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Dermatology (Skin Conditions)

Herpes Simplex Virus (HSV) Skin Infections

Viral infection caused by Herpes Simplex Virus type 1 (HSV-1, typically orolabial) or type 2 (HSV-2, typically genital), characterized by localized primary infection, latency in nerve ganglia, and potential for recurrent vesicular eruptions.

Also known as: Cold Sores, Fever Blisters, Genital Herpes

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Referral and warning signs

When to refer

Refer if: Severe primary infection (esp. gingivostomatitis interfering with intake). Eye involvement suspected (URGENT ophthalmology referral). Disseminated infection / Eczema herpeticum. Meningitis/Encephalitis suspected. Immunocompromised patient with severe/atypical disease. Neonatal herpes suspected (URGENT Peds). Frequent/severe recurrences needing consideration for suppressive therapy.

Red flags

  • Eye symptoms (pain, redness, photophobia, blurred vision).
  • Severe headache, neck stiffness, altered consciousness.
  • Widespread skin involvement, especially in patient with eczema.
  • Signs of systemic illness / sepsis.
  • Lesions in a newborn infant.

Signs and symptoms

  • Primary Infection (Gingivostomatitis - HSV1; Genital Herpes - HSV2):
  • - May be asymptomatic or mild.
  • - Prodrome: Tingling, itching, burning at site.
  • - Eruption: Clusters of small, painful vesicles (blisters) on an erythematous base.
  • - Vesicles rupture -> shallow, painful ulcers -> crusting.
  • - Associated symptoms: Fever, malaise, lymphadenopathy (local).
  • - Primary gingivostomatitis: Extensive painful ulcers on gums, lips, oral mucosa, fever (common in children).
  • - Primary genital herpes: Painful vesicles/ulcers on genitals, buttocks, thighs; dysuria, vaginal/urethral discharge, tender inguinal nodes.
  • Recurrent Infection (Reactivation):
  • - Prodrome (tingling/itching) often precedes eruption.
  • - Recurrent clusters of vesicles at or near site of primary infection (e.g., Herpes labialis on lip border, recurrent genital lesions).
  • - Usually less severe and shorter duration than primary infection.
  • - Triggers: Stress, illness, fever, sunlight, menstruation, trauma.
  • Other Manifestations: Herpetic whitlow (finger), Eczema herpeticum (widespread vesicles superimposed on eczema), Herpes keratitis (eye - See OPH005), Neonatal herpes (severe systemic), Meningoencephalitis.

Risk factors

  • Direct contact with active lesions or asymptomatic shedding.
  • Oral-genital contact.
  • Immunosuppression (HIV, malignancy, transplant) - leads to more severe, frequent, atypical lesions.
  • Atopic eczema (risk factor for eczema herpeticum).

Diagnosis

Clinical assessment

Diagnosis usually based on characteristic appearance of grouped vesicles/ulcers in typical locations, often with history of recurrence.

Differential diagnosis

  • Orolabial: Aphthous ulcers (usually inside mouth, not vesicular initially), Impetigo, Hand-foot-mouth disease, Angular cheilitis, Stevens-Johnson Syndrome.
  • Genital: Syphilis (chancre - usually painless), Chancroid (painful ulcer, nodes), Lymphogranuloma venereum (LGV), Granuloma inguinale, Behcet's disease, Fixed drug eruption, Trauma.
  • Other: Varicella Zoster (shingles - dermatomal), Contact dermatitis.

Investigations

  • Usually clinical diagnosis sufficient.
  • Viral Swab: PCR or Viral Culture from active vesicle fluid/ulcer base (confirms HSV and can type 1 vs 2) - specialist level.
  • Tzanck Smear: Shows multinucleated giant cells (supportive, less sensitive/specific) - rarely used.
  • Serology: Limited use for diagnosing acute/recurrent episodes (IgG indicates past exposure).

Diagnostic criteria

Clinical appearance of grouped vesicles/ulcers, often recurrent. Confirmation by PCR/culture if needed.

Management

Non-pharmacological management

  • Keep lesions clean and dry to prevent secondary bacterial infection (clean with antiseptic like Chlorhexidine 0.05% or dilute H2O2 6%).
  • Avoid touching lesions and then touching eyes or other body parts/people.
  • Avoid triggers for recurrence if known.
  • Use condoms consistently to reduce genital transmission risk (reduces but doesn't eliminate risk).

Pharmacological treatment

  • Analgesia: Paracetamol, NSAIDs for pain.
  • Antiviral Therapy: Most effective if started early (within 48-72h of onset or during prodrome). Reduces duration/severity, doesn't cure latency.
  • - Primary Orolabial/Gingivostomatitis (Severe):
  • - Acyclovir 400mg PO TID or 200mg 5 times/day for 7-10 days. (Child dose varies by age/weight). (LOC: HC2/3)
  • - Recurrent Herpes Labialis (Cold Sore):
  • - Topical Acyclovir/Penciclovir cream (apply early/frequently - modest benefit).
  • - Episodic Oral Acyclovir (e.g., 400mg TID for 5 days) if started early in frequent/severe recurrences.
  • - Primary Genital Herpes:
  • - Acyclovir 400mg PO TID for 7-10 days (OR 200mg 5x/day).
  • - OR Valacyclovir 1g PO BID for 7-10 days.
  • - OR Famciclovir.
  • - Recurrent Genital Herpes:
  • - Episodic Therapy (Start at prodrome/onset): Acyclovir 400mg TID x 5d OR 800mg BID x 5d OR 800mg TID x 2d. OR Valacyclovir 500mg BID x 3d OR 1g OD x 5d. OR Famciclovir.
  • - Suppressive Therapy (If frequent/severe recurrences >6/year): Acyclovir 400mg PO BID daily OR Valacyclovir 500mg-1g PO OD daily. Reassess annually. (Specialist guidance)
  • - Severe/Disseminated/Immunocompromised: IV Acyclovir required (Hospital management).
  • Topical Antiseptics: (e.g., Chlorhexidine, H2O2) for cleaning.

Monitoring

Monitor healing of lesions. Assess frequency/severity of recurrences if considering suppressive therapy.

Complications

  • Secondary bacterial infection.
  • Eczema herpeticum.
  • Herpetic whitlow.
  • Herpes keratitis / Eye involvement -> Blindness.
  • Erythema multiforme.
  • Aseptic meningitis.
  • Neonatal herpes (severe, high mortality/morbidity).
  • Psychosocial distress.

Prevention

  • Avoid direct contact with lesions.
  • Use condoms for genital herpes (reduces risk).
  • Antiviral suppression during late pregnancy may reduce neonatal transmission risk (specialist).
  • Caesarean section if active genital lesions at time of labour.
  • Sunscreen may help prevent UV-triggered labial herpes.

Patient education

  • Explanation of HSV infection (viral cause, latency, recurrence).
  • How it spreads (direct contact, asymptomatic shedding).
  • How to manage acute episodes (hygiene, antivirals if prescribed).
  • Recognizing prodrome symptoms.
  • Strategies to reduce transmission (avoid contact during outbreak, condoms for genital herpes).
  • Potential triggers for recurrence.
  • When to seek medical advice (severe symptoms, complications, eye involvement).

Uganda-specific notes

HSV-1 (oral) very common. HSV-2 (genital) also prevalent. Clinical diagnosis common. Acyclovir availability increasing but may be limited at lower levels. Important opportunistic infection in HIV.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 22, Section 22.2.1

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 3, Section 3.2.8 (Genital Ulcer Disease Syndromic Management - includes Herpes)

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