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Key Features

Essentials of Diagnosis

  • Recurrent small grouped painful vesicles, especially in the orolabial and genital areas, on an erythematous base

  • May follow minor infections, trauma, stress, or sun exposure

  • Regional tender lymphadenopathy may occur

  • Direct fluorescent antibody tests are positive

General Considerations

  • The patient may have recurrent self-limited attacks, provoked by sun exposure, orofacial surgery, fever, or a viral infection

  • Herpes simplex type 2 (HSV-2) causes lesions whose morphology and natural history are similar to those caused by herpes simplex type 1 (HSV-1) but are typically located on the genitalia; the infection is acquired by sexual contact

  • Genital herpes may also be due to HSV-1

  • Risk factors for HSV transmission include

    • Black race

    • Female gender

    • History of sexually transmitted infections

    • An increased number of partners

    • Contact with commercial sex workers

    • Lower socioeconomic status

    • Young age at onset of sexual activity

    • Total duration of sexual activity

  • Asymptomatic shedding of either virus is common and may be responsible for transmission

  • Asymptomatic HSV-2–infected individuals shed the virus less frequently than those with symptomatic infection

  • HSV-2 seropositivity increases the risk of HIV acquisition (it is threefold higher among persons who are HSV-seropositive than among those who are HSV-2 seronegative)

  • Conversely, HSV-2 reactivates more frequently in advanced HIV infection


  • Up to 85% of adults have serologic evidence of HSV-1 infections, most often acquired asymptomatically in childhood

  • About 25% of the US population has serologic evidence of infection with HSV-2

  • In monogamous heterosexual couples where one partner has HSV-2 infection, seroconversion of the noninfected partner occurs in 10% over a 1-year period

    • Up to 70% of such infections appeared to be transmitted during periods of asymptomatic shedding; uninfected female partners are at greater risk than males

Clinical Findings

Symptoms and Signs

  • HSV-1 and HSV-2 disease

    • Burning and stinging are principal symptoms

    • Neuralgia may precede or accompany attacks

    • Lesions consist of small, grouped vesicles on an erythematous base that can occur anywhere but that most often occur on the vermillion border of the lips, the penile shaft, the labia, the perianal skin, and the buttocks

    • Any erosion in anogenital region can be due to herpes simplex

    • Regional lymph nodes may be swollen and tender

    • The lesions usually crust and heal in 1 week

  • HSV-1 disease

    • Largely involves the mouth and oral cavity

    • Occasionally, primary infections may be manifested as severe gingivostomatitis

    • Digital lesions (whitlows) are an occupational hazard in medicine and dentistry

    • Contact sports (eg, wrestling) are associated with outbreaks of skin infections

    • Primary infection is usually more severe than recurrences but may be asymptomatic

    • Recurrences often

      • Tend to be labial

      • Involve fewer lesions

      • Heal faster

    • HSV-2 lesions

      • Largely involve the genital tract, with the ...

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