Herpes simplex (HSV) is a vesicular viral infection primarily affecting the mouth or genital area.

One of two viral strains, HSV-1 and HSV-2, either of which may cause lesions, causes the herpes simplex virus. HSV-1 and HSV-2 are found in and released from the sores caused by the virus, and may be released between outbreaks from skin that does not appear to be broken or to have a sore. Recurrences of herpes simplex may be provoked by a variety of stimuli, such as

• sexual contact,

• exposure to ultraviolet light,

• febrile illnesses, or

• emotional stress.

Herpes simplex virus type 1 (HSV-1) is the most common herpes simplex virus and is usually acquired in childhood. It is transmitted by contact with infected saliva and commonly causes lip, mouth and skin lesions. Most adults (90%) have developed antibodies to HSV-1.

Herpes simplex virus 2 (HSV-2) is sexually transmitted and is usually the type that causes genital lesions, although HSV-1 can also be responsible. Most transmissions of herpes simplex occur during asymptomatic shedding. Approximately 30% of adults in the United States have antibodies against HSV-2. Cross-infection of HSV type 1 and 2 viruses may occur from oral-genital contact.

In general, manifestations of herpes simplex infection occur following a latency period. It then results in a recurring red-based rash with painful vesicular eruptions (blisters) on the skin, mucosal surfaces, and the genitals. Primary outbreaks are generally more severe while secondary outbreaks, which can appear weeks or months after the first, typically are less severe and shorter than the first outbreak. Other symptoms generally include enlarged lymph nodes in the neck or groin, and fever and malaise may be present especially during the first episode. Most individuals have no or minimal signs or symptoms from HSV-1 or HSV-2 infection.

Herpes simplex virus type 1 (HSV-1) is usually associated with infections of the lips, mouth, gums, and face and often causes lesions inside the mouth such as fever blisters (cold sores). Additional symptoms include irritability, anorexia, and fever.

Symptoms of Herpes simplex virus type 2 (HSV-2) include ulcers or sores on or around the genitals or rectum that may be preceded by a burning or tingling sensation. There may be localized pain, itching, dysuria, or other sensations that begin prior to the appearance of a skin rash. There may also be pain in the hips or legs from neuropathic symptoms.

Primary lesions develop in about 4 to 7 days after contact with an infected individual. Ulcerations crust over after a few days and generally heal in about 10 days. In addition to oral and genital lesions, HSV-2 may lead to complications such as

• meningoencephalitis, which may cause

  • fevers,

  • headaches,

  • altered mental status,

  • seizures, or

  • coma; or

• keratoconjunctivitis, an infection of the eye particularly affecting the conjunctiva and cornea.

Even though some individuals with HSV-2 do not display symptoms, the virus may be transmitted even in the absence of symptoms or visible lesions.

Other complications of herpes simplex include

• eczema herpetiform (widespread herpes across the skin);

• transverse myelitis;

• autonomic nervous system dysfunction;

• severe neuralgia;

• prolonged, severe infections that may be widely disseminated in immunosuppressed individuals;

• pneumonia; and

• infection of the trachea.

A finger infection, called herpetic whitlow, is another form of herpes infection that usually affects health care providers who are exposed to oral secretions during procedures.

In most cases, the physical appearance of the lesions confirms the diagnosis of herpes simplex infections. For a definitive diagnosis, a blood test, viral culture of the lesion, Tzanck test, and direct fluorescent antibody (DFA) test may be indicated.

Mild lesions usually heal on their own in 7 to 10 days and may not require treatment. However, first occurrences may take two to four weeks to heal. An individual with an underlying condition that weakens the immune system may have a more severe and longer lasting infection.

Antiviral medications, such as Acyclovir and related drugs may be used in the treatment of severe or prolonged cases, or in individuals who are immunosuppressed or who have frequent outbreaks of HSV 1 and 2. These medications may also aid in decreasing the frequency and duration of recurrences while taking the medicine. However, once discontinued they have no effect on recurrence or asymptomatic shedding. In addition, analgesics may be administered.

Avoiding skin-to-skin contact with open lesions of infected individuals is necessary. Use of oral anesthetics, a soft toothbrush and saline or bicarbonate based mouthwash, and consuming soft foods may decrease the discomfort of oral lesions. Using lip balm with sunscreen may reduce the reactivation of oral lesions.

Patients with genital herpes must use meticulous hand washing after bathroom use. Sexual intercourse should be avoided during active stage of disease, and sexual partners informed of the condition. Pap smear for females with HSV-2 are performed annually when results are normal and more frequently for abnormal results.

Chronic treatment with antiviral medications may be necessary to reduce recurrences for individuals experiencing six or more genital herpes outbreaks per year. Patients with genital herpes may require counseling services. There is risk to the infant of a pregnant patient who has an outbreak of HSV when labor begins with intact membranes, and delivers vaginally or by caesarean section.

Once infected, the virus spreads to nerve cells and stays in the body for the rest of a person's life and may intermittently reactivate. The number of outbreaks tends to decrease over a period of years with or without treatment. However, treatment may improve the quality of the patient's life.

Recurrences may be precipitated by overexposure to sunlight, fever, stress, acute illness, and medications or conditions that weaken the immune system such as cancer, HIV/AIDS, or use of corticosteroids. Recurrent lesions at the same site may cause atrophy and scarring.

Special Considerations

• When 38 CFR 4.118 offers variable methods to evaluate a skin condition, assign a single evaluation using the criteria that results in the highest rating. 

• Consider this condition pursuant to 38 CFR 4.27 and 38 CFR 4.20, when applicable. Analogous ratings are utilized when a specific disability is not listed in 38 CFR Part 4. Certain hyphenated codes do not necessarily denote analogous ratings – a hyphenated DC may also be used to identify the proper evaluation of a disability or a residual from disease. Diagnostic Codes (DCs) must be carefully selected as a condition specifically listed in the rating schedule may not be rated by analogy, unless otherwise directed (e.g., amyotrophic lateral sclerosis, multiple sclerosis).  When multiple DCs apply to a given disability, consider whether separate evaluations are warranted, and/or which DC will result in the most advantageous outcome for the claimant.

• If a Veteran has HIV and one or more opportunistic infections (e.g., herpes simplex-chronic ulcers for greater than one month), regardless of the CD4 (T4) count, the Veteran is considered to have a diagnosis of AIDS.

Notes

• 38 CFR 4.118 (a) For the purposes of this section, systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. 

• 38 CFR 4.118 (b) Two or more skin conditions may be combined in accordance with 38 CFR 4.25 only if separate areas of skin are involved. If two or more skin conditions involve the same area of skin, then only the highest evaluation shall be used.