Genital Herpes

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Cold sore or Oral-labial Herpes

BOTHERSOME BLISTERS STOP 54 % OF SUFFERERS FROM KISSING LOVED ONE

TORONTO, Ontario (May 22, 2003) -- Cold sores can mean less puckering up for sufferers. According to a recent Canadian survey conducted by Ipsos Reid, 54 per cent of cold sore sufferers said that their infections have stopped them from kissing loved ones such as partners, family members and friends. In addition, results of the survey show that 55 per cent of cold sore sufferers said their infections make them feel self-conscious, frustrated and/or embarrassed. Some cold sore sufferers (9 per cent) have gone as far as to cancel social engagements due to an outbreak.

Treatment at the first tingle

With the approval of Valtrex© (valacyclovir hydochloride) by Health Canada, the first one-day, oral antiviral medication indicated for the treatment of cold sores, sufferers have an option for treating their infections. Shown to reduce the pain and duration of a cold sore when taken at the first ‘tingle’, itching, burning or early signs of an outbreak, Valtrex© may ease discomfort of those who suffer from these bothersome blisters.

"Valtrex© is taken for just one day. It stops the growth of the virus at the source," said Dr. K.A. Papp, dermatologist and President of Probity Medical Research. "Valtrex is able to not only shorten the duration of the cold sore, but also alleviate the pain and discomfort associated with cold sores more quickly than placebo."

About cold sores and VALTREX©

Commonly referred to as fever blisters, cold sores are highly contagious ulcers or blisters that form on the outer edge of the mouth, and generally last for seven to ten days. Those who suffer from cold sores typically feel a tingling sensation just beneath the surface of the skin before the blisters actually form. People with cold sores are advised to avoid kissing, or direct contact with the sores, and to wash their hands immediately after touching the sore.

It is estimated that 20 to 40 per cent of the adult population suffer from cold sores. Typically, cold sore sufferers will experience three to four outbreaks every year. Exposure to certain triggers including sunlight, stress, fatigue, and hormonal changes can cause a cold sore outbreak.

The recommended dosage of Valtrex© for cold sores is two grams twice daily for one day only (24-hour period). The second dose should be taken approximately 12 hours after the first dose, but not less than six hours after the first dose. Therapy should be initiated at the earliest symptom of a cold sore (e.g., tingling, itching or burning). There are no data on the efficacy of treatment initiated after the development of clinical signs of a cold sore (e.g., blister, bump or open sore). Possible side effects with Valtrex© for cold sores include headache and dizziness.

Genital Herpes

You have just been diagnosed with herpes, you suspect that you are suffering from herpes, or your sexual partner has just informed you of the fact that they are infected with genital herpes...you are stressed, overwhelmed or in shock. Let's try to put things in perspective - education is an important step in treating and managing herpes.

What causes genital herpes?

Herpes viruses are very common in our society and are responsible for many types of diseases i.e. chickenpox or varicella and mononucleosis are caused by viruses belonging to the herpes virus family. Genital herpes is caused by a virus of which there are two types; herpes simplex 1 and herpes simplex 2.

The common denominator when exploring herpes viruses is that they have the ability to recur, or come back. They are viruses that gain access into our bodies via breaks in the skin or mucus membranes (thin linings of the mouth or genitalia). Contrary to common belief, herpes infects the nerve responsible for sensation in the region afflicted. It is able to house itself in the center (ganglion) of the infected nerve and sleep (latent phase). When it wakes up (recurrence) it replicates or reproduces and travels down the nerve to the skin where the virus creates the damage evidenced by blisters, sores and wounds (more on that later).

How is herpes transmitted?

Genital herpes is transmitted through sexual contact. It is not an infection that is passed along on shared ustensils, towels or soaps - albeit this is a frequent question in our clinic. Herpes may be transmitted through simple skin-to-skin contact (genital to genital) or through contact with contaminated genital secretions. This implies a risk associated with sexual penetration; vaginal, anal or oral as well as direct contact without penetration. After exposure to the virus, a 2 to 20 day incubation period ensues followed by the primary genital herpes outbreak. Unfortunately, approximately half or 50 % of individuals infected will not develop symptoms and thus remain unaware of their herpes status.

The greatest risk of transmitting or acquiring genital herpes is when you or your infected partner are suffering from an outbreak. It is felt that this increased risk period likely includes the 12 to 24 hours prior to the visual appearance of skin lesions (when the virus is reproducing in the nerve cells). Many individuals who experience recurrences of their genital herpes are able to identify the imminent onset of an outbreak because of their « prodrome » . A prodrome may include odd neural sensations such as localized itching, burning, tingling or numbness, and this in the region where the lesions tend to occur. High risk begins at this point and persists until the lesions have « crusted over » - meaning that there are scabs on the surface.

