What is recurrent genital herpes?

Genital herpes is caused by herpes simplex virus. The first signs of infection are usually some tingling or discomfort followed by small lumps, then blisters which quickly turn into painful sores a few millimetres across. The sores can last for 5 to 10 days. In the first episode there is often a mild flu-like illness with fever, lethargy, and irritability as well. Sometimes a flu-like illness can develop without typical genital ulceration and sometimes there is also a vaginal or urethral discharge. The sores will eventually heal, even with no treatment. The virus is not gone but remains quietly in nerve cells close to the original infection - it is this virus which can then break out again and cause a recurrence of symptoms. Symptoms are usually less severe in subsequent episodes. Sores in a totally different area are not likely to be linked to the original outbreak and should be checked again by a doctor.

How do I know if the sore is genital herpes or something else?

Sores in the genital area can also be caused by other sexually transmitted infections. You need to see a doctor or visit an STI clinic to have a clinical diagnosis made and to be tested. More than one sexually transmitted infection can be present together. It is not safe to self-treat without a confirmed medical diagnosis.

Sexual health clinics

• England
• Wales
• Scotland
• Northern Ireland

How did I catch genital herpes?

Genital herpes simplex viruses are spread from person to person, usually during sex (without condoms) or by genital kissing (oral sex). In up to two thirds of people there are no symptoms at the time of first infection. It cannot be caught from toilet seats, towels, swimming pools, or saunas.

Why do I have lumps in my groin as well as ulcers?

A third of people will develop inflamed groin glands when the genital herpes is active. This is a natural reaction to an infection and indicates that your body is fighting the virus.

Is genital herpes a rare condition?

No. Genital herpes is quite common and it is estimated that up to 70% of people in the UK may pick up the infection before they are 25 years old. In fact, many people have it without knowing it – possibly 4 out of 5 people who are carrying the virus are unaware of it.

Data from British Association for Sexual Health & HIV (BASHH) - Genital herpes information leaflet.

What causes repeat episodes of genital herpes?

After any herpes virus infection, the herpes viruses live on in the body, staying in nerves close to the site of the original infection. In some people, especially if they are stressed or run down, the virus will reactivate and travel to the surface again and cause a recurrence of the infection in the same area. With genital herpes, subsequent infections tend to be milder than the first infection, and not everybody has recurrences. If you do, they tend to become less frequent over time. It is less likely to have recurrent symptoms if your first infection was with HSV1 (herpes simplex virus type 1).

How can I prevent recurrent episodes of genital herpes?

Recurrent episodes often happen when you are run down or stressed, so try to maintain a healthy lifestyle and control stress in your life. Other potential triggers are friction in your genital area - for example, from sex, or tight clothing; smoking; drinking alcohol; your monthly period; surgery; other illnesses; a weakened immune system - for example, from having chemotherapy for cancer or HIV.

Sometimes a prolonged suppressive course of daily aciclovir can help reduce outbreaks. If attacks are frequent (6 or more attacks per year), you can consider starting on suppressive aciclovir.

What is the difference between type 1 and type 2 herpes infection?

These are both strains of herpes simplex. In the past type 1 was usually the cause of cold sore infection and type 2 caused genital herpes. It is now common to find type 1 also causing genital herpes. It may be helpful to know which type causes your genital herpes as type 1 can cause fewer recurrent symptoms. To determine this you would need to have a swab taken from active ulcers. This may be available from your doctor or a sexual health clinic.

How do I get a herpes swab test?

You will need to see a doctor or nurse in a sexual health clinic or your regular doctor. A swab test will be taken from an active sore. This will be tested in a laboratory and your results will be available in a few days.

What is the difference between herpes simplex and herpes zoster?

Herpes simplex and herpes zoster (also called varicella-zoster) are both members of the herpes virus family. There are several other herpes family viruses affecting humans including cytomegalovirus and Epstein-Barr virus.

Herpes simplex infections cause cold sores and genital herpes sores and occasionally small areas of characteristic sores on skin in other areas of the body.

A first herpes zoster infection causes generalised chickenpox.

Both herpes simplex and herpes zoster then remain in the body in the dorsal root ganglia of the sensory nerves. Both are able to reactivate but herpes simplex tends to do so more frequently causing the typical lesions of cold sores or genital herpes sores. When herpes zoster reactivates, it causes shingles, which is a more painful blistering rash over much of the skin supplied by a particular nerve (dermatome).

How can I treat genital herpes?

Genital herpes sores will heal without treatment, but treatment can reduce the intensity and length of an outbreak. Medication needs to be started as soon as possible and won't make any difference if started more than 6 days after sores appeared. Dr Fox prescribes aciclovir 400mg or 800mg - an antiviral tablet to treat genital herpes.

