Oral Herpes vs. Genital Herpes: Spotting the Differences
- Two Types of Herpes Virus: HSV-1 typically causes oral herpes (cold sores), and HSV-2 usually results in genital herpes, with increasing crossover due to oral-genital contact.
- Herpes is a Lifelong Condition: Once contracted, the herpes simplex virus remains in the body permanently, with potential for recurrent outbreaks.
- Variety of Symptoms: Herpes can manifest in many forms, from cold sores and genital lesions to more severe conditions like encephalitis and neonatal herpes.
- Treatment Options Available: Antiviral medications like acyclovir are effective in managing symptoms and reducing transmission risk, but they don’t cure the virus.
- Prevention and Management: Safe sexual practices, regular medical check-ups, and stress management are crucial for preventing transmission and managing outbreaks.
Herpes Simplex Virus (HSV) is a widespread viral infection that manifests primarily in two forms: oral herpes, commonly known as cold sores, and genital herpes. These conditions are primarily caused by two distinct strains of the virus: HSV-1 and HSV-2. Traditionally, HSV-1 has been associated with oral herpes, characterized by sores around the mouth, while HSV-2 has been linked to genital herpes, causing lesions in the genital area.
However, in recent times, there has been an increasing crossover of these two strains between the oral and genital regions. This shift is largely attributed to oral sexual practices, leading to HSV-1 causing genital herpes and HSV-2 leading to oral infections. Understanding the nuances of these two types of herpes, their transmission, symptoms, and treatment is crucial for effective management and prevention.
HSV-1 and HSV-2
HSV type 1 (HSV-1) and type 2 (HSV-2) are distinguished by two main criteria: antigenicity and location of lesions. Lesions caused by HSV-1 are, in general, above the waist, whereas those caused by HSV-2 are below the waist. Once a person contracts herpes, it’s a lifelong condition.
Herpes simplex may strike anyone at any age. This increases your risk of contracting the virus:
- Had a female provided at birth.
- Possess several sexual partners.
- Began having sex when she was quite young.
- Possess a medical history of any sexually transmitted illness.
- Possess a compromised immune system.
- For oral sex, avoid using dental dams and condoms during sexual activity.
HSV-1 and HSV-2 are structurally and morphologically indistinguishable. They can, however, be differentiated by the restriction endonuclease patterns of their genome DNA and by type-specific monoclonal antisera against glycoprotein G. Humans are the natural hosts of both HSV-1 and HSV-2.
Recognizing HSV-1: A Spectrum of Symptoms and Conditions
Gingivostomatitis: Common in children, this condition is marked by fever, irritability, and mouth sores. The primary infection is usually more severe and lasts longer than subsequent outbreaks.
Herpes Labialis (Cold Sores): This recurrent form of HSV-1 manifests as blister-like sores, typically around the lips or nose. Recurrences often occur at the same site.
Keratoconjunctivitis: This eye infection involves corneal ulcers and lesions on the conjunctiva, which can lead to scarring or blindness if recurrent.
Encephalitis: A severe brain infection caused by HSV-1, characterized by fever, headache, vomiting, seizures, and altered mental status. It has a high mortality rate and can cause significant neurological damage.
Herpetic Whitlow: A painful skin lesion, usually on the fingers or hands, often seen in medical personnel due to contact with infected patients.
Herpes Gladiatorum: Seen in wrestlers and those in close physical contact, this form causes lesions on the head, neck, and trunk.
Eczema Herpeticum (Kaposi’s Varicelliform Eruption): Occurs in patients with atopic dermatitis, leading to vesicular lesions at eczema sites, primarily affecting children.
Disseminated Infections: In immunocompromised patients, HSV-1 can lead to more severe conditions like esophagitis and pneumonia.
For insights on the differences between herpes lesions and similar conditions, such as distinguishing herpes from ingrown hairs, check out our detailed guide.
Clinical Overview of Genital Herpes and Associated Complications
Epidemiology of Herpes Genitalis
- HSV-2 Prevalence: Approximately 80% to 90% of herpes genitalis (genital herpes) cases are attributed to Herpes Simplex Virus Type 2 (HSV-2).
- HSV-1 Contribution: The remaining cases are increasingly caused by Herpes Simplex Virus Type 1 (HSV-1), predominantly due to oral-genital contact.