The risk of transmission is diminished in the absence of lesions, although is not considered to be « no risk » . In the past it was believed that if there were no skin lesions, then there was no risk. Studies have documented that individuals infected with genital herpes may in fact occasionally excrete herpes virus from the nerve and through the skin, and this even in the absence of an episode. Rates of asymptomatic excretion vary greatly from one person to another, and from one study to another. It is felt that there is approximately one day in ten when such excretion occurs...obviously it is impossible to know which day (outside of research techniques). This is typically frustrating for patients and couples living with herpes (we will discuss living with herpes later).

What are the symptoms of genital herpes?

A very important point when discussing the symptoms of herpes is that genital herpes comprises a vast spectrum of disease. This means that it may present very differently from one person to the next and even from one episode to another in the same individual. One can describe a « classical » or « typical » herpes outbreak as such : an initial tingling or prodromal sensation in the region affected, followed by the appearance of a slight redness and/or swelling at the site. This is rapidly (hours to days) followed by the development of small clustered vesicles (fluid-filled blisters) that are quite fragile, quickly breaking open to expose small punctate (punched-out appearance) ulcers or sores. These sores are sensitive or painful to touch. Within days these sores crust over via the development of a scab and then skin healing ensues. From beginning to end, a recurrence may last anywhere from a couple of days to a couple of weeks. On average, most recurrences of genital herpes last 5-7 days.

What is the difference between the first outbreak and recurrences?

As your physician may have explained, when the initial episode of genital herpes is symptomatic, it is quite often the worst episode you will experience. When your body encounters genital herpes for the first time there tends to be not only a local immune reaction, but a generalized one as well. You may experience « consitutional symptoms » that include fever, fatigue, nausea and or vomiting, muscle aches or pains, etc.. This is accompanied by the sequence of skin lesions described previously and may also be accompanied by swollen lymph nodes (part of your immune system) in the groin or inguinal region. These nodes may be sore and sensitive to the touch.

When we talk about a recurrence of genital herpes, one tends to experience fewer lesions and symptoms in comparison with the initial outbreak. There are rarely swollen lymph nodes or constitutional symptoms. The time from outbreak to skin healing is typically shorter in a recurrence.

How is genital herpes diagnosed?

Quite often, a well-qualified physician is able to make a diagnosis of genital herpes based on a compatible history and visual examination that is compatible with herpes. There are only a few recurring genital diseases. When the lesions of herpes are classical, they are difficult to confuse with other illnesses.

When possible, your physician will culture your herpes lesions in an attempt to "confirm" the diagnosis and thus enable an analysis of the type of herpes and its associated prognosis.

Is a herpes culture test painful?

It must be said, that herpes lesions in and of themselves are often quite sensitive to the touch or even downright painful. In an attempt to increase the success of a herpes culture test, your physician will need to gently swab or rub the surface of one of your herpes lesions.."ouch!". Fortunately, this is a rapid test. The results of a herpes culture take approximately 2 - 3 weeks. A frequent question is "why does it take so long to receive results?". Herpes cultures require that the virus be grown and identified in the laboratory. This is a process that we cannot rush.

My results are negative???

A frequent source of consternation is when the physician's diagnosis of herpes is accompanied by a negative culture result. What does this mean? It is important to stress that timing is critical when attempting to successfully confirm the presence and type of herpes. The highest rates of confirmation and identification result from cultures performed in the first 24-48 hours following onset of herpes sores - even moreso when the lesions are still intact. When your sores have blistered open or have been present for greater than 48 hours, the culture success rate decreases enormously. Timing is everything! A negative result in the presence of a physician diagnosis does not rule out herpes - it is not unusual to require two or three culture attempts prior to confirmation.

If you suspect that you are suffering from a herpes outbreak - call for an emergency appointment! Make sure to highlight the reason for your call - Timing is everything and we will do our best to see you as soon as possible!

How else can herpes be confirmed?

At times a special test termed a "differential serology" or blood test may be offered in an attempt to confirm the presence and type of herpes infection present. Older blood tests available are unable to distinguish between HSV-1 and HSV-2 infections – these tests have been available for years and are only useful when negative. We now have at our disposition newer blood tests that are able to identify and differentiate between the two types of herpes. After an initial infection or primary infection it may take several weeks for the antibodies produced by your body in reaction to herpes to appear. The timing of such tests are important- speak with your doctor. Test results may be erroneous at times; false-negative and false-positive tests do occur, albeit infrequently.

What about genital herpes and pregnancy?

