KEY POINTS |
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First clinical episode may, but does not always, reflect recent infection. |
The ’72 hour’ herpes zoster rule does not apply to first episode herpes. |
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The first clinical episode of genital HSV-1 or HSV-2 may, but does not always, reflect recent acquisition of infection. It may represent a primary HSV infection or a new non-primary infection or a first recognised clinical expression of a previously acquired infection. It is not possible to reliably distinguish between these on clinical grounds alone. Nonetheless, as the first episode genital herpes is generally more severe and/or more prolonged, treatment should always be offered regardless of time of symptom onset.
Valaciclovir prescriptions do not require specialist authorisation and the medication is available through any pharmacy. Patients are often very unwell and therapy should be initiated regardless of how long the lesions have been present and before virological confirmation. This is based on evidence that the virus is shed from the infected area for a median of 11 days, with systemic and local symptoms lasting 2–3 weeks if untreated. Oral antiviral therapy substantially reduces the duration and intensity of symptoms.(18,19) GRADE A
Management for patients presenting with a first episode of genital herpes should encompass the following:
It is not necessary or desirable to attempt to cover all these issues at the initial clinical assessment. However, recognition of the psychosocial impact of the diagnosis, and the provision of adequate information and/or referral to the Herpes Helpline, is important.
It may be helpful to discuss how results will be given, e.g. in person, over the phone. If giving results over the phone, check the person is in an appropriate situation to receive the call.
Symptoms may appear 2–20 days following exposure to infection with the virus. However, initial symptoms of genital herpes may not be recognised or may not occur until months to years later. Symptom severity differs markedly with severe cases having lesions lasting up to 3 weeks.
The prodrome (if experienced) is signalled by flu-like symptoms of fever, headache and general myalgia, accompanied by local tingling, irritation and/or pruritus or pain in the genital region. Rapidly, pruritic erythematous papules appear, followed by multiple small vesicles that contain clear to cloudy fluid. These vesicles rupture within 1–2 days to form painful, sloughy, shallow ulcers with irregular margins, which may become confluent. The area may be oedematous and can be extremely tender. Pain on urination is typical, particularly in women and spontaneous urination may be impossible. The ulcers dry to form crusts and later heal, leaving a transient red macule with minimal scarring (if any). Less commonly, lesions can pass through the blister phase quickly and blisters may not be noticed. Involvement of the cervix occurs but speculum examination may not be possible. Lesions may also appear extra-genitally, commonly on thighs and buttocks and less commonly on hands, lips, face and breasts. Local lymph nodes, i.e. inguinal nodes with genital infection, are usually enlarged and tender.
Women are more severely affected than men. Immunosuppressed people may develop very extensive disease.
A relevant specialist should review any patient with complications.
Examination should include inspection of the genital region; speculum examination should be considered, but may need to be delayed if discomfort is anticipated.
Laboratory confirmation of the diagnosis is important, but should not delay the initiation of treatment. A negative result does not necessarily exclude a diagnosis of HSV (see Diagnostic Tests).
Refer to Genital Herpes in Pregnancy if there is a possibility of pregnancy. Refer immunocompromised patients, or those with herpetic proctitis, to an appropriate specialist, e.g. infectious diseases, sexual health.
Recommended treatment for first episode genital herpes:
Lesions may not completely heal over during the course of drug treatment; similarly, mild neurological symptoms may not yet have fully resolved. Nonetheless, a further course of therapy is not usually indicated unless new lesions continue to appear.
Intravenous (IV) aciclovir therapy could be considered for patients who have severe disease or complications that necessitate hospitalisation.(24)
Topical aciclovir creams are not recommended because they offer minimal clinical benefit (see Topical antiviral therapy).