- Clinical Consideration: Given the higher recurrence rate of lesions caused by HSV-2 compared to HSV-1, suppressive chemoprophylaxis is often indicated for HSV-2 lesions to reduce the frequency of outbreaks.
- Transmission: Neonatal herpes primarily results from exposure to HSV in the birth canal. This can occur even in the absence of visible lesions due to asymptomatic viral shedding.
- Clinical Spectrum: Manifestations range from severe systemic involvement, including disseminated lesions and encephalitis, to localized skin, eye, or mouth lesions, or even asymptomatic infections.
- Preventive Measures: Cesarean delivery is recommended for women with active genital lesions or positive HSV cultures to reduce neonatal transmission.
- Infection Risk: The risk of severe neonatal infection is higher with primary maternal herpes infection than with recurrent infection due to higher viral loads and the absence of transplacental IgG antibodies that offer neonatal protection.
HSV-2 and Aseptic Meningitis
- Clinical Presentation: Aseptic meningitis caused by HSV-2 generally presents as a mild and self-limiting illness with minimal long-term consequences.
HSV and Erythema Multiforme:
- Dermatological Association: Both HSV-1 and HSV-2 infections are known to be associated with erythema multiforme, a hypersensitivity reaction manifesting as target-like lesions, primarily affecting the trunk, hands, and feet.
- Treatment: Acyclovir has been shown to be effective in preventing recurrent episodes of erythema multiforme, likely by reducing HSV antigen levels.
- Differential Etiology: It’s important to note that erythema multiforme can also be triggered by other factors, including certain drugs like sulfonamides and other infections like Mycoplasma pneumoniae and hepatitis viruses.
Erythema Multiforme Major (Stevens-Johnson Syndrome)
- Severe Manifestation: Characterized by fever, erosive oral lesions, and extensive skin desquamation. The most common infectious cause is M. pneumoniae infection.
Transmission of Herpes Simplex
- The primary way that HSV-1 is spread is by contact with surfaces in or near the mouth, saliva, or sores. Genital herpes can be less often caused via oral-genital contact transferring HSV-1 to the genital region. The highest risk of transmission occurs when there are active sores, although it can spread from oral or cutaneous surfaces that seem normal. Individuals who have already contracted HSV-1 are not at risk of re-infection, although they are still susceptible to HSV-2 infection.
- The major way that HSV-2 is spread during intercourse is by contact with anal or genital surface skin, lesions, or bodily fluids of an infected person. HSV-2 is frequently spread in the absence of symptoms and can be transferred even if the skin seems normal.
If you develop HSV, your body produces particles of virus that you can transmit to others. The virus sheds from sores during an episode, but it also sheds at other times when you have no sores or obvious symptoms. You may not even know you have HSV.
Some research-trusted Source suggests shedding happens on:
- about 10 percent of days if you have asymptomatic HSV
- about 20 percent of days if you have symptomatic HSV
However various factors can affect viral shedding, including the type of HSV and where you experience symptoms. HSV-1 which affects the genitals tends to involve less frequent shedding than HSV-2 which affects the genitals, for example. how long you’ve had HSV — shedding tends to decrease with time. If you’ve had HSV for nearly 10 years, for instance, you’ll likely shed the virus less frequently than someone who contracted it recently. your immune health. If you’re immunocompromised, you may shed the virus more frequently.
While discussing the transmission of herpes, it’s important to note that it’s one of several STIs that can spread through direct skin contact. To learn more about similar infections, read about other STIs spread by skin contact in our detailed article.
Recurrence of Herpes Simplex
The likelihood of reactivation of HSV infection differs between HSV-1 and HSV-2 infections and between the sacral and trigeminal anatomical sites. The sixfold more frequent clinical recurrence rate of genital HSV infections as compared with oral-labial HSV infections may account for the relatively rapid increase in the prevalence of clinically recognized genital herpes in recent years.
Factors that might influence recurrence
A trigger may activate the virus. This activation, called an outbreak, causes symptoms, such as sores.
Common outbreak triggers include:
- Fever or illness.
- Menstrual periods.
- Sun exposure.
