days after being infected with the virus. The sores usually appear within days afterward and may last for 2 to 4 weeks.

During this time, some people will experience a second crop of lesions, and some will have flu-like symptoms including fever and swollen glands, particularly in the lymph nodes and groin.

However, some people with genital herpes do not get symptoms or have a first episode so mild they don’t even notice it. In other cases, the first outbreak may happen years after the virus is picked up. Or, it may be a later episode, known as “reactivation,” that is first noticed months or years later.

Herpes is different from other common viral infections in that it sets up a lifelong presence in the body, called “latency.” The virus can travel the nerve pathways in a particular part of the body and hide away, virtually sleeping, in the nerve roots for long periods of time. This means that even though HSV may not be causing “cold sores” or genital signs and symptoms at a given time, it can still cause symptoms later.

Does It Recur?

It does. But if you have recently made it through a first episode that consisted of full-blown symptoms, you know something about signs and symptoms already. The good news is that the first episode is almost always the worst that HSV throws your way. Signs and symptoms of recurrent episodes (when they occur) tend to be milder and heal much more quickly, typically within two to twelve days.

If the first episode produced fairly mild symptoms, then subsequent recurrences will not usually increase in severity. But, as noted earlier, the first episode doesn’t always cause recognizable signs and symptoms. Some people have recurrent outbreaks with the so-called “classic” blister-like herpes lesions that crust over, or with painful sores. More good news: In recurrent herpes, however, this process usually takes about half the time it does in first episodes. In addition, many people have very subtle forms of recurrent herpes that heal up in a matter of days. And lastly, herpes is capable of reactivating without producing any visible lesions (asymptomatic reactivation).

Research suggests that reactivation is influenced by HSV type and how long one has been infected. People with a marked first episode caused by HSV-2 can expect to have several symptomatic recurrences a year. The average is four or five. Some may not be recognizable. In most cases, the first year has the most viral activity.

HSV-1 behaves quite differently in the genital area. People with HSV-1 in the genital area may have a marked first episode but are much less likely to have outbreaks in the first year. Their average number of symptomatic recurrences is closer to one per year and their rates of unrecognized recurrences are lower as well.

What Triggers a Herpes Outbreak to Recur?

Herpes “triggers” (determining exactly what leads to an outbreak) are highly individual, but with time, many people learn to recognize, and sometimes avoid, factors that seem to reactivate HSV in their own bodies.

It occurs on the same part of the body but is not as severe. It may simply be a temporarily itchy area. What one can say with confidence is that, in general, recurrent attacks become less frequent and less severe as time goes by.

As for the reasons for recurrences, it is not really known, but based on research, there is agreement on some predisposing factors associated with outbreaks:

      • Prolonged exposure to strong sunlight or ultra-violet light can trigger (usually) oral herpes.
      • Trauma: surgical trauma and steroidal medication (such as asthma treatment)
      • Friction in the genital area: some people (and this is pretty rare) find that they get recurrences following sex.
      • Stress (emotional or physical): enough people with herpes believe that stress is involved to give it credence as a provoking factor.
      • High fever and illness
      • Poor diet

The frequency of outbreaks can often be managed through effective stress management and getting adequate rest, nutrition and exercise. For people with frequent outbreaks, suppressive (daily) therapy with any one of the antiviral treatments can reduce outbreaks by as much as 80%.

What Are the Warning Signs of a Reactivation Outbreak of Genital Herpes?

In the early phase of genital herpes reactivation (also called an outbreak) many people experience an itching, tingling or painful feeling in the area where their recurrent lesions will develop. This sort of warning symptom is called a “prodrome” and often comes a day or two before lesions appear. To be on the safe side, it’s best to assume that the virus is active (and, therefore, can be spread through direct skin-to-skin contact) during these times.

Where Do These Symptoms Appear?

When a person has genital herpes, the virus lies dormant (sleeps) in the bundle of nerves at the base of the spine. When the virus reactivates (wakes up), it travels nerve paths to the surface of the skin, sometimes causing an outbreak. The nerves in the genitals, upper thighs and buttocks are connected; therefore, a person can experience outbreaks in any of these areas. Such areas include the vagina or vulva, penis, scrotum or testicles, buttocks or anus, or thighs.

Genital herpes, regardless of whether it is HSV-1 or HSV-2, does not cause symptoms on the mouth or face.

But What if You Don't See Any Lesions or Have Other Symptoms?

In some studies, people with herpes were completely unaware of lesions about one-third of the time that the virus was found to be active in the genital area. While recognizing lesions and other symptoms is important, this cannot always tell you when the virus is active.