It is also important to keep the area clean with a daily salt water wash. Paracetamol and anti-inflammatory medication like ibuprofen may help with pain. Petroleum jelly such as vaseline dabbed on the sores can be soothing.

Occasionally with sores close to the urethra it is very painful to pass urine. You can try peeing whilst sitting in a warm bath. Anaesthetic gel either on prescription or purchased from a pharmacist may help to ease this.

For further information see NHS - Aciclovir (including Zovirax).

Why does Dr Fox offer two different dosing regimes to treat recurrent genital herpes?

BASHH and NICE suggest several different regimes for treatment of recurrent genital herpes with aciclovir and other anti herpes virus medications. All regimes have been shown in studies to be equally effective. Dr Fox offers a short 2-day course of treatment with aciclovir 800mg tablets, and a longer course of 5 days taking aciclovir 400mg tablets.

How do I choose which dosing regime of aciclovir to use to treat recurrent genital herpes?

The choice comes down to personal preference. There is a possibility of more side effects when taking stronger tablets as in the short 2-day course. However both courses are equally effective at reducing the length and intensity of an outbreak.

Can I pass it on to my partner?

Genital herpes is a sexually transmitted condition. It can therefore be passed on through any sexual activity via skin-to-skin contact especially from the sores when they are open. A condom for all sexual contact, including oral and anal sex, will offer some protection, but is not 100% reliable. The herpes virus can probably also be passed on when you don't have obvious sores, so a condom is always recommended. Any contact with the genital sores should be avoided by your partner and anyone with cold sores should avoid genital kissing (oral sex) as this can also lead to genital herpes in your partner. Avoid sharing sex toys and use them with a condom.

Do I need to tell my partner?

As your sexual partner is at risk of catching genital herpes even if you do not have active sores, it is best to tell them, and to use condoms for sex. Research has shown that when herpes is discussed openly between partners it is less likely to be passed on. Sexual health clinics can advise as to how best to tell a partner.

Can I have sex whilst taking aciclovir?

It is recommended to abstain from sex with a new partner whilst you have an outbreak of genital herpes and also whilst you are treating it. However, if it is the same partner and they have previously had genital herpes, then you can resume sex once it is no longer sore to do so. If using sex toys, use them with a condom.

Can I have a genital herpes vaccine?

No. There is currently no genital herpes vaccine.

When do I stop being infectious?

You are definitely infectious until the sores are totally healed. For a few months after a first episode of genital herpes, there is often 'asymptomatic shedding' of the virus so you may still be infectious even when there are no sores. It is often helpful to discuss this with your partner and condom use is recommended as it reduces the risk of transmission. If your partner has previously had genital herpes it is not possible to pass the same infection to them again. Continued asymptomatic shedding is rare after two years.

Can I get genital herpes again?

As there are two types of herpes virus it is possible to pick up the other one, however after infection with the other type, there are usually very few symptoms. Most cases of another bout of herpes will be from the dormant virus reactivating, travelling to the surface from the nerves and causing new sores.

How does aciclovir treat genital herpes?

Aciclovir is an antiviral treatment which targets the herpes virus family. It is a nucleoside analogue, which specifically targets the ability of the virus to replicate. This reduces the length of an episode of herpes. The treatment should begin as soon as symptoms seem to be starting - usually there is some tingling or pain before the sores appear. It is best to start treatment at least within the first 24 to 48 hours of symptoms, so it is often helpful to keep a supply handy at home. There is no benefit to starting treatment more than 6 days after the outbreak has begun.

Why does the information leaflet have a different dose to the prescription label on the box?

Aciclovir can be used in many different dose regimes for different types of herpes infection. Dr Fox follows NICE/BNF and British Association for Sexual Health and HIV (BASHH) dose recommendations for treating recurrent genital herpes outbreaks, i.e. 400mg 3 times a day for 5 days or 800mg 3 times a day for 2 days.

Aciclovir tablets supplied by Dr Fox may also come in blank medicine boxes, depending on the dosage regime.

I get lots of herpes outbreaks - can I take aciclovir all the time?

If you get severe or very frequent recurrences of genital herpes, you can take a continuous suppressive dose of aciclovir 400mg twice daily for a minimum of 6 months. A trial of stopping suppressive treatment is advised after 12 months to reassess the overall frequency of outbreaks. There may be an outbreak 4-5 days after stopping long-term treatment. This is not a sign that there will be repeated outbreaks. However, if outbreaks do continue again frequently, the suppression can be re-started. Research has shown that aciclovir can be safely continued for many years if necessary.

Is there an alternative to aciclovir?

There are two other antiviral medications in the same class as aciclovir which can be used to treat herpes infections - they are famciclovir and valaciclovir. These are NOT available from Dr Fox.

