Herpes Simplex

Herpes simplex virus is a common infection that affects millions of people worldwide. While there is no cure, the infection can be effectively managed with proper treatment and care.

Table of contents

• What is herpes simplex?
• Types of herpes simplex virus
• How common is herpes?
• Signs and symptoms
• How herpes spreads
• Parts of the body affected
• The virus stays in the body for life
• Getting tested for herpes
• Treatment options
• Preventing herpes
• Living with herpes
• Herpes and relationships

What is herpes simplex?

Herpes simplex virus (HSV) is a common infection that can cause painful blisters or ulcers on different parts of your body. The virus spreads primarily through skin-to-skin contact and is treatable but not curable^[1][2].

HSV causes fluid-filled blisters that break open and crust over wherever the infection occurs. This is known as a herpes outbreak. However, it’s also possible to have no symptoms at all and not realize you’re infected^[1].

Once you’re infected, the virus stays in your body for life. It usually remains dormant, or “asleep,” but may “wake up” and cause outbreaks. How HSV affects you depends on many factors, including the specific virus type and your overall health^[1].

Types of herpes simplex virus

There are two types of herpes simplex virus:

• Herpes simplex virus type 1 (HSV-1)
• Herpes simplex virus type 2 (HSV-2)

Both HSV-1 and HSV-2 can cause oral herpes or genital herpes. They also cause infections in other areas of your body^[1].

HSV-1 is traditionally associated with oral disease, while HSV-2 is traditionally associated with genital disease. However, lesion location is not necessarily indicative of viral type, as HSV-1 is now associated with genital infections more often than HSV-2 in some populations^[6].

HSV-1 often causes oral herpes, which can result in cold sores or fever blisters on or around the mouth. Most people with oral herpes get it during childhood or young adulthood from non-sexual contact with saliva^[3].

How common is herpes?

Herpes is extremely common worldwide. An estimated 3.8 billion people under age 50 (64%) globally have HSV-1 infection, which is the main cause of oral herpes^[2].

An estimated 520 million people aged 15-49 (13%) worldwide have HSV-2 infection, the main cause of genital herpes^[2].

In the United States, more than 50 percent of the adult population has oral herpes. According to the Centers for Disease Control and Prevention (CDC), about 12% (one in eight) persons ages 14-49 in the United States has genital HSV-2 infection. However, as many as 90 percent are unaware that they have the virus^[4].

In 2018, CDC estimates show there were 572,000 new genital herpes infections in the U.S. among people aged 14 to 49^[3].

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].

Up to 80% of herpes simplex infections are asymptomatic. When symptoms do occur, they can include painful, recurring blisters or ulcers^[6].

If symptoms occur, they often begin with tingling, itching, or burning near where the sores will appear. Blisters may break open, ooze, and then crust over^[2].

Symptoms may be different during the first episode (or outbreak) of infection than during a recurrent episode. New infections may cause fever, body aches, and swollen lymph nodes^[2].

Oral herpes symptoms

Common oral herpes symptoms include:

• Blisters (cold sores) or open sores (ulcers) in or around the mouth or lips
• Pain, burning, tingling, or itching on the lips or mouth
• Skin may tingle, itch, or burn up to 48 hours before blisters appear^[1][2]

Genital herpes symptoms

Common genital herpes symptoms include:

• Bumps, blisters, or open sores around the genitals or anus
• Blisters on and around your genitals
• Symptoms in the 48 hours leading up to blisters appearing may include fever, headache, swollen lymph nodes, and itching or tingling^[1][2]

During their first infection, people may experience fever, body aches, sore throat (oral herpes), headache, and swollen lymph nodes near the infection^[2].

Mild symptoms may go unnoticed or be mistaken for other skin conditions like a pimple or ingrown hair. Because of this, most people do not know they have a herpes infection^[3].

How herpes spreads

Herpes is transmitted through direct skin-to-skin contact. This happens when a contagious area comes into contact with a tiny break in the skin or mucous membrane tissue (the moist tissues that line body openings), usually on the mouth or genitals^[4].

You can get herpes if you have contact with:

• A herpes sore
• Saliva from a partner with an oral herpes infection
• Genital fluids from a partner with a genital herpes infection
• Skin in the oral area of a partner with oral herpes
• Skin in the genital area of a partner with genital herpes^[3]

You can also get genital herpes from a sex partner who does not have a visible sore or is unaware of their infection. It is also possible to get genital herpes if you receive oral sex from a partner with oral herpes^[3].

