There are two Types (strains) of Herpes simplex virus: Type-1 (“HSV-1”) and Type-2 (“HSV-2”). HSV-1 usually first enters the body through the mouth during childhood (when kids cough & spread saliva among each other); HSV-2 is an STD that usually enters through the genitals or the rectum.
However, either strain can enter either way, or other ways. For example:
- “Herpes whitlow” = HSV-1 around the fingernail, common among dentists & nurses before using gloves became routine in the 1980s
- One mother gave her small baby HSV-1 on the toe, as she cut his nails by biting them
- A child gave Mom HSV-1 on the breast while nursing
- “Herpes Gladiatorum” = “wrestler’s herpes” that they get all over their body from sweaty contact
- Newborn babies can get HSV-2 from the mother’s vagina during birth. It can spread throughout the body including the brain, & they often die. It’s pretty rare.
The first time either strain enters the body (“primary herpes”), people can get fairly ill, with fever. HSV-1 can cause lots of painful mouth sores (“stomatitis” since “stoma” = “mouth”), usually in children. HSV-2 can cause painful sores all over the genitals, in women it might interfere with urination to such an extent that they may need a catheter. However, most people don’t get any symptoms of primary herpes, for whatever reason.
Primary herpes lasts 10-14 days, and goes away on its own. Then the virus lies latent (dormant, “sleeping”) in a nearby nerve ganglion (local center for several nerves). From time to time it awakens, travels back down the nerve, & causes an outbreak. HSV-1 usually winds up on the lip as a cold sore (sometimes it might go to the throat, causing sore throat, or the eye or brain; see below). HSV-2 usually winds up as a cluster of bothersome blisters on the genitals or anus.
Outbreaks last a few days & go away on their own. They may occur every 2 weeks, every 50 years, or anything in between. Lots of people with herpes never even have outbreaks, and have no idea they’re infected. They can still spread it, as the virus comes out every few months, but it’s lots more contagious during outbreaks. In U.S. cities, maybe 25% of young adults have HSV-2 in them.
Herpes is more a nuisance than a danger. But it carries a bad reputation, since it’s an STD. People feel angry getting it from a sex partner, & feel guilty passing it to one (even if they honestly never knew they had it). If a person gets a herpes outbreak for the first time, it may well have been lying latent for years, in which case they shouldn’t necessarily blame a recent partner.
We can likely make the diagnosis by simply seeing a group of small itchy blisters on the genitals, or tiny ulcers (if the blister falls off), especially if the patient had it before. But we like to send a swab to lab to be sure, since there’ve been lawsuits for wrong herpes diagnoses. The swab has to be done on the first day of an outbreak, maybe the second, or there can be a false-negative. For patients I see after the first day or two, I tell them, “It’s quite possibly Herpes,” but they should drop-in on the first day of a recurrence to test for sure. We never do blood tests (see below)
Treatment of outbreaks has to involve pills; creams don’t work. There are different strategies:
- Ignore it, since the outbreak goes away on its own pretty soon
- Take pills for 5 days as soon as the outbreak starts, or even right before (people sometimes feel a typical tingling just before the skin blisters). This cuts the outbreak a day shorter. If a patient has infrequent outbreaks, we give them a prescription to keep pills at home just in case.
- Take medicine every day (“suppression”), which works very well to prevent outbreaks. We usually only recommend it to patients with frequent outbreaks. It also helps a little to prevent contagion, but not completely. For example, in one study over 8 months, 2% of people on treatment passed HSV-2, compared to 3.5% of people on placebo. So over 20 yrs., 60% of people taking medicine might still pass the virus.
There are rare occasions when Herpes is truly dangerous. If HSV-1 travels down the wrong nerve to the brain, it causes terrible encephalitis that’s usually fatal or disabling. If HSV-1 travels down the wrong nerve to the cornea of the eye, it can cause blindness (see Keratitis).
HSV-2 in newborn babies is catastrophic (see above). It usually only occurs if the mother gets Primary Herpes in the second half of pregnancy. It doesn’t tend to occur from an outbreak (recurrence), because a mother infected in the past has protective antibodies that get passed on to the fetus. If a pregnant woman’s partner has had Genital Herpes, and she never did, the safest thing would be for the couple to use condoms [or avoid penetrative sex] for the second half of pregnancy.
There are blood tests for Herpes antibodies, but they’re never recommended. That’s because HSV-2 comes out false-positive in one-third of people, due to cross-reaction with HSV-1 antibody (in infected people who may never have cold sores or any symptoms of it). Serious depression can result from a positive HSV-2 test, relationships have been ruined, & we can’t even tell for sure whether the result was simply an error due to HSV-1 in the mouth. If both HSV-1 and -2 are negative, we know the person never had either, but HSV-1 is so common, that testing isn’t worth it.