The word 'herpes' has invoked both interest and awe in the past decade. It is one of the common topics discussed in health discussions of various medias, especially herpes genitalis. There is still some amount of confusion with regard to different types of herpes. The following text would help the readers to have a better understanding of this subject.

Herpetic infections are caused by viruses belonging to herpes virus group.
There are two types of herpes namely herpes zoster and herpes simplex. The latter has two varieties namely herpes simplex labialis and herpes simplex genitalis.

Herpes zoster is caused by the varicella-zoster virus, which is also the causative agent of chicken pox. Herpes zoster occurs in persons who had an attack of chicken pox earlier. In some of them the viruses remain dormant in the dorsal nerve root ganglion. As a result of immune suppression due to various causes and for some unknown reasons the dormant viruses get reactivated, multiply and travel along the nerves and result in herpes zoster. It is usually seen in middle aged and old persons as grouped blisters on a reddish base, distributed in a band like fashion on one side of the body, mostly over the chest or abdomen and sometimes over the face or extremities. In the immune suppressed persons the lesions can be extensive and sometimes generalized. Intense pain and burning sensation in the affected part can precede or coincide with the appearance of the blisters. The condition lasts for about two weeks and the dried up scabs fall off leaving superficial and sometimes deep scars.

One of the complications of herpes zoster is post herpetic neuralgia, where the severe pain in the affected area persists even after the lesions completely heal. This occurs in elderly persons and the pain and burning sensation lasts for a few months to a couple of years. Although herpes zoster is self limiting, oral acyclovir or valacyclovir given in the early stages shortens the duration of the disease and also diminishes the chances of developing post herpetic neuralgia.

Herpes simplex labialis is caused by Herpes Simplex Virus type-1 (HSV-1). Eighty five percent of adults worldwide are sero-positive for HSV-1 infection. Primary or initial infection is commonly seen in children and young adults. It is usually asymptomatic and goes unnoticed. In about 1% the condition is severe with fever, malaise and multiple painful blisters and ulcers in and around the mouth. The entire episode lasts for about
10 to 14 days and a lasting immunity ensues in a majority. For unknown reasons in about 5% of affected cases, some viruses remain dormant in the sensory ganglion and the blisters recur at varying intervals secondary to various triggering factors like high fever, severe cold, exposure to excessive sunlight, child birth, anxiety etc. Recurrent attacks are milder and are characterized by the appearance of grouped painful blisters over the lips, around the mouth or nose. The condition lasts for about a week. Both primary and secondary herpes labialis are self-limiting, but severe infection and eye involvement requires hospitalization and systemic treatment with acyclovir or valacyclovir.

Herpes simplex ginitalis is a sexually transmitted disease. It is caused by Herpes Simplex Virus, Type-2 (HSV-2). Its incidence is increasing every year all over the world. It is reported that in Scandinavia the rate of infection with HSV-2 increases from 2% in the
15 year olds to 25% in 30 year olds. Currently in the U.S. about 23% 0f the adults are said to be infected with HSV-2 and in their STD clinics its incidence is said to be between 30-50%. Further HSV-2 infection is found to be higher in HIV positive persons worldwide. As a result of change in the sexual behavior, particularly in the developed countries the incidence of HSV-2 infection in and around the mouth and infection with HSV-1 in the genital and anal regions are not uncommon. Chances of acquiring HIV infection are more in the presence of herpes genitalis.

Genital herpes is acquired by skin-to-skin contact usually during sexual activity. The incubation period is about 5-7 days. In about 40-45% of patients the initial or primary infection is asymptomatic or sub clinical and they do not realize that they have contracted the disease. In the remaining 55-60% the primary infection occurs in the form of grouped, painful vesicles over the genitalia, perianal region or in and around the mouth depending on the sexual practice. A few patients develop fever and regional lymphadenopathy. The condition heals in two to three weeks with the scabs falling off and there is usually no scarring. Although self-limiting the primary herpes genitalis should be treated with oral acyclovir or valacyclovir and this helps in clearing the lesions faster and probably the chances of getting recurrent attacks are less.

A majority of patients (around 70%) infected with HSV 2 will have recurrences. Amongst them in about 20% the recurrences are asymptomatic and in another 50-60% it is very mild and atypical and goes unrecognized. Further asymptomatic shedding of the viruses take place now and then even in the absence of lesions. These are the patients who are mainly responsible for transmitting the disease and contribute to the increase in the incidence of genital herpes. In the remaining 20-30% of cases, recurrent herpes genitalis occurs with tingling, itching or burning and within the next 24 hours grouped papules appear and these become vesicular the next day. They burst open forming superficial tiny ulcers and these heal in another 4 to 5 days. The entire episode lasts for a week. Recurrent lesions appear over and around the site of initial infection. Severe recurrent infections should be treated with systemic acyclovir or valacyclovir. Pregnant women with HSV-2 infection, both primary and recurrent, can transmit the infection to the fetus mostly during delivery resulting in severe neonatal HSV-2 infection. If the fetus acquires the infection in utero it can result in abortion or fetal abnormalities.

There is no cure for recurrent herpes, both herpes simplex labialis and herpes simplex genitalis. Over a course of years the frequency of recurrences gradually decreases. Recurrent herpes genitalis is a nagging nuisance and has a social stigma attached to it. Many patients can get emotionally disturbed. They show profuse anger with themselves and also the presumed source of infection. Frustration and depression ensues in a few patients. They have to be properly counseled and advised to accept the situation, not to panic but face it and carry on with their lives. They should take care not to transmit it to others. As there is no vaccine and no effective medication available for a cure the only way to avoid this disease is to take proper preventive steps. Say 'no' to premarital and extramarital sex, but if it is inevitable use a condom positively. This will prevent not only herpes genitalis but also other sexually transmitted diseases including HIV infection. "Play safe" is the fitting advice given in this regard by the renowned Brazilian footballer Ronaldo.

DR. K. DINAKAR RAO,
Consultant Dermatologist,
LAMA Polyclinic (opposite Bank Muscat Br.),
M.B.D.

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