Herpes simplex virus infections

Last updated: June 29, 2022

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Herpes simplex virus infections may be caused by two virus genotypes: herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). Worldwide seroprevalence is high, with antibodies detectable in over 90% of the population. Of these cases, approx. 60% are caused by HSV-1. The most common infections are labial and genital herpes, which present with painful ulcerations. Two further conditions, seen especially in children, are herpetic gingivostomatitis and herpetic whitlow. While herpetic gingivostomatitis is characterized by painful lesions of the oral and pharyngeal mucosa, herpetic whitlow causes blisters on the fingers with pronounced regional lymphadenopathy. In individuals with underlying dermatological conditions, infection with HSV can cause eczema herpeticum, resulting in painful erosions spread diffusely over the head and upper body. However, the majority of primary infections remain asymptomatic, while recurrent infections present with the typical manifestations. The diagnosis of HSV infections is usually confirmed through viral cultures, but may also be based on detection of HSV DNA in PCR, or multinucleated giant cells in Tzanck smears. Treatment consists mainly of topical or oral acyclovir; IV administration may be needed in critical cases, such as HSV infection in immunocompromised patients.

  • Prevalence: More than 90% of the world's population over the age of 40 years carries HSV. [1]
  • Types
  • Transmission
    • Direct contact with mucosal tissue or secretions of another infected person
    • Infection with HSV-1 usually is acquired in childhood via saliva.
    • HSV-2 is mostly spread through genital contact and should, therefore, raise suspicion for sexual abuse if found in children.
    • Perinatal transmission (e.g., during childbirth if the mother is symptomatic) is more common for HSV-2.
  • Type of infection
    • Primary infection
      • Mostly asymptomatic (up to 80% of cases, but virus is still shed)
      • If symptomatic, the infection is often sudden and severe with systemic symptoms (e.g., fever, malaise, myalgias, and headaches)
    • Reactivation of infection
      • Frequency and severity vary individually; symptoms are usually less severe than in primary infection.
      • Often at the same site as primary infection

Eczema herpeticum is considered a dermatological emergency and treatment with oral or IV acyclovir must be initiated quickly.

  • Pathogen: HSV-1 in 60% of cases; HSV-2 in 40% of cases (in the adult population)
  • Etiology
    • Direct contact with infected secretions through a break in the skin, e.g., torn cuticle
    • Main groups:
      • Children (via sucking of thumb/fingers (may have a history of labial herpes)
      • Health care workers exposed to oral secretions (e.g., dentists)
  • Incubation period: 2–20 days
  • Clinical features
  • Differential diagnoses: paronychia, cellulitis, felon
  • Diagnostics and treatment: See “Diagnostics” and "Treatment" below.

Surgical treatment is not indicated because it may cause severe complications (e.g., bacterial superinfection, systemic spread, herpes encephalitis)!



  • Congenital herpes simplex, neonatal herpes simplex
  • Benign recurrent lymphocytic meningitis: rare benign recurrent aseptic meningitis caused by HSV-2
    • Affected patients have recurrent episodes of meningitis (headache, meningismus) with transient neurological symptoms (in 50% of cases).
    • Most patients have spontaneous remission of symptoms and no permanent neurological sequelae.


Diagnosis is primarily based on clinical features, with confirmation through the following tests:

“I SMEARED my HERPES all over the TANK:” Herpes is detected by TzANcK smear.

Resources: [7][8]

Depending on the site, type, and severity of HSV-1 infection, antiviral drugs are administered either topically or systemically. In most cases of recurrent infection, topical and/or symptomatic treatment is sufficient.

Antiviral treatment

Early treatment of herpes infections is essential to prevent complications because antiviral drugs only inhibit the virus during its replication phase.

Symptomatic treatment


  • Use of condoms, gloves
  • Consider isolation of hospitalized patients with shedding lesions
  1. Wald A, Corey L, Arvin A, et al. Persistence in the population: epidemiology, transmission. Cambridge University Press. 2007 .
  2. Miller JM, Binnicker MJ, Campbell S, et al. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis. 2018; 67 (6): p.e1-e94. doi: 10.1093/cid/ciy381 . | Open in Read by QxMD
  3. CDC - Genital HSV Infections. https://www.cdc.gov/std/tg2015/herpes.htm#a1. Updated: June 4, 2015. Accessed: March 29, 2021.
  4. Genital Herpes - CDC Fact Sheet. https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm. Updated: January 19, 2021. Accessed: March 29, 2021.
  5. Wang HW, Kuo CJ, Lin WR, et al. Clinical Characteristics and Manifestation of Herpes Esophagitis: One Single-center Experience in Taiwan.. Medicine. 2016; 95 (14): p.e3187. doi: 10.1097/MD.0000000000003187 . | Open in Read by QxMD
  6. Johnson R. Herpes gladiatorum and other skin diseases. Clin Sports Med. 2004; 23 (3): p.473-484. doi: 10.1016/j.csm.2004.02.003 . | Open in Read by QxMD
  7. Wei EY, Coghlin DT. Beyond Folliculitis: Recognizing Herpes Gladiatorum in Adolescent Athletes. J Pediatr. 2017; 190 : p.283. doi: 10.1016/j.jpeds.2017.06.062 . | Open in Read by QxMD
  8. Usatine RP, Tinitigan R. Nongenital herpes simplex virus.. Am Fam Physician. 2010; 82 (9): p.1075-82.

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