Genital herpes

For many years, genital herpes remained outside the scope of attention of practical healthcare physicians, which was primarily due to insufficient laboratory diagnostic capabilities for herpesvirus infection, underestimation of the role of the herpes simplex virus (HSV) in human infectious pathology, and the lack of effective treatment methods.

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Epidemiology of genital herpes

Herpes is a common viral infection of humans and is a serious medical and social problem. In the early 1970s, a sharp increase in the incidence of genital herpes was noted in the United States and European countries, which by the 1980s had increased 10-fold and amounted to 80 cases per 100,000 people in England and France, and 178 cases per 100,000 in the United States. According to WHO, diseases transmitted by the herpes virus are the second most common cause of death (15.8%) after influenza (35.8%).

It has now been established that about 90% of the urban population in all countries of the world is infected with one or more types of the herpes virus. Clinical manifestations of the infection are present in 20% of them. Recurrent herpes infections are observed in 9-12% of residents of different countries. The highest incidence of genital herpes is recorded in the age group of 20-29 years and 35-40 years.

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Causes of Genital Herpes

The causative agent of genital herpes are two serotypes of the herpes simplex virus: herpes simplex virus type 1 (HSV-1) usually causes oral-labial herpes, herpes simplex virus type 2 (HSV-2) often causes genital lesions. Possessing neurodermotropism, HSV affects the skin and mucous membranes, the central nervous system, and the eyes. HSV causes pathology of pregnancy and childbirth, often leading to "spontaneous" abortions and fetal death. After infection, the virus is latent in a locally located sensory ganglion and periodically reactivates, causing symptomatic lesions, or asymptomatic, but no less infectious, shedding of the virus occurs. Infection with any of these viruses can cause an identical first episode of the disease. However, the frequency of subsequent relapses is higher with HSV-2 infection than with HSV-1 infection.

Infection occurs by contact, usually through skin-to-skin contact. The incubation period is 2 to 12 days (6 days on average).

Considering that during the incubation period and during relapse of the disease there is high contagiousness, it is necessary to refrain from sexual intercourse during this time. The risk of transmission is higher from man to woman. Primary infection with the HSV virus reduces the risk of seroconversion to HSV-2 in serodiscordant couples. Genital herpes is more common in women and in blacks compared to whites. Genital infection caused by HSV-1 recurs much less frequently than with genital localization of the focus of infection caused by HSV-2, which accounts for 95% of the total number of patients with recurrent genital herpes (RGH). HSV is characterized by neurotropism (a tendency to live in nerve cells).

The main links in the pathogenesis of herpes infection are:

• infection of the sensory ganglia of the autonomic nervous system and lifelong persistence of HSV;
• HSV tropism to epithelial and nerve cells, which determines the polymorphism of clinical manifestations of herpes infection.

Under certain conditions, HSV multiplies in the patient's T and B lymphocytes.

In recent years, it has been established that HSV also persists in epidermocytes of the skin, mucous membranes and secretions. Various clinical manifestations and severity of the infection are explained by the peculiarities of local and general immunity.

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Symptoms of Genital Herpes

50-70% of patients infected with the herpes simplex virus do not complain or complain only of pain and burning. In the clinical course of HSV, it is customary to distinguish between primary and recurrent herpes.

Primary herpes is an acute disease that occurs during a person’s first contact with HSV in the absence of specific antibodies against it.

Primary genital herpes occurs primarily in women as vulvovaginitis, but the cervix may also be involved. Primary herpetic vulvovaginitis is characterized by the appearance of pronounced edema and hyperemia of the labia majora and minora, vaginal mucosa, perineal area, and often the inner thighs. Pain, itching, dysuria, vaginal discharge, or urethral discharge are observed.

In men, primary elements are often localized on the head, body of the penis, neck of the head, scrotum, thighs and buttocks. Grouped vesicles appear, first with transparent and then cloudy contents. After the vesicles open, extensive wet erosions of a round shape are formed. Merging, they form extensive ulcers with a wet surface. Epithelial defects heal in 2-4 weeks, leaving behind hyperpigmented spots. There are usually no scars.

When the urethral mucosa is affected, frequent urination occurs and sometimes cystitis develops. In atypical cases, vesicles may be absent, and hyperemia develops in the foreskin area, burning and itching are observed. In severe cases, erosive and ulcerative lesions, skin edema, severe intoxication, and fever occur. Frequent relapses lead to lymphostasis and elephantiasis of the genitals.

