herpes%20simplex%20virus%20infection
HERPES SIMPLEX VIRUS INFECTION
Primary herpes simplex virus (HSV) infection is first infection with either herpes simplex virus-1 (HSV-1) or herpes simplex virus-2 (HSV-2) in individuals who do not have antibodies to either HSV-1 or HSV-2.
First episode-non primary infection is infection with either HSV-1 or HSV-2 in individuals who have previously existing antibodies against HSV-1 or HSV-2 respectively.
Recurrent HSV infection results from reactivation of latent virus. It is usually brought about by triggering factors eg UV light, immunosuppression.
Orolabial HSV disease is mostly caused by HSV-1 that occurs most commonly in children <5 years of age. It is transmitted through close contact with individuals who have active viral shedding.
Genital HSV disease is caused by HSV-2 that is the usual cause of herpes genitalis. It typically occurs in adults and transmitted through sexual contact.

Prevention

  • Educate patient on how to prevent transmission by:
    • Abstaining from sexual contact during lesion recurrences or prodromes
    • Limiting the number of sexual partners
    • Informing sexual partner or former sexual partner(s) from preceding 60 days prior to diagnosis to seek evaluation & treatment
    • Understanding that asymptomatic viral shedding may cause transmission
      • Asymptomatic viral shedding is more likely to occur w/ HSV-2 infection, in the 1st year following an infection, or if recurrences are symptomatic; however, shedding decreases w/ time
    • Using a condom to protect against transmission (not foolproof)
    • Taking daily suppressive antiviral therapy which decreases recurrent genital lesions, asymptomatic viral shedding & transmission

Management Strategies for Recurrent Genital Herpes

Supportive Treatment Alone
  • Recurrent infections are generally self-limiting, less severe w/ a shorter duration of symptoms & supportive treatment alone may be effective to control symptoms
Episodic Antiviral Treatment
  • Patient-initiated therapy that needs to be pre-prescribed
    • Start antiviral therapy as soon as possible within 1 day of lesion onset or during the prodrome that heralds some outbreak
  • Best for HSV-infected patients who have mild symptoms & infrequent recurrences
  • Reduces duration of symptoms by 1-2 days
Suppressive Antiviral Therapy
  • Recommended in patients w/ frequent recurrent genital herpes (≥6 episodes/year), severe or painful prodromes, pregnant patients w/ herpetic lesions in the last trimester, patients w/ psychological problems due to the infection, & in immunocompromised patients
  • Used to decrease frequency of recurrences, chance of transmission & provide relief of symptoms
  • Antiviral suppress symptomatic & asymptomatic viral shedding
    • Reduces clinical outbreaks & viral shedding by 80% & 95% respectively
  • Full suppressive effect is usually obtained when in treatment for 5 days
  • Outbreaks during therapy should investigate for poor compliance, need for dose adjustments, resistance or incorrect diagnosis
  • Annual evaluation & cessation of therapy after 1 year is required to assess frequency of recurrences
    • Period of assessment should include 2 recurrences to view both severity & frequency
    • It is safe & advisable to restart suppressive treatment in patients who continue to have significant infection
  • Suppressive treatment may incur higher costs & inconvenience

Counselling

Patient & Parent

  • Reduce patient’s anxiety & help patients to cope w/ the infection by educating them on the natural history of the disease, recurrent episodes, antiviral treatments, sexual relationships & perinatal transmission
  • Discuss treatment options:
    • Episodic treatment vs suppressive treatment
    • If patient has ≥6 episodes/year, consider suppressive treatment
    • Suppressive treatment may incur higher costs & inconvenience
      • Increase fluid intake to dilute urine

Follow Up

  • Interrupt treatment after 6 months-1 year to assess frequency of recurrence
  • Restart treatment if high rate of recurrences
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