Herpes Virus Infection

Herpes virus infection is a very common viral condition that affects billions of people worldwide. While there is no cure, most people with herpes experience either no symptoms or mild symptoms that can be effectively managed with treatment.

Table of contents

• What is herpes virus infection?
• Types of herpes simplex virus
• How common is herpes?
• Signs and symptoms
• How herpes spreads
• Parts of the body affected
• How the virus stays in the body
• Risk factors and links to other conditions
• Diagnosis and testing
• Treatment options
• Prevention
• Living with herpes

What is herpes virus infection?

Herpes virus infection, also known as herpes simplex, is a viral infection caused by the herpes simplex virus (HSV). This virus can infect many different parts of the body, most commonly the mouth area (called oral herpes) and the genitals (called genital herpes)^[1].

The infection causes fluid-filled blisters that break open and form crusts wherever the infection occurs. This is known as a herpes outbreak^[1]. However, many people with herpes have no symptoms at all and don’t realize they are infected^[2].

Once you are infected, the virus stays in your body for life. It usually remains dormant (asleep) but may reactivate and cause outbreaks from time to time^[1]. There is no cure for herpes, but treatments can help manage outbreaks and reduce the chances of spreading the virus to others^[1].

Types of herpes simplex virus

There are two types of herpes simplex virus^[1]:

• Herpes simplex virus type 1 (HSV-1): This type mostly spreads by oral contact and traditionally causes infections in or around the mouth, resulting in cold sores. However, HSV-1 can also cause genital herpes^[2].
• Herpes simplex virus type 2 (HSV-2): This type spreads by sexual contact and usually causes genital herpes^[2].

Both HSV-1 and HSV-2 can cause either oral or genital herpes. Recent research shows that an increasing number of genital herpes cases are caused by HSV-1, especially among young people^[3].

How common is herpes?

Herpes is extremely common worldwide. According to the World Health Organization, an estimated 3.8 billion people under age 50 (64% of the global population) have HSV-1 infection. About 520 million people aged 15-49 (13% worldwide) have HSV-2 infection^[2].

In the United States, more than 50 percent of adults have oral herpes. Most people contract oral herpes during childhood by receiving a kiss from a friend or relative^[4]. For genital herpes, about 12% (one in eight) persons aged 14-49 in the United States have HSV-2 infection^[4].

As many as 85-90% of people with herpes are unaware they have the infection. This is because many people experience no symptoms or have symptoms so mild that they don’t notice them or confuse them with something else, like a pimple or ingrown hair^[20].

Signs and symptoms

Most people with herpes have no symptoms or only mild symptoms. Many people aren’t aware they have the infection and can pass the virus to others without knowing^[2].

When symptoms do occur, they often begin with tingling, itching or burning near where the sores will appear^[2]. The main symptoms include painful, recurring blisters or ulcers. These blisters may break open, ooze, and then crust over^[2].

Oral herpes symptoms include blisters (cold sores) or open sores in or around the mouth or lips^[2]. Skin may tingle, itch or burn up to 48 hours before blisters appear^[1].

Genital herpes symptoms include bumps, blisters, or open sores around the genitals or anus^[2]. In the 48 hours leading up to blisters appearing, people may experience fever, headache, swollen lymph nodes and itching or tingling^[1].

During the first infection, people may experience fever, body aches, sore throat (with oral herpes), headaches, and swollen lymph nodes near the infection^[2]. The first episode is often more severe and may last 10 to 19 days^[7].

People can have repeated outbreaks over time. However, over time, episodes of active disease decrease in frequency and severity^[1]. Repeat outbreaks are usually shorter and less severe than the first outbreak^[3].

How herpes spreads

Herpes is highly contagious and spreads through direct skin-to-skin contact^[1]. A herpes simplex infection occurs when the virus enters your body through your skin and mucous membranes (the moist tissue that lines certain parts of the body, including the mouth and genitals)^[1].

You can get herpes if you have contact with a herpes sore, saliva from a partner with oral herpes, genital fluids from a partner with genital herpes, or skin in the affected area of a partner with herpes^[3].

Importantly, you can get genital herpes from a sex partner who does not have a visible sore or is unaware of their infection^[3]. Transmission may still occur when symptoms are not present^[1]. There are several days throughout the year when the virus may be on the surface of the skin, but there are no symptoms. This is called asymptomatic shedding, and herpes can be passed through sexual contact during this time^[4].

