| KEY POINTS |
|---|
| Genital herpes in childhood is less common than in adulthood, but can occur. |
| Genital herpes has been reported in <1% of sexually abused children.(1) |
| When assessing a child or young person with genital ulcers, the diagnosis of herpes simplex virus (HSV) infection should be considered, but not presumed. |
| Ulcers can occur as a manifestation of aphthosis in response to acute illness.(2) The appearance of aphthous genital ulcers is usually preceded by a history of fever, malaise and headache, but the results of polymerase chain reaction (PCR) testing (including HSV PCR) are negative. |
| Epstein-Barr virus and cytomegalovirus infections have also been reported to cause genital ulceration. |
| Any genital ulcers should be swabbed before decisions are made about management. |
| HSV Type 1 (HSV-1) and HSV Type-2 (HSV-2) infections in the genital or anal area can be spread via non-sexual or sexual transmission. Interpretation of these infections might require additional information. |
| All children with suspected genital herpes infection should be referred for specialist assessment and management. |
Pre-adolescent children
Occurrence and transmission
HSV infection that can be spread by nonsexual as well as sexual transmission. When preadolescent children present with genital herpes infection it is important to carefully determine the aetiology of the infection. Possible sources of transmission include an orolabial lesion or a herpetic whitlow in another family member, and autoinoculation. Additional information, such as the child's history of oral HSV lesions, can help to clarify the likelihood of sexual transmission. If an obvious source of infection cannot be identified, then sexual transmission should be considered.
Diagnosis
A diagnosis of HSV infection must be confirmed by HSV PCR testing, including HSV typing. The presence of HSV-1 does not rule out sexual transmission, and the presence of HSV-2 in the genital area does not automatically imply sexual contact. However, the latter does mean that sexual abuse must be seriously considered as a cause of the infection. In an Auckland-based review of 2,162 children and adolescent who were examined in the context of sexual abuse allegations, eight of the 1,909 children who underwent laboratory screening for sexually transmitted infections were positive for HSV, and sexual transmission was thought to be likely for six of these children.(3)
Differential diagnosis
Ulcers can be non specific and alternate diagnoses may be appropriate to rule out. Ulcers can occur as a manifestation of aphthosis in response to acute illness.(2) The appearance of aphthous genital ulcers is usually preceded by a history of fever, malaise and headache, but the results of polymerase chain reaction (PCR) testing (including HSV PCR) are negative. Epstein-Barr virus and cytomegalovirus, HIV, Syphilis infections have been reported to cause genital ulceration. Another uncommon cause in adolescents is a fixed drug eruption.
Management
Due to the very difficult issues in diagnosis, all children with suspected genital HSV infection should be referred to a paediatrician for assessment and treatment. The paediatrician may in turn seek advice from a local Sexual Abuse Assessment and Treatment Service (SAATS) that has special training in the recognition of child sexual abuse.
Adolescents
Internationally-accepted standards of practice state that adolescents who have never been sexually active should be managed in the same way as pre-adolescent children (see above), while sexually active adolescents should be managed as adults.
GRADE C
References
- Ashby J, Browne R, Dwyer E, et al. BASHH National Guideline on the Management of Sexually Transmitted Infections and Related Conditions in Children and Young People (2021). Available at: https://www.bashh.org/_userfiles/pages/files/resources/children_and_yp_2021.pdf. Accessed 25 Mar 2024.
- Huppert JS, Gerber MA, Deitch HR, et al. Vulvar ulcers in young females: a manifestation of aphthosis. J Pediatr Adolesc Gynecol 2006; 19 (3): 195-204.
- Kelly P, Koh J. Sexually transmitted infections in alleged sexual abuse of children and adolescents. J Paediatr Child Health 2006; 42 (7-8): 434-40.
The Ministry of Health supports the use of these clinical guidelines, developed by clinical experts and professional associations to guide clinical care.
Produced by the Professional Advisory Board (PAG) of the Sexually Transmitted Infections Education Foundation
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