Herpes and pregnancy

Once again, genital herpes is common, approximately 25 % of the adult population is infected (known or not) by genital herpes. This follows through that outbreaks of genital herpes during pregnancy can occur. In the event of recurrent outbreaks (you contracted herpes prior to pregnancy), the risk of contaminating the baby are during delivery and vaginal passage. The risk of infection to the newborn is very low if there are no active lesions detected in the week to days prior to delivery. In the event of lesions, your doctor may recommend a caesarean-section to be sure to avoid transmission of herpes which can lead to a severe lung infection (pneumonia) in the newborn. This is an infrequent occurrence and most women are able to deliver their children by spontaneous vaginal birth. If infection is suspected, there are effective anti-viral medications useful in treating and decreasing the rate of complications in the newborn.

The risk of flare-up at the time of delivery also depends on the natural history of your herpes…if you have had no or very few recurrences in the months to years prior to pregnancy and delivery then the chance of reactivation at delivery is likely quite slim. The chances of perinatal transmission are highest when genital herpes is acquired late in pregnancy.

At times your doctor may prescribe anti-viral medications to be taken during pregnancy. This is infrequent during the first two trimesters of pregnancy. Your obstetrician may encourage the use of anti-virals in the eighth or ninth month of pregnancy so as to prevent outbreaks and decrease the risk of asymptomatic transmission at birth.

To put neonatal herpes infections into perspective, an estimated 20-25% of pregnant women are sero-positive for genital herpes, while less than 0.1% of babies contract an infection. Protective antibodies against herpes are passed from the mother to the fetus and are in large part responsible for low transmission rates. These protective antibodies are transferred via the placenta at approximately 28 weeks gestation – this means premature babies may be at greater risk for infection at birth.

It is important that you inform your gynecologist-obstetrician or midwife of your genital herpes status such that an appropriate management plan may be decided upon.

The first outbreak can be more dangerous: If the first episode of genital herpes occurs while pregnant, the virus can be passed on through the placenta to the unborn child with serious consequences. About half of babies infected this way are either stillborn or suffer damage to the brain, nerves, eyes or skin.

The important question is whether this is truly a first episode during pregnancy or a reactivation..If performed promptly, a Western blot blood serology can tell you whether the outbreak is a true primary (a new infection in a person with no previous antibodies to either HSV-1 or HSV-2), a non-primary first episode (an infection of HSV-2 in a person with previous antibodies to (HSV-1), or a recurrence. Speak with your doctor – timing is of the essence in determining your situation.

Prevention is key!!

Your partner is pregnant, and you have herpes…

If you have either oral or genital herpes and your partner is uninfected and pregnant, you may want to take steps to ensure that you don't transmit herpes to her during this special time. Serological or blood testing may be considered to evaluate your partner’s HSV status, when unknown.

• Abstain from sex during outbreaks
• Use condoms for intercourse
• Avoid oral sex when suffering from a cold-sore
• Consider suppressive anti-viral therapy, particularly in the last trimester
• Consider alternatives to intercourse in the last trimester, mutual masturbation, massage, kissing, etc.

How is herpes treated?

One of the difficult parts of our job as a physician is informing you that there is no cure for herpes virus infections. While research continues in the field of vaccine development (vaccines to prevent infection and perhaps to assist your body in better virus control) we are still several years from a commercially available product. Antiviral medications have come a long way over the years and newer medications are easier to dose and are generally very well tolerated. Medications such as acyclovir (Zovirax), famcyclovir (Famvir), valacyclovir (Valtrex), have a significant effect via their ability to decrease the severity of your herpes symptoms and the duration of your outbreak. Antivirals (different from antibiotics) have had a tremendously positive effect on patient's "quality of life". When used to treat outbreaks, the medications are taken by mouth for a period of 3 - 5 days - dosages may vary. These same medications can also be used to prevent recurrences of genital herpes. The suppressive approach to genital herpes involves the daily administration of one of the three antivirals, thereby effectively suppressing the virus' ability to reproduce and consequently establish an outbreak...this is a great thing for patients who suffer from multiple or severe episodes. Typically your physician will discuss suppressive approaches when you suffer from more than 6 episodes per year. Talk with one of our physician consultants about your personal herpes experience.

New!! Dosage and administration of Valtrex©

Initial episode of genital herpe

The recommended dosage of Valtrex© Caplets for the treatment of an initial episode of genital herpes is 1000 mg orally twice daily for 10 days. There are no data on the effectiveness of treatment with Valtrex? When initiated more than 72 hours after the onset of signs and symptoms. Therapy was most effective when administered within 48 hours of the onset of signs and symptoms.

Recurrent genital herpes

The recommended dosage of Valtrex© Caplets for the treatment of recurrent genital herpes is 500 mg orally twice dailys for 3 days. Therapy should be initiated at the earliest sign or symptom of recurrence. Valtrex© Can prevent lesion development when taken at the first signs and symptoms of a genital herpes recurrence.

Suppression of genital herpes

The recommended dosage of Valtrex© Caplets for chronic suppressive therapy of recurrent gential herpes is 1000 mg orally once daily in patients with normal immune function. In patients with a history of 9 or fewer recurrences per year, an alternative dose is 500 mg orally once daily.

