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Herpes Simplex Infections (Non-Genital)
Herpes Simplex Infections
(Non- Genital)
Herpes simplex infections are common, unsightly, and embarrassing. When they appear in their most common location, around the mouth and lips, people often refer to them as "cold sores" and "fever blisters."
How many kinds of herpes virus are there?
The herpes virus has two forms called -- what else? -- type I and type II. In general, type I infections occur above the waist, while type II infections occur below the waist. Type II infections are associated with genital herpes.
However, the distinction between types I and II herpes is not absolute. Clinically, the distinction doesn't matter a great deal since a determination between the two types plays no role in diagnosing and treating people with herpes infections in everyday practice.
What is the most characteristic feature of herpes infections?
The most striking characteristic of herpes infections, no matter where they occur on the body, is their tendency to recur in more or less the same place. Such recurrences may happen often (for example, once a month) or only occasionally (for example, once or twice a year).
What makes herpes recur?
The tendency of this virus to establish itself in the nerve collections (called ganglia) under the skin is responsible for the recurrences. Repeated episodes occur when the virus is reactivated by: - Fever;
- Systemic (body-wide) infection;,
- Ultraviolet radiation (like a sunburn);
- Stress;
- Changes in the immune system;
- Trauma; or
- Unidentified causes.
What other conditions can look like herpes?
Before we discuss herpes simplex itself in more detail, we should mention some herpes "look-alikes." These conditions, including angular stomatitis and " canker sores ," can be confused with herpes.
What is angular stomatitis?
Angular stomatitis refers to cracking and irritation at the corners of the mouth. In contrast, herpes infections usually appear on the upper or lower lip margins, not in the corners. Angular stomatitis occurs especially in people who wear dentures, whose saliva can accumulate and lead to the overgrowth of yeast.
What are canker sores?
Aphthae, or cankers, typically appear inside the mouth, where herpes itself rarely develops. The exception is in severe primary attacks of herpes.
Canker sores are small and quite painful. They are found on the inner cheeks and lower lip as well as on the tongue, palate, and the covering of the gums. Although canker sores are presumed to be caused by a virus, none has ever been identified and the condition is not contagious.
What does true herpes look and feel like?
The hallmark of herpes is grouped blisters on a red base. These blisters dry up rapidly and leave scabs that last anywhere from a few days to a few weeks, depending on the severity of the infection. This pattern has important implications for the many people who fear they have herpes but don't:
If something totally goes away in a day or two or if, on the other hand, it lasts for more than a few weeks, it can't be herpes!
Herpes infections feel dry and crusty and they sometimes itch. Some patients have a "prodrome," which is the occurrence of certain symptoms before the actual condition becomes fully evident. The prodrome to herpes infections typically involves a burning or tingling sensation that precedes the appearance of blisters by a few hours or a day or two.
What is primary herpes?
The first time someone is exposed to herpes, the virus often infects the body without causing any noticeable problem. This process generates an antibody response in which the immune system produces specific proteins that are directed against the herpes virus. The antibody response usually makes recurrences mild.
Sometimes, however, the first attack of herpes causes people to become very sick. It may cause fever, swollen glands, and bleeding gums, together with painful sore(s) around the mouth (gingivostomatitis). These signs and symptoms may last several days. Difficulty in eating and drinking may lead to dehydration. The viral infection typically lasts 10 to 14 days. The herpes blisters themselves may last anywhere from 2 to 6 weeks before they scab over and go away, usually without scarring.
Primary herpes is typically contracted during childhood.
What does recurrent herpes look like?
By far the most common manifestation of herpes infections -- what people usually mean when they speak of "herpes" or "cold sores" -- is a recurrence of the virus when it is reactivated from its latent sleep in the nerves below the skin. What this looks like depends on where the virus has been hibernating: - Labial herpes: This is the familiar cold sore that appears on the lip margins (labial refers to the lip). When labial herpes reappears, it usually occurs at most a few millimeters away from its previous location(s).
- Herpetic whitlow: Sometimes, the herpes virus shows up on the fingertip. This is especially common in dental and medical workers who have to put their fingers inside people's mouths, despite the use of gloves.
- Wrestlers' herpes: This has the picturesque name, "herpes gladiatorum." Gladiators, or nowadays just plain wrestlers, can contract herpes from an opponent who is shedding the virus. This form of herpes can appear all over the body.
