The patient may be distraught with severe ganital pain or just concerned about paresthesias and subtle genital lesions, desirous of pain relief
during a recurrence, or suffering complications
such as superinfection or urinary retention. Instead of the classic grouped vesicles on an erythematous base, herpes in the genitals usually
appears as groupings of 2-3mm ulcers, representing
the bases of abraded vesicles. Resolving lesions
are also less likely to crust on the genitals.
Lesions can be tender, and should be examined with
gloves on, because they shed infectious viral
particles.
What to do:
If necessary for the diagnosis, perform a Tzanck
prep, by scraping the base of the vesicle (this
hurts!), spreading the cells on a slide, drying,
and staining with Wrights or Giemsa stain. The
presence of multinucleate giant cells with
nuclear molding confirms the diagnosis of herpes.
Alternatively, use this sample for herpes virus
culture, if available.
Send a serologic test for syphilis and culture
any cervical or urethral discharge in search of
other infections requiring different therapy.
Prescribe acyclovir (Zovirax) 200mg q4h (5x
daily) for 10 days (dispense 50 tablets) or 5 days (25 tablets) for recurrent infections.
Prescribe anti-inflammatory analgesics (Motrin to
Percodan) for pain.
Warn the patient that:
lesions and pain can be expected to last 2
weeks during the initial attack (usually less in
recurrences);
although acyclovir reduces shedding, he should
assume he is contagious whenever there are open
lesions (and can potentially transmit the virus
other times as well);
he should be careful about touching lesions and
washing hands, because other skin can be
inoculated, and
recurrences can be triggered by any sort of
local or systemic stress, and will not be helped
by topical acyclovir.
Try sitz baths for comfort.
Discussion
Currently there is no role for topical acyclovir in the treatment of genital herpes. Oral prophylaxis has been shown to be effective.
Acyclovir is activated by phosphorylation inside infected
cells and acts by blocking viral DNA replication, but it is
ineffective once viral latency is established. Latent herpes
virus DNA already residing in the sensory ganglia can cause
recurrences with impunity, and topical acyclovir only
decreases the amount of viral shedding. Famcyclovir is currently being used tid for zoster and is in clinical trials for herpes simplex.
References:
Benedetti J, Corel L, Ashley R: Recurrence rates in genital herpes after symptomatic first-episode infection. Ann Intern Med 1994;121:847-854.
