Herpes simplex virus (HSV) is a common virus that establishes a lifelong infection in the body, manifesting in various ways. While often discussed in the context of genital infections, this article focuses on “nongenital” presentations affecting the skin, eyes, and nervous system. Understanding how the virus spreads, its manifestations, and how outbreaks are managed is important. This article explores the viral agents, their frequent manifestations, and the management strategies for recurring episodes.
The Viruses Responsible and How They Spread
The primary cause of nongenital herpes is Herpes Simplex Virus Type 1 (HSV-1), which is widespread globally. Although HSV-1 is the typical agent, Herpes Simplex Virus Type 2 (HSV-2), usually associated with genital infections, can also cause nongenital outbreaks. Both viruses are highly contagious and spread through direct skin-to-skin contact, involving mucous membranes or abraded skin. Transmission also occurs through saliva or contact with active lesions, which are fluid-filled blisters.
HSV can spread even when no sores are visible, a process known as asymptomatic viral shedding. After the initial infection, the virus remains in the body, traveling along sensory nerve pathways to a collection of nerve cells called a ganglion. For oral and facial infections, the virus establishes a latent state in the trigeminal ganglion. The virus can then periodically reactivate and travel back down the nerve to the skin surface, causing a recurrent outbreak.
Primary Nongenital Manifestations
The most frequent nongenital manifestation is oral herpes, commonly referred to as cold sores or fever blisters, which usually appear on or around the lips. An outbreak begins with a prodromal stage, where a person feels a tingling, itching, or burning sensation at the site where the lesion will form. This sensation signals that the virus is actively moving toward the skin surface.
The next stage involves the formation of a cluster of small, fluid-filled blisters on a reddened base. These vesicles rupture, resulting in painful, shallow, open sores, which are the most contagious phase. A scab or crust forms over the ulcer as the lesions dry out. The entire process, from the first tingle to complete healing, usually takes about eight to ten days, often resolving without scarring.
Distinct Non-Oral Presentations
While oral sores are the most common, HSV can affect other areas of the body, leading to distinct clinical presentations.
Herpetic Whitlow
Herpetic Whitlow involves the fingers or nail beds, appearing as painful, swollen, and reddish lesions. This condition results from direct inoculation, such as a child with oral herpes sucking their thumb or a healthcare worker touching an infected area without proper protection.
Herpes Gladiatorum
Herpes Gladiatorum is a skin infection characterized by lesions on the torso, face, neck, or limbs. This form is often seen in athletes engaging in high-contact sports, such as wrestling, where the virus spreads easily through skin-to-skin abrasion and contact with shared equipment. Prompt recognition is important to prevent its spread among teammates and competitors.
Herpes Keratitis
Herpes Keratitis is a serious manifestation involving infection of the eye, specifically the cornea. This infection is caused by transferring the virus from an oral sore to the eye by touch. Symptoms include pain, redness, blurred vision, tearing, and sensitivity to light. If the infection penetrates the deeper layers, it can lead to scarring and potentially irreversible vision impairment or blindness if not treated quickly.
Managing Recurrence and Long-Term Implications
The latent virus remains in the sensory nerve ganglia, and its reactivation can be triggered by various factors. Common triggers include psychological stress, concurrent illnesses, fever, and exposure to ultraviolet light. Hormonal changes, such as those experienced during menstruation, can also be a factor.
Management of recurrent outbreaks primarily involves antiviral medications, such as acyclovir, valacyclovir, and famciclovir. These drugs interfere with the virus’s ability to multiply, reducing the severity and shortening the duration of an outbreak, especially when taken at the first sign of symptoms. For individuals with frequent or severe recurrences, a healthcare provider may recommend long-term suppressive therapy, where the antiviral medication is taken daily to prevent outbreaks.
While most nongenital herpes infections are mild and manageable, serious long-term implications exist, particularly for immunocompromised individuals. Rare complications of HSV-1 can include encephalitis, which is inflammation of the brain, or viral meningitis, which is inflammation of the membranes surrounding the brain and spinal cord. Furthermore, transmission to infants during childbirth, known as neonatal herpes, is a serious concern that can lead to lasting neurological disability or death, underscoring the importance of ongoing clinical management.