Confusingly, someone who was unknowingly infected in the past may suddenly develop symptoms for the very first time, maybe years later. This resembles a recurrence, rather than a primary attack, that is not as bad.

It used to be thought that all of HSV’s active times were marked by “outbreaks” such as a sore, blister or some kind of symptom like an itch. Then researchers learned that the virus could become active without causing signs or symptoms. This phenomenon has been called a number of things, including “asymptomatic shedding” and “subclinical shedding.” But the best term for it might simply be “unrecognized” herpes. Even if you’re a person with recurring signs and symptoms that you can usually recognize as herpes, there are almost certainly days when you won’t be aware that the virus has reactivated and traveled to the skin or mucous membranes.

How is Genital Herpes Treated?

Since herpes is a virus, there is no cure. There are however treatments which can decrease the pain and length of the outbreaks. There are two types of treatments: episodic and suppressive.

Episodic therapy means taking medication during an outbreak to speed healing. That means you would begin taking medicine at the first sign of a prodrome and continue for five days. It doesn’t suit everybody but, for those with a reliable warning of an attack, it works well and avoids continuous suppressive therapy. But listen up, once a recurrence has started, and the outbreak appears, acyclovir or other anti-herpes drugs have no significant effect on the severity or length of the attack.

Suppressive therapy means taking antiviral medication every day to hold HSV in check so that it’s less likely to flare up and cause symptoms. It is designed to stop recurrences. This greatly reduces the number of outbreaks for most people and can prevent outbreaks altogether for some. It can also greatly reduce asymptomatic shedding (the recurrence of virus on the skin). Studies are underway to find out whether antiviral medication can help prevent transmission. People have taken it for many years without side effects or complications. However, most people with herpes don’t feel the need to take medication because their outbreaks are relatively mild. The virus is killed with soap and water.

In the old days, Acyclovir (Zovirax) use was limited by cost, but when the patent ran out in the ‘90’s, copies of acyclovir became available at a greatly reduced price allowing for much more widespread use, in particular for suppressive therapy.

Valacyclovir (Valtrex) uses acyclovir as its active ingredient but is better absorbed by the body and can be taken less often.

Famciclovir (Famvir) works much the same way acyclovir does but is also better absorbed and can be taken less often.

All three are effective. All three drugs work by disrupting the virus’ ability to reproduce. All are safe and have virtually no side effects.

No vaccines against herpes have been shown to be effective.

How is It Diagnosed?

If an active sore is present, the virus can be cultured or seen using an electron microscope. Specific herpes DNA tests may differentiate between HSV-1 and HSV-2. Finally, blood tests can detect whether an infection has been caught in the past and whether it is type-1 or 2, or both. However, unless the infection is really very recent, when a different and transient sort of antibody is found, the blood test cannot tell for how long the infection has been present.

How Likely are You to Pass on Herpes?

If someone who already has HSV-1 is exposed to their sexual partner’s herpes virus, as long as it is also type-1, no reinfection will occur. You cannot catch the same virus twice! It is true that there exists a small minority of people who are infected with both 1 and 2, but they remain a small minority.

How Is It Prevented?

The only surefire way to prevent genital herpes is abstinence. Those who do have sex must properly use a latex or polyurethane condom every time they have any form of sexual intercourse (vaginal, oral, or anal sex).

Genital Herpes and Pregnancy

There is a risk of transmission to the newborn if the mother suffers a primary attack. The attack needs to be primary and in the last few weeks of pregnancy. A recurrent attack is not an equivalent risk at childbirth.

Probably the most important factor is in the transfer of antibodies from the mother to the baby across the placenta. Along with oxygen and nutrients, the placenta also transmits a ready-made immune package full of antibodies to all the infections the mother has ever suffered from, including this year’s common cold, last year’s flu and most importantly, her HSV-1 or 2. This passive immunity is quite enough to prevent any serious infection taking hold in the baby. Secondly, there are fewer virus particles in a recurrent episode than a primary attack.

There have been several studies showing that even when there are genuine herpetic sores on the vulva at the time of delivery, the baby does not develop infection. Most authorities agree that caesarean section is not necessary under these circumstances.

Some Interesting Facts
  • Women are more likely to be infected than men;
  • Gay men more than straight;
  • American more than British;
  • African more than European;
  • European more than Indian subcontinent.
  • Type-1 has a better outlook, in terms of genital recurrences, than type-2.
  • There are one million new infections per year.
  • 45 million people are currently living with it.
  • By the age of 25, at least 80% of people worldwide have been infected with either 1 or 2.
  • Herpes is not life-threatening nor does it destroy your immune system.
Resources

DISCLAIMER: The information contained in this post is intended to inform readers and is not intended to replace specific advice from a health care professional.