Oral herpes caused by HSV-1 can spread from the mouth to the genitals through oral sex. This is why some cases of genital herpes are due to HSV-1^[3].

You will not get herpes from toilet seats, bedding, or swimming pools. You also will not get it from touching objects such as silverware, soap, or towels^[3]. Herpes is a very fragile virus and does not live long on surfaces^[4].

Parts of the body affected

Herpes simplex virus can cause infections in many parts of the body^[1]:

• Mouth and face: An oral herpes infection causes cold sores on the lips and around the mouth. Some people develop herpetic gingivostomatitis (sores inside their mouths and other symptoms) when they first get infected^[1].
• Genitals: A genital herpes infection causes sores in the genital area, including the parts you can see (like the vulva or penis) and those you can’t see (like the cervix)^[1].
• Skin on other areas: HSV can infect the fingers (herpetic whitlow) or skin anywhere on the body (herpes gladiatorum)^[1].
• Eyes: HSV can cause a serious eye infection called herpes keratitis^[1].
• Brain and spinal cord: HSV can infect the brain (herpes simplex encephalitis) or the protective layers surrounding the brain and spinal cord (herpes meningitis)^[1].
• Other organs: HSV can affect organs in the chest and belly, including the esophagus, lungs, and liver. These types of infections are more likely to affect people who are immunocompromised^[1].

How the virus stays in the body

One thing that distinguishes herpes viruses from other types of viruses is something called latency. Once HSV gains a foothold, the virus begins making copies of itself and spreading. In response, the immune system mobilizes to limit the virus’s spread^[4].

After the first infection, the virus stays in the body for life. To avoid the immune system, HSV retreats along the nerve pathways, hiding in a nerve root called a ganglion. In cases of genital herpes, HSV retreats to the sacral ganglion, located at the base of the spine. In oral or facial herpes, HSV finds its way to the trigeminal ganglion, at the top of the spine. In the ganglion, the virus remains inactive (latent) for an indefinite period of time^[4].

The virus may reactivate many times. While HSV is latent, various biological events can cause it to become active and begin traveling the nerve pathways back to the skin, where it can cause signs and symptoms again^[4]. Reactivation may be triggered by fever, emotional stress, suppression of the immune system, physical trauma, overexposure of the lips to sunlight, or other factors. Often, the trigger is unknown^[7].

Risk factors and links to other conditions

Anyone who has ever kissed can get oral herpes. Anyone who has ever had any type of sex can get genital herpes^[4]. Anyone who is sexually active can contract genital herpes^[4].

Risk factors for oral herpes include any activity that exposes one to an infected patient’s saliva, such as shared drinkware or cosmetics, or mouth-to-mouth contact^[8].

There is an important link between genital herpes and HIV. Herpes infection can cause sores or breaks in the skin or lining of the mouth, vagina, and rectum. This provides a way for HIV to enter the body. Even without visible sores, herpes increases the number of immune cells in the lining of the genitals. HIV targets immune cells for entry into the body^[3].

Having both HIV and genital herpes increases the chance of spreading HIV to an HIV-negative partner during oral, vaginal, or anal sex^[3]. HSV-2 genital herpes infection increases the risk for acquiring HIV twofold to threefold^[11].

Diagnosis and testing

Healthcare providers can usually make a diagnosis of herpes based on a physical exam and a history of sexual activity^[3]. Doctors easily recognize the sores caused by herpes in most cases^[7].

To confirm a diagnosis, providers will likely take a sample from an active sore. Tests of these samples are used to see if you have herpes simplex virus infection and show whether the infection is HSV-1 or HSV-2^[12].

The most sensitive tests for diagnosing herpes are NAAT assays (nucleic acid amplification tests, including PCR). These tests detect HSV from genital ulcers or other mucocutaneous lesions^[11]. Viral culture is another option but is less sensitive, especially for recurrent lesions^[11].

Less often, a lab test of your blood may be used for confirming a diagnosis or ruling out other infections. Type-specific serologic tests can be used to aid in the diagnosis of HSV infection in the absence of genital lesions^[11]. A blood test can show if you have herpes and, if so, whether it’s HSV-1 or HSV-2. However, a blood test cannot tell you what part of your body the virus will affect^[18].

A simple blood test can tell you if you have HSV in your body^[1]. If you want to be tested for herpes, ask your clinician, as a standard screening for sexually transmitted diseases may not include herpes unless you specifically ask^[18].

