Short summary:
Herpes is a common STD caused by two viruses: HSV1 & HSV2 (herpes simplex virus type-1 & type-2).
Most people with herpes do not show any symptoms; up to 80% infections go unnoticed.
Genital herpes might show sores, blisters around genitalia (mainly from HSV2).
Oral herpes often show up as a cold sore or a fever blister around mouth (mainly from HSV1 in childhood).
HSV testing requires a blood sample to confirm the antibodies from HSV viral infection.
Herpes is treatable with antivirals but cannot be fully cured; symptoms of recurrent herpes outbreaks are normally less severe.
There is no herpes vaccine yet but a few are in trials.
"Herp" or Herpes is a very common sexually transmitted disease in US and across the world.
It is one of the most challenging STDs to diagnose and manage.
Herpes is a combination of two overlapping conditions: oral herpes and genital herpes.
If you are a young, sexually active person with an ulcer around genitals, the most likely reason is genital herpes (or syphilis).
There are many more cases of oral herpes because it can easily spread with skin contact. However, it is less common to transfer it sexually.
In this discussion, we will mainly focus on genital herpes, especially herpes type 2 from HSV2.
Globally, almost half-a-billion people have genital herpes.
In 2018, there were close to 20 million infections in US alone. This includes over half a million new infection every year (Kreisel et al., 2021).
Herpes is everywhere: Of all the blood tests performed in the US from 1999 to 2015, more than half had a positive HSV infection.
Almost one-in-ten people aged 14 to 49 years in US is infected with HSV2 as per CDC.
The rate of herpes in women is double the rate for men.
The following discussion focuses on the STD genital herpes from HSV2 (Herpes Simplex Virus - Type 2) that spreads sexually.
An image of the herpesvirus: There are 9 known herpesviruses that cause several diseases including chickenpox, shingles, infectious mononucleosis, nasopharyngeal carcinoma, Kaposi’s sarcoma, oral herpes and genital herpes.
There are two types of herpes, depending on the type of virus that causes the infection:
Oral herpes - is caused by HSV1 (also called orolabial herpes due to cold sores on the lips). Symptoms rarely appear, but include cold sores or fever blisters around the mouth. Infection often happens during childhood when it can transfer via saliva, skin contact or during birth. Type one herpes infections are rare through sexual contact but they seem to be growing.
Genital herpes - is mainly caused by HSV2. Symptoms include blisters and sores around genitals. It mainly transfers through sexual contact and can cause serious health issues even if symptoms are not visible.
Genital herpes is often called GUD or genital ulcer disease. GUD is a painful condition that includes both HSV-1 and HSV-2 genital infections.
Herpes type 2 can increase the risk of acquiring HIV by two or three times according to the STI Guidelines of 2021.
Herpes may not always show any symptoms.
But after the first herpes infection, symptoms often appear as sores or blisters on the mouth or genitals, e.g., as a fever blister or a cold sore inside the lip.
Such a lip blister often starts with little red bumps on the skin that turn into wet sores.
These often break and leave painful blisters that last for about a week.
In next few days, the sores become dry, leaving a crust and then fully disappear.
However, in next few weeks, the symptoms appear again in the form of blisters around mouth and genitals.
Such repeat of symptoms or flairs, is called "herpes outbreak."
Repeat symptoms are often less severe or mildly painful. Their outbreak periods also get shorter over time or may even become infrequent. But they rarely go away.
Some herpes outbreaks may even occur after 10 years.
The key difference between first herpes outbreak in a female or male (versus follow up outbreaks) is that symptoms are limited to genitals and become milder over time.
Repeat herpes outbreaks vary significantly from person-to-person and the reason is not yet fully understood.
A repeat herpes outbreak starts with mild tingling or pain in pelvic area. Then it follows the same cycle of red and white skin bumps, wet sores, and finally a dry crust. Meanwhile, shedding of the virus continues that can infect others from skin contact.