In patients with HIV infection with CD4 counts 100, the recommended dosage of Valtrex© Caplets for chronic suppressive therapy of recurrent genital herpes is 500 mg orally twice daily.

How can I prevent transmission of genital herpes?

As mentionned above, vaccine research has recently demonstrated that the current studies into preventive vaccines are successful in women who have never had genital or oro-labial herpes (herpes type 2 or type 1). Interestingly, the studies show no real benefit for men - reasons for this discrepancy are being explored. While this vaccine is not yet commercially available, the next phase of research (to commence early 2003) will be recruiting women (negative for herpes type 1 and 2) who are in a stable relationship with a partner(positive for herpes type 2). Inquire!

Abstinence is the only sure method of preventing the transmission of genital herpes from one person to the next. The correct and regular use of condoms(covering all infected skin areas), and avoiding sexual activity when sores are present will significantly decrease the risk of infection, but will not entirely eliminate the risk. The bottom line is that condoms work to a certain extent, not 100 %. The long-term use of condoms in a stable monogamous relationship is a decision to be made as a couple.

An additional approach in the prevention of herpes transmission is the use of suppressive antiviral medications (mentioned earlier). A recent large study demonstrated that when the herpes infected partner maintained suppression with a daily dose of valacyclovir, he/she was able to decrease the transmission of symptomatic herpes infection by 50 %. This is very interesting news!

How to avoid transmitting genital herpes?

• Have an open discussion with new sexual partners about STD’s and herpes… before engaging in sexual relations!
• Use a condom to decrease the male to female transmission of herpes
• Avoid all sexual relations during an outbreak of herpes
• Consider the use of suppressive anti-herpes medications as discussed in the treamtment section; speak with your doctor.

Who is at risk of genital herpes?

• people who have several different sex partners
• people whose sex partners have a number of different sex partners (and so on, and so on…)
• people who don't use condoms
• people with a history of other sexually transmitted infections

How to avoid contracting genital herpes?

• Avoid passive oral sex if your partner is suffering from a cold-sore
• Avoid sexual relations if your partner is suffering from a known outbreak of genital herpes
• Avoid sexual relations if your partner is suffering from bumps, sores, itching, burning or an undiagnosed rash in the genital-anal region
• Women should consider the use of condoms at all times as they help to decrease the risk of male to female transmission of genital herpes

How do I tell my sexual partner I have herpes?

There is no single or easy answer to this very important question. At times you may want to consider seeking professional help from one of our knowledgeable specialists (sexologist) in order to prepare for disclosure, particularly the first time. It is important to inform your sexual partner(s).

It is important to realize that education is one of the first steps. It is important to understand the infection and thereby diffuse the myths and mysteries that seem to accompany the term "herpes". It is important to be able to address any questions that your new partner may have. Important points are the frequency of herpes in the general population (25%) and its similarity to cold-sores (oro-labial herpes).

It is important for you to have come to terms with your own infection. If you are still unable to handle living with herpes yourself, it will be difficult to successfully talk about herpes with a new or potential partner. Your calm, direct and open approach will often help to generate further discussion and, once again, education. Fear of herpes often stems from your own or your partner’s ignorance of herpes. You may want to suggest a joint visit to one of our physicians, so as to talk freely in a stable environment – this may serve to reassure your partner. Ensure that this discussion takes place in a quiet and private location. The fewer the distractions, the better.

Timing is important…do not wait until after sex! Announcing your herpes infection just before sexual relations is probably not the best time, and may fall to the wayside in the heat of the moment. Developing a relationship prior to sex, and disclosing herpes before intimate relations is in most instances the best approach.

Your new partner may surprise you with the same news – herpes is common! In the event of a negative or emotional reaction, remember that your first reaction was likely spontaneous and emotional…it may take your partner some time to think through and deal with the news. Give them the space and time needed.

Herpes and HIV/AIDS infection

It is important to note that the presence of an HSV or herpes infection increases your risk of contracting the HIV virus, from an infected sexual partner with HIV. The inverse is also true, the presence of HIV infection increases your risks of contracting the HSV or herpes virus from an infected partner. A co-infection with both viruses may have a negative effect on the immune system that is likely to be clinically insignificant .

What’s new?

Well, there is still a lot of research going into genital herpes. A new phase of research into vaccines to prevent genital herpes infections will be underway in 2003. This latest trial will be looking to recruiet some 7,500 women who have never been infected by either herpes-1 or herpes-2. Remember, the last vaccine trial appears to have a 70 % protective effect in women, not men – to be followed.

The latest look at the use of suppressive anti-virals by infected individuals has shown to be able to decrease infection rates in their previously non-infected partners by 50%. While an important study with significant results, further research is required.