Treatment options

There is no cure for herpes. However, treatments can help make outbreaks more manageable while lowering the chances that you’ll spread the virus to others^[1].

Antiviral medications are the primary treatment for herpes. Three antiviral medications are FDA-approved for the treatment of genital herpes^[13]:

• Acyclovir: The oldest antiviral medication for herpes. It has been shown to be safe in people who have used it continuously (every day) for as long as 10 years^[13].
• Valacyclovir: A newer drug that uses acyclovir as its active ingredient. This medication delivers acyclovir more efficiently so that the body absorbs much of the drug, which has the advantage of taking the medication fewer times during the day^[13].
• Famciclovir: This medication uses penciclovir as its active ingredient to stop HSV from replicating. Like valacyclovir, it is well absorbed, persists for a longer time in the body, and can be taken less frequently than acyclovir^[13].

Antiviral medications can treat single outbreaks or help you manage HSV long-term^[1]. There are two kinds of treatment approaches^[13]:

Episodic therapy: A person begins taking medication at the first sign of an outbreak (ideally at first signs of tingling or other warning symptoms) and continues taking medication for several days to speed healing or even prevent an outbreak from fully occurring. For best results, treatment should begin at the very first sign of symptoms^[13].

Suppressive therapy: People with genital herpes who want to eliminate (suppress) outbreaks can take antiviral medication daily. For individuals who have frequent recurrences (six or more per year), suppressive therapy can reduce the number of outbreaks by at least 75% while the medication is being taken. For some people, taking an antiviral daily can prevent outbreaks altogether^[13].

Suppressive therapy also significantly reduces asymptomatic shedding. Studies have shown that suppressive acyclovir resulted in a 94% reduction in subclinical shedding while taking daily therapy. This helps lower the risk of transmitting the virus to sexual partners^[13].

In addition to antiviral medication, you can take ibuprofen or acetaminophen to limit pain, sit in a warm or cool bath, or use a moist compress to reduce the itching of sores^[19].

Prevention

The only way to completely avoid sexually transmitted infections is to not have vaginal, anal, or oral sex^[3].

If you are sexually active, you can do the following things to lower your chances of getting genital herpes^[3]:

• Being in a long-term mutually monogamous relationship with a partner who does not have herpes
• Using condoms the right way every time you have sex

Using condoms can help reduce the risk of transmission, although herpes can be present on skin that isn’t covered by the condom^[20].

To keep from infecting others, it’s important to get treatment and talk with your provider about medicines to reduce spreading the virus^[19]. If you have herpes, it’s crucial not to have sex during outbreaks and to be cautious even when there are no symptoms present. Taking suppressive antiviral therapy can significantly reduce asymptomatic shedding and help prevent passing the virus to partners^[13].

It’s super important to always tell partners if you have herpes, so you can help prevent it from spreading^[16].

Living with herpes

Finding out you have herpes can be tough, but it’s not the end of the world. Millions of people living with herpes have great lives and relationships^[16].

It’s normal to have lots of different feelings after you find out that you have herpes. You might feel mad, embarrassed, ashamed, or upset at first. But you’ll probably feel a lot better as time goes by, and you see that having herpes doesn’t have to be a big deal^[16].

Most people get at least one sexually transmitted infection in their lifetime, and having herpes or another sexually transmitted infection is nothing to feel ashamed of or embarrassed about. It doesn’t mean you’re “dirty” or a bad person — it means you’re a normal human who got a really common infection^[16].

Herpes isn’t deadly and it usually doesn’t cause any serious health problems. While herpes outbreaks can be annoying and painful, the first flare-up is usually the worst. For many people, outbreaks happen less over time and may eventually stop completely^[16].

For most people, herpes is a very manageable skin condition. Many people with herpes, both oral and genital, have no idea they have it. Imagine a person who has a single cold sore as a child or teen and then never has another—that is an HSV-1 infection that caused one outbreak and was never thought about again^[20].

The best thing to do when you find out you have herpes is follow your doctor’s directions for treating it. If you’re having a hard time dealing with the news, talking with a close friend or a support group for people living with herpes may make you feel better^[16]. The American Sexual Health Association has a list of support groups that meet in person, and there are many online support groups as well^[16].

People with herpes have romantic and sexual relationships with each other, or with partners who don’t have herpes. Talking about sexually transmitted infections isn’t the most fun conversation you’ll ever have, but it’s super important to always tell partners if you have herpes^[16].