After the first herpes infection, an HSV outbreak often occurs every 3 to 12 months. In general, an HSV2 outbreak is more frequent (once every 3 months) than an HSV1 outbreak (once a year).
The most painful and clear symptoms appear during first herpes outbreak (for a female or a male, they almost always happen around the genitals).
During the first HSV2 infection, other symptoms often include fever, difficulty in swallowing, tiredness, body-ache, and it almost feels like a flu infection.
If herpes diagnosis is confirmed with HSV antibody testing, an antiviral can help reduce the intensity of outbreaks.
Herpes is a life long condition and can not be cured. But symptoms and flairs may reduce with antivirals.
Other symptoms of herpes sometimes include:
Skin blisters on the face, cheek, lip, neck, nose, around mouth lining, vagina, buttocks, rectum or nearby areas. Sometimes they may have severe pain.
Unexpected body sores or pustules (white, red bumps on skin, sometimes with pus) that might be difficult to explain.
Genital discharge with foul smell.
Difficult urinating with burning sensation.
Herpetic whitlow finger, i.e., red swollen blisters on fingertips
Unexplained and sudden urinary retention in which the bladder may not fully empty during peeing.
Infection of the rectum opening (also called proctitis).
Persistent feeling of emptying the bowel although you know it's empty (also called tenesmus).
Unexplained bleeding in between periods.
Infection of the urinary tract causing pain while peeing.
Other infections on skin due to broken blisters and cracks in the skin.
In rare cases one might have severe headaches (meningitis)
You can see photos of herpes on this link (from slides 27 to 29): https://www.std.uw.edu/lectures/lecture/lecture-series/genital-herpes.
The genital ulcer disease (GUD) is a hallmark of herpes. But it's not exclusively due to herpes alone.
However, sometimes such ulcers may be due to other STDs such as syphilis, mpox (formerly called monkeypox), chlamydia, or chancroid.
In rare cases, other non-infectious conditions might also cause genital ulcers, e.g., Behcet's disease, candida yeast infection, or IBS (inflammatory bowel syndrome) or reaction to certain medicines.
Normally, HSV-1 or oral herpes infection occur from saliva and skin contact. This non-sexual transfer mainly happens during birth or in childhood and adolescence.
However, cases of HSV1 oral herpes are increasing in recent years. One likely reason is saliva transfer during oral sex.
HSV2 infections of genital herpes spread commonly through sexual contact.
A condom may not be sufficient to prevent herp: a skin blister anywhere on the body can still infect your partner.
A herpes simplex virus infection can spread from:
Contact with an open herpes sore or blister.
Saliva of another person who already has herp.
Other fluids, e.g., from genitals of infected person.
Skin contact in the genital area, buttocks, anus, orolabial (even if there are no open blisters, but when they are shedding the virus).
Skin contact with herpes sores on face, mouth, eyes, gums, nose, neck, lips, cheek, tongue, hands, legs, thighs and other parts of the body.
A sexual partner who is infected but doesn't know it or have any visible symptoms (but is shedding the herpes virus).
HSV does not spread by air, as the virus is not able to survive outside the body.
The herpes simplex virus does not spread through:
Toilet sheets or bathroom sinks or faucets.
Cloths, towels, undergarments or beds.
Swimming pool or sauna.
Soaps, shampoos, conditioners, creams, hand sanitizers, etc.
Spoons, forks, knives, places, glasses, and other kitchenware.
Below is an actual case study of a person that reflects a typical herpes infection:
Figure showing steps in an actual herpes infection. The steps below walk you through them one-by-one.
A woman collected swabs every day to monitor her symptoms and activities:
Mar 1: tested negative (-) for the virus on swabs collected from genital area.
Mar 2: tested positive (+), but no symptoms.
Mar 3: positive, but had a sexual contact with her male partner.
Mar 5: first signs of itching for her; had another sexual contact.
Mar 7: another sexual contact; no itching but later on samples showed this was the peak day of virus shedding with highest volume (red color).
