Genital Herpes: Treatment, Why It Comes Back and Living Well With It

I have had patients cry in my consulting room after learning they have herpes. Not because the sores hurt, but because they fear no one will love them, or because they have fought with their partner, believing the other person cheated. I want to start this article with facts that may ease your mind. Herpes is one of the most common infections in the world. The World Health Organization estimates that more than half of people under 50 carry HSV-1, and many more carry HSV-2, most without ever knowing. Herpes can be brought under control, and people with herpes can have good relationships and a good sex life.

What is herpes and how is it spread?

Herpes is caused by the herpes simplex virus (HSV). There are two types:

• HSV-1 is usually caught in childhood through mouth contact and causes cold sores on the lips. Today it is an increasingly common cause of genital herpes through oral sex.
• HSV-2 is usually caught through sex and comes back on the genitals more often than HSV-1.

The virus spreads through direct contact with skin or mucous membranes, such as kissing, oral sex and intercourse. It can be passed on even when there are no sores, because the virus comes to the skin surface from time to time without symptoms (asymptomatic shedding). Condoms reduce the risk partly, but not completely, because they do not cover all the skin. Catching herpes from toilet seats, towels or swimming pools almost never happens.

After infection, the virus hides in the nerve ganglia for life, and can come out as sores when your body is run down, stressed, short of sleep, menstruating or exposed to a lot of friction.

1. 1
   Lies dormantThe virus stays in the body for life
2. 2
   TriggersStress, poor sleep, fatigue, periods, friction
3. 3
   Warning signsItching, burning, tingling at the same spot 1–2 days before blisters
4. 4
   Blisters and soresRecurrences are usually milder and shorter, about 5–10 days
5. 5
   Sores healVirus goes back into hiding; recurrences often fade over time

Even without sores, the virus can be passed on from time to time (asymptomatic shedding).

First outbreak versus recurrences

First episode

• Usually 2–12 days after exposure, but many people have no symptoms at first and only have their first outbreak months or years later
• Clusters of small clear blisters that break into shallow, very painful sores
• There may be fever, aches, swollen lymph nodes in the groin and burning on urination
• Without treatment it can last 2–3 weeks

Recurrences

• Usually milder and shorter, about 5–10 days
• Many people get warning signs such as itching, burning or tingling in the same spot 1–2 days before blisters appear
• Recurrences usually become less frequent over time

Diagnosis

• The doctor looks at the sores, and the most accurate method is a swab of the sore for PCR testing, which can tell whether it is HSV-1 or HSV-2. This works best while the sore is fresh.
• Blood tests for HSV antibodies are not recommended for screening people without symptoms, because they are hard to interpret, false positives occur, and they cannot tell when infection happened. They may be used in some situations at the doctor's discretion.
• A genital sore is not always herpes. Syphilis can also cause sores, so a syphilis blood test should be done as well. Read Syphilis.

Treatment with antiviral medicine

The medicines used are acyclovir or valacyclovir, prescribed by a doctor. They do not remove the virus from the body, but they help a great deal. There are three ways to use them:

1. Treating the first episode: about 7–10 days of tablets helps sores heal faster with fewer symptoms.
2. Episodic treatment: a short course started as soon as warning signs appear, or within the first 24 hours of a sore. It works best when started early, so many people ask their doctor for a supply to keep at home.
3. Daily suppressive therapy: suits people with frequent recurrences, a lot of anxiety, or a partner who does not have the virus. It reduces recurrences by about 70–80%, and a study in the New England Journal of Medicine found that once-daily valacyclovir cut transmission of HSV-2 to a partner by almost half.

Creams help little for genital herpes. Keeping sores clean and dry, wearing loose cotton underwear and taking painkillers as needed will make you more comfortable.

First episode

• About 7–10 days
• Sores heal faster, fewer symptoms

Episodic

Per recurrence

• Start at the first warning sign
• Or within 24 h of the sore appearing
• Many keep a backup supply

Suppressive

Daily, ongoing

• Cuts recurrences by about 70–80%
• Cuts HSV-2 spread to a partner by almost half
• For frequent outbreaks or an uninfected partner

Medicine doesn't clear the virus but helps a lot. Use as your doctor prescribes.

Lowering the risk of passing it to a partner

• Avoid all sexual contact from the first warning signs until sores have completely healed.
• Use condoms every time, even when there are no sores.
• Consider daily suppressive therapy, especially if your partner does not have the virus.
• If you have a cold sore on the lip, avoid kissing and oral sex until it heals.
• Tell your partner honestly. Appropriate disclosure lets you make decisions together and reduces guilt in the long run.

Pregnancy

The risk to the baby is highest when the mother catches herpes for the first time in the last trimester. If you or your partner have herpes, tell your obstetrician at your first antenatal visit. The doctor may give suppressive medicine late in pregnancy and plan a safe delivery.

Caring for your feelings as well as the sores

Shame, fear that no one will accept you, and anger at your partner are reactions anyone can have. Give yourself time, get information from reliable sources, and if the worry is affecting your sleep, eating or work, ask for help. Read more in Feeling guilty after an STI and When your partner has an STI. If you feel so bad you cannot cope, you can call 1323, Thailand's free 24-hour mental-health hotline (Thai language; ask for English support).

When to see a doctor, and how the clinic can help

See a doctor when you have genital sores or blisters for the first time, to confirm the diagnosis and rule out other conditions. Go urgently if you cannot pass urine, have a severe headache with a stiff neck, have a sore on or near the eye, or have a weakened immune system and the sores are spreading.

At Dr. Kris Clinic, I do PCR tests from sores, plan episodic or daily treatment with you, and offer couples counseling, both on reducing transmission and on talking about it with understanding. Online consultations are available nationwide, and English-speaking consultations are available.