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].

Genital herpes can be transmitted sexually both when symptoms are present and sometimes when symptoms are not present. 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].

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. Herpes is a very fragile virus and does not live long on surfaces^[3][4].

Parts of the body affected

Herpes simplex virus can cause infections in many different parts of your body, including:

• Mouth and face: An oral herpes infection causes cold sores on your lips and around your mouth. Some people develop herpetic gingivostomatitis (sores inside their mouths and other symptoms) when they first get infected. Rarely, sores develop on or inside your nose (nasal herpes)
• Genitals: A genital herpes infection causes sores in your genital area, including the parts you can see (like your vulva or penis) and those you can’t see (like your cervix)
• Skin on other areas of your body: HSV can infect your fingers (herpetic whitlow) or skin anywhere on your body (herpes gladiatorum). Eczema herpeticum, a widespread skin infection, is a complication of HSV infection that affects people with atopic dermatitis
• Eyes: HSV can cause a serious eye infection called herpes keratitis (a type of ocular herpes)
• Brain and spinal cord: HSV can infect your brain (herpes simplex encephalitis) or the protective layers surrounding your brain and spinal cord (herpes meningitis). If HSV infects both your brain and its protective layers, you can develop a life-threatening condition called herpes meningoencephalitis
• Other organs: HSV can affect one or more organs in your chest and belly, including your esophagus (herpes esophagitis), lungs (HSV pneumonia), and liver (HSV hepatitis). These types of infections are more likely to affect people who are immunocompromised^[1]

The virus stays in the body for life

One thing that distinguishes viruses in the herpesvirus family 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 limits HSV’s spread^[4].

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 (cold sores), HSV finds its way to the trigeminal ganglion, at the top of the spine. In the ganglion, the virus remains inactive or latent for an indefinite period of time^[4].

The phenomenon of latency is similar to a sleep cycle. The virus remains in a safe haven and sleeps, sometimes for long periods. Unfortunately, while HSV is latent, various biological events can cause it to become active and begin traveling the nerve pathways back to the skin. There it can cause signs and symptoms again, though it doesn’t always do this^[4].

People can have repeated outbreaks over time. However, for many people, outbreaks happen less over time and may eventually stop completely^[2].

Getting tested for herpes

Your health care provider can usually make a diagnosis of genital herpes based on a physical exam and a history of your sexual activity. To confirm a diagnosis, your provider will likely take a sample from an active sore^[14].

The best way to determine if someone is infected with HSV-1 or HSV-2 is to perform a laboratory analysis on a sample from a fresh herpes sore. One or more 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^[14][16].

Nucleic acid amplification tests (NAAT), including PCR assays, are the most sensitive tests because they detect HSV from genital ulcers or other mucocutaneous lesions. Although multiple assays exist for HSV detection, these tests vary in sensitivity from 90.9% to 100%; however, they are considered highly specific^[10].

In certain settings, viral culture is the only available virologic test. The sensitivity of viral culture is low, especially for recurrent lesions, and decreases rapidly as lesions begin to heal^[10].

Because not everyone with herpes has symptoms, your clinician may instead use a blood test that can detect antibodies to herpes viruses. 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^[16].

Both type-specific and type-common antibodies to HSV develop during the first weeks after infection and persist indefinitely. The majority of available, accurate type-specific HSV serologic assays are based on the HSV-specific glycoprotein G2 (gG2) for HSV-2 and glycoprotein G1 (gG1) for HSV-1^[10].

If you want to be tested for herpes, ask your clinician. A standard screening for sexually transmitted diseases may not include herpes unless you specifically ask^[16].

Treatment options

There’s no cure for genital herpes. However, treatment with prescription antiviral pills may be used to help sores heal during a first outbreak, lower the frequency of recurrent outbreaks, lessen the severity and duration of symptoms in recurrent outbreaks, and reduce the chance of passing the herpes virus to a partner^[14].

Commonly prescribed medicines used for genital herpes include:

• Acyclovir (Zovirax)
• Famciclovir
• Valacyclovir (Valtrex)^[14]

These medications all act by interfering with the viral DNA polymerase and hence, viral genome replication. Long-term use of these antiviral drugs is considered safe. Acyclovir has been shown to be safe in persons who have used it continuously (every day) for as long as 10 years^[11][12].