Wrestlers differ from most other patients with herpes who only develop recurrences in one spot. The reason for this is that although the antibodies in the bloodstream do not prevent the herpes from returning, they do make it hard for the virus to get a foothold anywhere else on the body. (If this weren't so, cold sores would spread to other parts of the body from routine actions, such as face washing, which doesn't happen.)
How is herpes spread?
Air droplets can spread the virus, as can direct contact with the fluid from the blisters. It is not easy to catch herpes from towels and washcloths. Additionally, once the blisters have dried and crusted over (within a few days), the risk of contagion is significantly lessened.
Some people with herpes shed low levels of the virus even when there is no visible evidence of herpes on their skin. There is little or nothing that they or their contacts can do about this. Although the likelihood of transmission from invisible herpes is low, there is still some risk of contagion.
How is herpes diagnosed?
By and large the diagnosis of herpes is a clinical diagnosis, meaning that laboratory tests are often neither necessary nor useful. Swabbing the blister in an attempt to culture the virus in the lab is only productive in the first couple of days before the blister has a crusted over. By the time the culture has grown the virus, generally 3 to 5 days, the condition has usually healed.
A common and challenging situation presents itself when someone thinks he or she might have had herpes, but whatever the rash was has disappeared without leaving a trace. Cultures are of course no help, because there's nothing to culture. Blood tests are likewise often irrelevant, since a finding of antibodies to herpes just means that the body has been exposed to this virus at some point in the past. It does not mean that there was a particular infection or that there is one now. (Once in a while, a test showing the absence of antibodies provides useful as evidence that the rash was not herpes. However, most people do have antibodies in their bloodstream since herpes infections are extremely common.)
In such baffling cases, the most useful approach is to encourage the person to see a doctor at the first sign of a recurrence. This makes a visual diagnosis, perhaps aided by a culture, feasible. There is of course no way to anticipate when or if such a recurrence will actually happen.
How is herpes treated?
Currently, there is no method to eliminate the herpes virus from its resting place in the nerve cells. Treatments are available, however, to help the infections heal faster and, if taken continually, to suppress most recurrences. - OTC topical medications: Over-the-counter (OTC) topical products that state they are for herpes do absolutely nothing but make the skin tingle. These preparations have the effect of allowing the infection to heal in the same number of days as it would have done anyway.
Topical anesthetics are sold that can be applied directly with a swab (often containing dyclonine or benzocaine, which are the local anesthetic agents). When large areas are affected by the herpes, a thick (viscous) preparation of the local anesthetic lidocaine is also available that can be used as a mouth rinse. However, swallowed lidocaine is hazardous because it anesthetizes (numbs) the inside of the mouth, the throat, and even the epiglottis (the cover to the windpipe). Children should probably not use such topical anesthetics for fear of aspiration (getting something they've swallowed down the wrong way into the lungs).
- Prescription-strength topical medications: Prescription- strength topical medicines (ones you put on the herpes sores) are not much more effective than OTC preparations. Patients who have a prodrome (a tingling or burning sensation which lets them know they are about to get a cold sore) can reduce the duration of their infection by applying acyclovir (Zovirax) ointment or one of its newer relatives, such as famciclovir (Famvir), valaciclovir (Valtrex), or penciclovir (Denavir). These medications are available only by prescription. (Their safety during pregnancy and nursing and their safety and efficacy for children under the age of 18 years have not been established.)
- Oral medications: Effective anti-herpes antibiotics include acyclovir (Zovirax), famciclovir (Famvir), and valaciclovir (Valtrex). (Again, the safety of these drugs during pregnancy, nursing, and in children under the age of 18 years has not been established.) All of these anti-herpes antibiotics are remarkably easy to tolerate and are generally free of side effects. When taken early, preferably during a prodrome, these drugs can limit the duration of the infection to some extent. They are also useful in helping prevent or minimize recurrences when taken for extended periods. This method is helpful for patients who experience frequent recurrences, or who have a particular event or situation (such as a wedding, honeymoon, or vacation) at which an unsightly recurrence would be especially unwelcome.
- Lysine supplements: Although the amino acid lysine suppresses the growth of the herpes virus in laboratory test tubes, taking lysine pills by mouth has not proved effective. What works in the lab doesn't necessarily work in a person, and that is the case with lysine. Nevertheless, some people find this over-the-counter remedy helpful.
Last updated on 07/03/2008
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