Does aciclovir medication cure genital herpes?

Unfortunately, there is no 'cure' for recurrent genital herpes, as the virus has settled in the nerve system and cannot be completely eliminated. However, the recurrent episodes will often diminish over time, and there can be many months or even years between outbreaks. The aciclovir medication will reduce the severity of an episode if taken early enough or it can be taken regularly to help suppress frequent outbreaks. If you continue to get outbreaks on suppression therapy you should see your GP or a sexual health clinic.

What other medicines interact with aciclovir?

There are possible interactions between aciclovir and a few rarely used medications:

• Mycophenolate mofetil (used to stop your body rejecting transplanted organs).
• Theophylline (used in asthma and other breathing problems).

If the patient information leaflet of a medication you are taking mentions urine or kidney problems as a side effect, aciclovir may add to those problems.

If you take any of these medications it is important to consult a doctor or pharmacist before taking aciclovir. Dr Fox checks for other medication use during the online herpes consultation.

Can anyone take aciclovir?

A few people are unable to take aciclovir. If you have reduced renal (kidney) function or kidney disease, or are over 65 years, then you should consult your regular doctor.

Other conditions when aciclovir may not be appropriate are: patients with reduced immunity e.g. after bone marrow transplant, low white cell count, HIV, with neurological illness, low oxygen levels, or liver function test or blood chemistry abnormalities.

Dr Fox pharmacy supplies medicine to adults only (over 18s). Do not take if pregnant or breastfeeding without first discussing with a doctor.

Is it safe to take aciclovir during pregnancy?

The manufacturers do not recommend taking aciclovir if you are pregnant. However, several studies have shown that aciclovir does not increase the risk of babies having a birth defect, miscarriage, or still birth. In some instances, doctors will recommend a course to prevent a genital herpes outbreak during labour. It can also be used if a pregnant woman who is non-immune has been in contact with chickenpox. Using aciclovir in pregnancy needs to be discussed with your regular doctor or obstetrician. Dr Fox does not supply aciclovir to pregnant women.

See also BUMPS best use of medicines in pregnancy - Aciclovir.

If you develop an outbreak of genital herpes in pregnancy, you should discuss this with your regular doctor, obstetrician, or specialist clinic.

Is it safe to take aciclovir when breastfeeding?

A significant amount of aciclovir from aciclovir tablets will pass into breast milk. This is unlikely to harm your baby, but the manufacturers advise caution. If you have a small infant and develop a genital herpes outbreak, you should discuss this with your GP or midwife. There are concerns around risk to the baby from herpes itself. Intravenous aciclovir is used to treat herpes infection in babies.

Dr Fox does not supply aciclovir to breastfeeding women.

Can herpes cause a miscarriage?

No, there is no evidence that herpes causes miscarriage. There is a risk of passing herpes to your baby during childbirth and if you become pregnant you should inform your midwife of any history of genital herpes and if you have an outbreak when pregnant.

What are the side effects of aciclovir?

All medicines can cause side effects, although not everybody gets them. The most common side effects of aciclovir (can affect up to 1 in 100 people) are headache, feeling dizzy, stomach problems (nausea, sickness), stomach pains, or diarrhoea. Also fever, tiredness, skin rashes and itch, and photosensitivity - a rash triggered by exposure to light.

Allergic reactions (anaphylaxis) are very rare, possibly affecting up to 1 in 1,000 people. If you have a severe allergic reaction, stop taking aciclovir tablets and seek medical attention (telephone 999 in the UK) straight away.

The signs of an allergic reaction may include:

• Hives rash or itching on your skin.
• Swelling of your face, lips, tongue, or other parts of your body.
• Shortness of breath, wheezing, or trouble breathing.
• Collapse.

Other side effect information is found in the Aciclovir 400mg patient leaflet or Aciclovir 800mg patient leaflet supplied with the medication.

Can I use Zovirax/aciclovir cream for genital herpes on my penis/vulva?

Zovirax/aciclovir cream is not as effective for genital herpes as taking aciclovir tablets and there is no added benefit to using it as well as tablets. So, it is not recommended to use Zovirax/aciclovir cream in the genital area.

Can I take lysine to reduce the number of outbreaks I get?

It has been suggested that lysine supplements may help prevent and treat herpes simplex outbreaks both for genital herpes and cold sores. Lysine is an amino acid used to build proteins in the body. Scientific studies have not found that taking lysine supplements reduces the frequency or shortens herpes outbreaks.

Do aciclovir tablets contain lactose?

Some brands of aciclovir tablets do contain lactose. If you react to lactose please message Dr Fox when you place an order, to request a lactose-free brand.

Genital herpes treatment