Such prodromal phenomena in recurrent genital herpes as burning or tingling precede the appearance of rashes. In recurrent genital herpes, the rash elements are the same as in primary herpes, but are less pronounced. A hyperemic plaque 2 cm in diameter is covered with vesicles. After opening, erosions are formed, which heal in 1-2 weeks. In case of relapse, the elements of the lesion are located in men on the body and head of the penis, in women - on the labia majora and minora, in the perineum and on the inner surface of the thighs. Regional lymph nodes in the second or third week become enlarged, dense, painful, there is no fluctuation, the lesion is usually unilateral. If the pelvic lymph nodes are affected, pain in the lower abdomen appears. The disease is often accompanied by headache, fever, malaise and myalgia. In atypical forms of genital herpes, one of the stages of development of the inflammatory process in the lesion (erythema, blistering) or one of the components of inflammation (edema, hemorrhage, necrosis) or subjective symptoms (itching) predominates, which give the corresponding name to the atypical form of genital herpes (erythematous, bullous, hemorrhagic, necrotic, itchy, etc.).

Atypical forms are more common in women than in men. In most patients, genital herpes is atypical and is accompanied by symptoms that can easily be mistaken for other genital infections or dermatoses.

The course of genital herpes

According to the course of recurrent genital herpes, there are 3 degrees of severity:

• mild - exacerbations 3-4 times a year, remissions of at least 4 months;
• moderate-severe - exacerbations 4-6 times a year, remissions - 2-3 months;
• severe - monthly exacerbations.

Reactivation of the virus after primary infection within a year occurs in 50-80% of patients. Antiviral drugs only reduce the titer of the virus that the patient releases into the environment, and reduce the risk of infection transmission by 100-1000 times.

Histopathology

Pathological changes are the same as in simple vesicular lichen.

Treatment of genital herpes

Antiviral therapy should be used in all cases of genital herpes diagnosis. Its goals are to alleviate the severity of the disease symptoms, prevent complications and relapses.

Sexual partners of patients with herpes infection of the urogenital tract are subject to active identification. Treatment should be carried out at clinical manifestations of herpes. It is recommended to abstain from sexual activity or use condoms during exacerbations.

Treatment of the initial episode of genital herpes is with acyclovir, valacyclovir, or famciclovir.

For the primary episode of genital herpes, acyclovir (Ulkaril, Herpsevir, etc.) is used at 400 mg 3 times a day or 200 mg orally 5 times a day for 7-10 days (in the USA) or 5 days (in Europe). This reduces the duration of virus shedding and clinical manifestations. In addition, acyclovir may affect the course of neurological complications such as aseptic meningitis and urinary retention.

Proteflazit is widely used in practice, as it has an antiviral and immunocorrective effect. The drug is prescribed 15-20 drops 2 times a day. The effectiveness of therapy increases when Proteflazit is applied to the affected areas.

In severe cases accompanied by neurological complications, acyclovir is administered intravenously at 5-10 mg/kg 3 times a day. A comparative study of the use of a high oral dose of acyclovir (4 g/day) and a standard dose (1 g/day) for the treatment of genital herpes infection did not reveal any clinical advantages of the higher dose.

In the United States, valacyclovir is approved for the treatment of a primary episode of genital herpes at a dose of 1000 mg twice daily for 7-10 days.

Famciclovir 250 mg 3 times daily for 5-10 days is as effective as acyclovir in the initial episode of genital herpes.

During relapses of the disease, acyclovir is administered orally at 400 mg 3 times a day or 200 mg 5 times a day for 5 days. Although this treatment leads to a reduction in the duration of viral shedding and the manifestation of symptoms of individual episodes, it does not eliminate the interval between relapses.

Valaciclovir is recommended for the episodic treatment of recurrent genital herpes at 500 mg orally twice daily for 5 days.

Famciclovir is used as an episodic treatment for recurrent genital herpes at a dose of 125 mg orally twice daily for 5 days.

Preventive treatment of genital herpes

Preventive (preventive, suppressive) treatment of genital herpes consists of the use of acyclovir, valacyclovir or famciclovir in a long-term continuous regimen. Such treatment is indicated for patients with a frequency of exacerbations of 6 episodes per year.

Daily intake of 400 mg of acyclovir orally 2 times a day prevents the development of relapses of genital herpes. With such use, the frequency of exacerbations decreases by 80%, and in 25-30% of patients, they do not occur at all during the entire period of taking acyclovir.

Valaciclovir is recommended for suppressive therapy at a dose of 500 mg orally once daily (for patients with no more than 10 relapses per year) or once daily (for patients with more than one relapse per year).

Famiclovir is also effective in suppressing recurrent genital herpes at a dose of 250 mg orally twice daily.

External treatment is the same as for simple vesicular lichen.