In addition to oral antivirals, other measures to control symptoms should be suggested. Paracetamol 4-hourly is usually adequate, but stronger pain relief may be necessary. Drinking fluids hourly produces dilute urine that is less painful to void. Female patients can be advised to sit in a bath or bowl of warm water to pass urine. Advice about drying lesions with the lowest setting of a hair dryer may be helpful. Bathing in salt water (e.g. half a cup of household salt in the bath or 2 teaspoons per litre of warm water for topical application) may help relieve pain and promote healing. Adequate pain relief should be provided. Topical anaesthetic jelly such as lignocaine (Xylocaine) gel applied 5 minutes before micturition helps relieve the pain. As lignocaine is a potential skin sensitizer, patients should be warned to use it for the shortest possible time (usually 1 or 2 days maximum). GRADE C
It is important to ensure that patients receive accurate up-to-date information about genital herpes. A range of printed materials can be downloaded from the NZHF website, or ordered at no cost (please refer to resources listed on the inside front cover). Primary care practitioners should have access to these resources or be able to advise their patients on how to obtain them, e.g. www.herpes.org.nz. There is also a Herpes Helpline 0508 11 12 13, a telephone service which is free to all New Zealanders.
Informing the patient of the diagnosis can be a delicate matter. Health providers may find it helpful to review the 3 minute patient tool on the NZHF website which provides information on what patients tell us they want to know at this point in their management. Although initial counselling can be provided at the first visit, it may be preferable to wait until the initial outbreak settles to discuss chronic aspects of the infection. Written materials, such as the NZHF Myth vs Facts leaflet and The Facts booklet, should be offered to patients at the first visit with discussion and further questions encouraged at the follow-up and subsequent visits.
See Key Information for Health Professionals to Give Patients in Counselling. GRADE C
Follow-up is important for those with first episode herpes. For most patients, one visit is insufficient to properly manage the impact of genital herpes. Counselling and advice often form the major part of a follow-up appointment and time should be allowed for this. The practitioner should be alert to the possibility of further psychological problems manifesting after a diagnosis of genital herpes.
At the initial visit, a follow-up appointment should be offered for 5–7 days later, to evaluate symptoms, their psychological status, complete a full STI screen if appropriate, discuss results and answer any questions they may have. It should be noted that it might take longer than 5 days for skin lesions to heal completely. Further therapy is not usually required unless new lesions continue to appear.
Anticipatory episodic therapy is recommended. Episodic antiviral therapy is more effective when patients start therapy themselves at the first signs of a recurrence. GRADE A
Suppressive antiviral therapy can be considered for those with frequent and/or severe recurrences or associated psychosocial morbidity. It is suggested that either a minimum of two recurrences or approximately 3 months without suppressive therapy is required to establish the pattern.
KEY POINTS |
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Most recurrent herpes is mild and infrequent. |
There is effective oral antiviral treatment for frequent, severe, problematic genital herpes. |
Treatment/management options should be discussed with the patient. No treatment is also a common and acceptable option. |
Individualised treatments and increased emphasis on prompt initiation of episodic treatment. |
Suppressive therapy can be considered for those with frequent and/or severe recurrences, and/or associated psychological morbidity and those associated with erythema multiforme. |
20–25% of patients may have ‘recurrences’ despite being on suppression. If the patient is compliant with suppressive therapy, it is important to consider other genital conditions that mimic or coexist. A positive HSV DNA result in a patient who is compliant with suppression suggests ACV-resistant virus which is very rare. |
Withdrawal of therapy should be for a sufficient length of time to establish whether the pattern of recurrence has changed (3 months). |
Reduced dose of valaciclovir or aciclovir should be considered in the presence of severe renal failure. |
Education and counselling are an extremely important part of management (refer to www.herpes.org.nz or Herpes Helpline tollfree 0508 11 12 13 or from a mobile 09 433 6526). |
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Management of recurrent herpes depends on whether there is prior virological confirmation of infection. Management of patients presenting with recurrent herpes should encompass the following:
Sufficient time should be allowed to address all these aspects.
A specialist should review any patient with complications.