Your health care provider will talk to you about the right treatment for you. Treatment depends on the severity of disease, the type of HSV, your sexual activity, and other medical factors. The dose will vary depending on whether you currently have symptoms^[14].

Episodic therapy

In this approach, a person begins taking medication at the first sign of an outbreak (or ideally at first signs of prodrome) and continues taking medication for several days, in order to speed healing or even prevent an outbreak from fully occurring. All three of the antiviral treatments mentioned above have been proven to help shorten the amount of time that a person may experience symptoms of herpes^[12].

Antiviral medication is commonly prescribed for patients having a first episode of genital herpes, but they can be used for recurrent episodes as well. Antivirals are effective when taken within 72 hours of lesion appearance in genital herpes^[11].

Suppressive therapy

People with genital herpes who want to eliminate (suppress) outbreaks can take antiviral medication daily to hold HSV in check so that it’s less likely to flare up and cause symptoms. For individuals who have frequent recurrences (six or more per year), studies have shown that suppressive therapy can reduce the number of outbreaks by at least 75% while the medication is being taken. Also, for some, taking an antiviral on a daily basis can prevent outbreaks altogether^[12].

While antivirals can be successful in controlling herpes symptoms, researchers have also found that suppressive therapy lowers the risk of unrecognized herpes reactivation. One study addressing this question found that women on suppressive acyclovir had a 94% reduction in subclinical shedding while taking daily therapy^[12].

Suppressive therapy has been studied in thousands of patients and appears to be both safe and effective^[12].

Other symptom management

To ease symptoms:

• Start treatment at the first sign of symptoms, such as itching or tingling. Call your healthcare provider at the first sign of an outbreak
• Take ibuprofen or acetaminophen to limit any pain
• Sit in a warm or cool bath or use a moist compress to reduce the itching of sores^[19]

Appropriate wound care is needed, and treatment for secondary bacterial skin infections may be required^[11].

Preventing herpes

The only way to completely avoid sexually transmitted infections is to not have vaginal, anal, or oral sex. If you are sexually active, you can do the following things to lower your chances of getting genital herpes:

• 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^[3]

It’s important to keep in mind that herpes can be transmitted even when condoms are used, as condoms may not cover all infected areas. However, condoms do reduce the risk of transmission^[3].

To keep from infecting others, get treatment and talk with your provider about medicines to reduce spreading the virus. Suppressive therapy can help lower your chances of spreading the virus^[19].

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^[15].

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^[15].

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. Even though the virus hangs around in your body for life, it doesn’t mean you’ll be getting sores all the time^[15].

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^[15].

There are a lot of online support groups for people who have herpes, and the American Sexual Health Association has a list of support groups that meet in person^[15].

Herpes and relationships

Some people feel like their love lives are over when they find out they have herpes, but it’s just not true. People with herpes have romantic and sexual relationships with each other, or with partners who don’t have herpes^[15].

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, so you can help prevent it from spreading^[15].

By disclosing your infection to your partner, you’re not only establishing a tone of trust — good for any healthy relationship — but you’re also taking an important step to reduce transmission. According to one study of discordant couples (where one partner had genital herpes and the other did not), there was a significant delay in transmission when the positive partner disclosed his or her infection. The average time for transmission was 60 days for those who didn’t disclose, compared to 270 days for those who did^[18].

Before you talk about herpes and sexual health with a partner, make sure you are prepared to address any misinformation or misconceptions he or she might have. Be prepared with information from reliable sources^[18].

While there’s no specific timeline that dictates the best time to talk about herpes with a new partner, the discussion should ideally occur before any sexual activity has taken place. Once the relationship is heading in the direction of sexual activity, and you’ve both had the opportunity to get to know each other and establish a degree of trust, you should feel more confident sharing this personal information^[18].

A few tips to consider when talking to a partner:

• Choose a neutral setting during a time when you won’t be distracted or interrupted
• Be natural and speak with confidence. You are not lecturing or confessing; you’re sharing personal information
• Remain calm. If you are upset, a partner might think it’s worse than it is^[18]

Remember that this should not be treated as a “confession” or some kind of admission that you have done something wrong. It is what it is — a sexually transmitted infection. The bottom line is that sexual activity is a natural act that most everyone will have at some point in their lives. With sexual activity anywhere by anyone, there is some level of risk^[18].