Medical Management of Herpes Simplex Virus Infections
Herpes Simplex Virus, with its two types HSV-1 and HSV-2, can lead to various health issues ranging from simple cold sores to more serious conditions. Treating these infections requires different antiviral medications, depending on the type and severity of the herpes. It’s important to understand how these treatments work to effectively manage and control the symptoms of herpes infections.
Acyclovir as Primary Treatment
- Encephalitis and Systemic HSV-1: Acyclovir, also known as acycloguanosine (brand name Zovirax), is the preferred treatment for encephalitis and other systemic diseases caused by HSV-1.
- Genital Herpes: It is effective for both primary and recurrent episodes of genital herpes, reducing lesion duration and viral shedding. However, it does not eliminate the virus in its latent state.
- Neonatal HSV-2 Infections: Acyclovir is also indicated for the treatment of neonatal infections caused by HSV-2.
- Acyclovir-Resistant HSV Strains: In cases of acyclovir-resistant HSV-1 strains, foscarnet is recommended as an alternative treatment.
Treatment for HSV-1 Eye Infections
- Nucleoside Analogs: For ocular HSV-1 infections, topical nucleoside analogs like trifluridine (Viroptic) are used.
Management of Orolabial HSV-1 Infections:
- Penciclovir and Docosanol: Recurrent orolabial HSV-1 infections in immunocompetent adults can be managed with penciclovir or docosanol. Penciclovir is a derivative of acyclovir, and docosanol is a long-chain saturated alcohol.
Valacyclovir and Famciclovir for Genital Herpes
- Suppression of Recurrences: Valacyclovir (Valtrex) and famciclovir (Famvir) are utilized in the treatment of genital herpes, particularly for suppressing recurrent episodes.
- Long-Term Suppression: While no pharmacological treatment can prevent the primary infection from establishing latency, long-term prophylactic administration of acyclovir, valacyclovir, or famciclovir can effectively suppress clinical recurrences.
Psychological Aspect of Herpes Diagnosis
- Emotional Impact: Healthcare professionals recognize the significant psychological distress associated with a herpes diagnosis. On average, clinicians perceive the emotional impact as being more severe than reported by patients.
- Long-Term Emotional Adjustment: Patients with a history of herpes for over a decade tend to report less distress compared to those with recent diagnoses. Notably, the psychological distress tends to escalate with an increase in the frequency of recurrences within a year.
Rechenchoski DZ, Faccin-Galhardi LC, Linhares REC, Nozawa C. “Herpesvirus: an underestimated virus.” Folia Microbiol (Praha). 2017 Mar;62(2):151-156. [PubMed]
Soriano V, Romero JD. “Rebound in Sexually Transmitted Infections Following the Success of Antiretrovirals for HIV/AIDS.” AIDS Rev. 2018;20(4):187-204. [PubMed]
Mostafa HH, Thompson TW, Konen AJ, Haenchen SD, Hilliard JG, Macdonald SJ, Morrison LA, Davido DJ. “Herpes Simplex Virus 1 Mutant with Point Mutations in UL39 Is Impaired for Acute Viral Replication in Mice, Establishment of Latency, and Explant-Induced Reactivation.” J Virol. 2018 Apr 01;92(7). [PMC free article] [PubMed]
Pfaff F, Groth M, Sauerbrei A, Zell R. “Genotyping of herpes simplex virus type 1 by whole-genome sequencing.” J Gen Virol. 2016 Oct;97(10):2732-2741. [PubMed]
van Oeffelen L, Biekram M, Poeran J, Hukkelhoven C, Galjaard S, van der Meijden W, Op de Coul E. “Update on Neonatal Herpes Simplex Epidemiology in the Netherlands: A Health Problem of Increasing Concern?” Pediatr Infect Dis J. 2018 Aug;37(8):806-813. [PubMed]
Chaabane S, Harfouche M, Chemaitelly H, Schwarzer G, Abu-Raddad LJ. “Herpes simplex virus type 1 epidemiology in the Middle East and North Africa: systematic review, meta-analyses, and meta-regressions.” Sci Rep. 2019 Feb 04;9(1):1136. [PMC free article] [PubMed]
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Dr. Raquel Molina Martinez is a board-certified dermatologist from Barcelona with over a decade of experience. Trained at Gothenburg’s University Hospital, she now practices at Centre Medic in Catalonia.