Genital Herpes Diagnosis and Treatment

Clinical Presentation

HSV-1 genital infections present identically to HSV-2 with vesicular and ulcerative lesions on the genitals, buttocks, or thighs in females 2
First episodes are often more severe than recurrences, with vesicles that burst forming shallow ulcers or erosions that eventually crust and heal spontaneously without scarring 2
Associated symptoms may include dysuria, vaginal discharge, and significant discomfort 2

Laboratory confirmation is essential because clinical diagnosis alone is unreliable and can lead to both false positive and false negative diagnoses 2
Type-specific testing to differentiate HSV-1 from HSV-2 is critical for prognostic counseling, as HSV-1 genital infections recur much less frequently than HSV-2 1
Collect specimens from vesicle fluid or ulcer base using a swab for PCR testing or viral culture 2
Serologic testing for syphilis should also be performed, as HSV can occasionally coexist with other sexually transmitted infections 2, 3

The CDC-recommended first-line treatment is valacyclovir 1 g orally twice daily for 7-10 days 4, 1
Alternative regimens include acyclovir 400 mg orally three times daily for 7-10 days 4, 1
Treatment may be extended beyond 10 days if healing is incomplete 4, 1

Genital herpes is incurable but highly controllable with antiviral therapy 1
HSV-1 genital infections have a significantly better prognosis than HSV-2, with much less frequent recurrences 1
The virus establishes lifelong latency and systemic antivirals control symptoms but do not eradicate the latent virus 4, 5
Abstain from all sexual contact when lesions or prodromal symptoms are present 1
Asymptomatic viral shedding can occur even without visible lesions, though this occurs less frequently with HSV-1 than HSV-2 1
Consistent condom use should be encouraged with all sexual partners, as transmission can occur even in the absence of symptoms 4, 1

Do not rely on clinical diagnosis alone - always obtain laboratory confirmation with type-specific testing 2, 1
Do not assume HSV-2 is the causative agent - HSV-1 accounts for up to 30% of first-episode genital herpes in young women 1
Do not prescribe topical acyclovir - it is substantially less effective than oral therapy 4, 5
Do not delay treatment - efficacy decreases significantly if treatment is not initiated within 72 hours 3
Do not forget to test for other sexually transmitted infections, particularly syphilis and HIV 2, 3