The aim of episodic treatment is to reduce symptoms and duration of viral shedding during recurrences, rather than reduce the frequency of recurrences. Further, early therapy may abort episodes, that is, lesions may be prevented from progressing beyond the papular stage.(26,27) In situations where patients have well recognised prodromes and/or have less frequent recurrences, some may find episodic treatment preferable to continuous suppressive therapy.
Effective episodic antiviral treatment of recurrent herpes requires initiation of therapy during the prodrome that precedes some outbreaks or within one day of lesion onset.(26,27) Beyond this timeframe there is no clear benefit, so it is important that a prescription is readily available. In consultation with the patient, sufficient quantities of medication may be prescribed with instructions to start treatment as soon as symptoms begin. GRADE A
If the patient is pregnant, specialist consultation is recommended (see Genital Herpes in Pregnancy). In cases of immunocompromised patients, refer to appropriate specialist.
Prescribe enough tablets for patients to be able to self-initiate treatment at onset of symptoms.
Note: Famciclovir is not subsidised or marketed in New Zealand.
Suppressive therapy is an oral antiviral taken continuously over a given period of time that effectively reduces the frequency of recurrences.(28,29) GRADE A
The main aims of suppressive therapy are:
Aciclovir, famciclovir and valaciclovir all suppress symptomatic and asymptomatic shedding, by up to 80–95%.(15) Suppressive once-daily valaciclovir has been shown to reduce transmission to an uninfected partner with a 48% reduction in acquisition of HSV infection and a 75% reduction in clinical symptomatic genital herpes.(16) Other antivirals may be similarly effective, but this has not been proven in clinical trials. Patients may wish to consider this as a useful adjunct to safer sex behaviour and the use of condoms for the prevention of genital herpes transmission.
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With long-term suppressive therapy it is strongly advisable to have virological confirmation of the diagnosis before commencing treatment. Patients who have suggestive symptoms but do not have virological confirmation of recurrences, or who have complications or ongoing issues relating to their herpes, should see a specialist.
If the patient is pregnant, specialist consultation is recommended (see Genital Herpes in Pregnancy).
In cases of immunocompromised patients, refer to appropriate specialist.
Recommended treatment regimens for suppressive therapy include:
Suggest prescribing for 12 months, followed by a break of 3 months to see if recurrences are still frequent. GRADE C
20–25% of patients may experience recurrent episodes whilst on suppressive therapy.(28,32) Other genital conditions may mimic and/or coexist and, even if symptoms are suggestive of breakthrough recurrences, such patients are advised to see a specialist. The usual recommended dose of valaciclovir may need to be altered if breakthrough episodes are confirmed; suppressive therapy does not alter the natural history of recurrences long term and it is common to have a recurrence soon after withdrawal of therapy. It is helpful to anticipate this and to provide sufficient medication to allow prompt self-initiated treatment of any early recurrences. It is suggested that either a minimum of two recurrences or approximately 3 months without suppressive therapy is necessary to establish the new pattern.
Some patients may need to be on suppressive therapy for years. Valaciclovir is well tolerated and safety and efficacy data are supportive of longer-term use.(33) Neurotoxicity (lethargy, confusion, hallucinations and involuntary movements) has been reported in those with renal impairment.
Topical aciclovir creams are less effective than oral aciclovir.(34) Hence, use of topical treatment is not recommended. Topical antiviral creams are available over the counter, but are no longer subsidised on the pharmaceutical schedule.
Newer topical agents such as immune modulators are currently in clinical trials.
Evidence for other therapies (oral L-lysine, aspirin, liquorice root cream, lemon balm, aloe vera cream, etc.) is absent.
Although rare in immunocompetent individuals, clinically refractory (large, severe and sometimes atypical) lesions due to genital HSV may occur in patients with severe immunodeficiency, including late stage HIV disease. Immunocompromised individuals need referral to specialist care.
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
Sexually Transmitted Infections Education Foundation
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