Mar 8: noticed regular etching; now her partner also noticed etching (this is very common: red skin bumps start appearing in about a week, for those getting first herpes outbreak; for 50% of such partners, with symptoms, this is indeed their first encounter with herpes simplex virus, remaining probably are already infected by then but never showed the symptoms).
Mar 12: both of them continued to notice etching (this is also typical: second week shows wet ulcers with pus and blisters).
Mar 13: her swabs were negative (-), and etching reduced.
Mar 15: cultures from her partner's swabs came positive (+), 2 weeks after first sexual contact; blood antibody tests were still negative.
Mar 29: her partner's blood test was positive (sufficient antibodies produced against the virus were detected; although it can take up to 16 weeks in some cases); usually, the blisters start to heal to form dry crusts by third week, during first episode of genital herpes.
It can be extremely difficult to prevent a herpes infection. Here are a few recommendations from CDC:
Avoid sex with anyone with herpes.
Be in a monogamous relationship to reduce the risk of getting infected.
Not have sex during a herpes outbreak.
Talk to your partner and have a honest conversation about possible risks.
Herp can pass from mother to a child during child-birth. In rare cases, a baby might get infected before birth.
Neonatal herpes can affect a baby with premature birth or miscarriage.
It's important to test and take regular medicine if genital herpes is suspected during pregnancy.
Herpes can be diagnosed in many different ways.
The first step is to confirm the symptoms by looking at sores and blisters from herpes simplex virus (genital blisters from HSV2 or orolabial herpes from HSV1).
There are two types of tests but they check different things.
If the symptoms are present, the most accurate method is a PCR herpes test.
For such a test, swab from an open sore or blister can be used to confirm the herpes simplex virus.
A HSV PCR test can also differentiate between HSV1 and HSV2. This can be psychologically important to some people, even when they have genital ulcers.
A herpes PCR test sample should be collected from a wet blister at the peak viral shedding period (but not after a dry crust has formed). See the case study above.
Without any symptoms, the recommended way for HSV testing is with a blood antibody test.
An HSV antibody or serological test is able to distinguish between HSV1 and HSV2.
One should note that herpes antibody test are not always the most accurate. They are yet to become the most sensitive tests, and might give false positives.
2021 CDC guidelines suggest that an antibody test must be performed at least 12 weeks after suspected infection.
It might take that long for the IgG antibodies to appear in the blood.
The new dry-blood spot tests allow checking for a herpes STD infection from the privacy of home. They are a reliable and cost-effective way to get tested for herpes and other STDs.
Herp is a life long condition and unfortunately there are no cures for herpes.
However, antiviral medicines such as Acyclovir can prevent or reduce the symptoms of a herpes outbreak.
The best treatment for herpes includes three antivirals: Acyclovir, Valacyclovir, and Famciclovir.
A daily suppressive therapy can lower the risk of spreading the virus by 70-80%. It can also lower the symptoms during herpes outbreaks.
Treatment of herpes depends on whether it's the first episode, a recurrent episode, or taken as a suppressive therapy for those prone to more frequent outbreaks.
Daily herpes therapy is useful: the HSV antiviral drugs are only activated in the body when the virus is present.
And they have very low risk of developing resistance.
Suppressive therapy is often used when people have critical events, e.g., a job interview or an upcoming vacation.
Some other ways to help reduce herpes spread include:
Condoms - only about 30% effective.
Male circumcision - has been shown to reduce the risk of transmission and symptoms of ulcer.
Talking to your partner if you are already infected - known to reduce chance of spread by 50%.
All 50 states and the District of Columbia explicitly allow minors to consent for their own STI services (however, the age varies by state).
None of the states require a parent's consent for STD testing and treatment.
According to CDC, as of 2019, in all 18 states allowed and did not require a doctor to notify parents of a minor’s receipt of STI services. This includes states where minors can legally provide their own consent to the service.
Here's a table of age of consenting by state (Last updated: 1 Sep 2023).
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