Diagnosis and management

Virus detection & characterisation

Confirmation and typing of the infection is essential for diagnosis and counselling on prognosis, transmission, and management. Laboratory diagnosis is based on direct detection of HSV from genital lesions; in the West of Scotland the HSV detection test used is PCR, which yields the highest sensitivity of all available tests and also allows virus typing. The quality of sample is crucial.

Specimens should be collected using the swab recommended by the testing laboratory. Ideally sample from a vesicle, or alternatively directly from the base of an ulcer. Material from several lesions should be taken, to maximise diagnostic yield.

Poorly taken swabs, swabs from old lesions, or swabs taken from patients already on anti-virals may result in a false negative report.

In the West of Scotland samples tested for herpes are also tested for T.pallidum. (syphilis).

Ensure that the virology request form includes appropriate information about lesions and risk-behaviour groups (e.g., genital ulcer and MSM). If dark ground microscopy is available this may be appropriate in certain cases.

Herpes serology - Generic and type specific

Herpes serology has a very limited role in overall herpes management.

The appropriateness of serology testing should be discussed with a senior colleague and local virology services, as this may be available in certain circumstances from Colindale, London.

Antivirals

Patients presenting within 5 days of the start of the episode, or while new lesions are still forming, should be given oral antiviral drugs.

There is no evidence of benefit for greater than 5 days but it can be considered if new vesicles are forming or systemic symptoms are persisting.

Aciclovir is the preferred treatment choice as there is no evidence of additional benefit from newer, more expensive antivirals.

Antiviral therapy does not alter the natural history of the disease in that the frequency or severity of subsequent recurrences remains unaltered.

Therapy may be continued beyond five days if new lesions are still appearing, systemic symptoms still present or complications have occurred.

Refer all clients presenting with genital herpes with HIV (or immunosuppression) urgently to a senior clinician experienced in the management of genital herpes in people with HIV or the immunosuppressed (do not delay initiating therapy).

Testing for other STIs

All clients should be encouraged to have tests for other STIs. As a minimum this should include tests for chlamydia, gonorrhoea, syphilis and HIV. It may be preferable to do a lower vaginal swab for chlamydia and gonorrhoea NAAT testing rather than doing a speculum examination. If chlamydia, gonorrhoea, HIV and syphilis tests are not done at the initial visit, or are done but are within the incubation or window period, arrangements should be made for them to be done or repeated at an appropriate follow up visit.

Supportive measures

• Saline bathing and the application of yellow soft paraffin (‘Vaseline’) to lesions as required.
• Appropriate analgesia.
• Topical anaesthetic agents, e.g., 5% lidocaine ointment, may be useful to apply, especially prior to micturition. Although the potential for sensitation exists in the use of topical anaesthetic agents, lidocaine is a rare sensitiser.
• Consider referral of clients with first diagnosis HSV to the sexual health advisers for information, partner notification and counselling/support.

Management of complications

Hospital admission may be required for:

• severe pain or constitutional symptoms
• meningism
• urinary retention
• severe secondary infection or cellulitis.

Recurrences of genital herpes are generally self-limiting and usually cause minor symptoms. Management strategies include:

1. supportive therapy only
2. episodic antiviral therapy
3. suppressive antiviral therapy.

The most appropriate strategy for managing an individual patient will vary over time, dependent upon:

• the patient’s psychological coping strategies
• recurrence frequency and duration
• symptom severity
• other factors such as relationship status, relationship difficulties and concerns of onward transmission.

Patients should be seen by an experienced clinician, where all relevant clinical and psychosocial issues can be addressed.

1. Supportive therapy only

Analgesia, 5% lidocaine ointment, saline baths, and use of yellow soft paraffin in the absence of specific antiviral treatment are suitable for patients with short, infrequent recurrences with minimum pain or distress.

2. Episodic antiviral treatment

Oral aciclovir, valaciclovir, and famciclovir are effective at reducing the duration and severity of recurrent genital herpes.

• The reduction in duration is a median of 1 to 2 days.
• Aborted lesions have been documented in up to one third of patients with early treatment.
• Patients who experience infrequent episodes which cause distress because of their severity and/or duration may benefit from episodic treatment.
• Patients with the occasional but prolonged episode (longer than 7 days), or those very concerned that episodes will occur during special events, holidays etc. may be particularly suitable for this approach.
• Some patients who would appear to be more suitable for suppressive therapy may also choose this option as they wish to avoid continuous use of medication.
• To ensure prompt treatment, consideration should be given to providing patients with the appropriate treatment in advance. Treatment started early (including during prodromal symptoms) in an episode and prior to the development of papules is likely to be of greatest benefit.

The regimen recommended is:

3. Suppressive therapy

Patients with virologically confirmed genital herpes and a recurrence rate of more than six episodes of genital herpes annually are likely to experience a substantial reduction in recurrence frequency on suppressive therapy. All patients in this category, especially those with prolonged and/or painful recurrences should therefore be given full information on the advantages and disadvantages of suppressive therapy, within the context of their overall clinical care.

Patients with lower rates of recurrences will probably also have fewer recurrences with treatment. The decision to start suppressive therapy is a subjective one, balancing the costs and inconvenience of treatment.

Experience with suppressive therapy is most extensive with aciclovir. Safety and resistance data on patients taking long term therapy now extend to over 20 years of continuous surveillance.

The regimen recommended is:

If breakthrough recurrences occur on standard treatment, the daily dose should be increased to aciclovir 400mg three times daily.

Sexual health services should supply an initial one month supply and local procedures will determine where the patient accesses on going supplies with appropriate correspondence if this is intended to be from their GP.

Suppressive treatment should be provided for a minimum of six months and a trial of discontinuation should be considered after one year of continuous therapy, to reassess recurrence frequency. Most patients will have an episode soon after stopping suppressive treatment, therefore the minimum period of assessment should include two recurrences. Patients who continue to have unacceptably high rates of recurrence or problematic disease may restart treatment.