There are eight herpes known to date and they are all double-stranded DNA viruses. They can give clinical manifestations in the skin and mucous membranes (mouth, genitals and anus) as appropriate. They generally take the form of recurrent diseases (i.e., they appear once and then other times, later). They are almost never serious, except for a few special cases. They are viruses spread in the environment, so, contracting the infection is quite easy.
The types of herpes identified to date are:
- HSV-1 (also known as cold sores)
- HSV-2 (also known as genital herpes)
- HHV-3 (also known as varicella zoster virus, VZV)
- HHV-4 (also known as Epstein Barr virus, EBV, mononucleosis virus)
- HHV-5 (also known as cytomegalovirus, CMV)
- HHV-6 (also known as sixth disease virus)
- HHV-7
- HHV-8 (also known as Kaposi's sarcoma-associated virus)
HSV-1 and HSV-2 (Herpes simplex-1 and -2)
In the case of cold sores, 9 times out of 10 people contract the infection asymptomatically during childhood, so most adults have HSV-1 antibodies without ever having had herpes on their lip.
In the case of genital herpes, however, 9 times out of 10 people contract the infection symptomatically during adolescence, early in their sexual lives.
Symptomatic infection means appearance of manifestations of the virus on the skin or mucous membranes often associated with pain and malaise; asymptomatic infection means, on the other hand, that we encounter the virus and do not notice it but our immune system develops antibodies against the virus.
Antibodies are the weapons our immune system possesses against something recognized as a potential harm to our body and often, as in the case of measles, are critical to not getting sick again. But this is not the case with herpes.
In HSV-1 and HSV-2 we may have antibodies against them but they will not be enough to prevent us from having it again.
For HSV-1 and 2 there are, in fact, recurrent infections, the periodic reappearance of clinical manifestations that are often more nuanced than the primary manifestation.
The first manifestation of cold sores, in 10% of those who develop it symptomatically, is acute herpetic gingivostomatitis. It occurs predominantly in children between 6 months and 3 years of age. It begins with a few days of pain, discomfort, hypersalivation, and difficulty eating; later blisters appear on the lips, palate, and gums, which then rupture and become ulcers. Often the manifestations are associated with fetid breath, inability to feed, pain, fever, and enlarged retroauricular, cervical, and submandibular lymph nodes.
Although it is quite frightening, it resolves in about 10-21 days.
Following manifestations are milder and present with tingling, discomfort, and pain in the lip and surrounding areas. Clustered vesicles then appear a few days after the onset of symptoms. Again, resolution is spontaneous and occurs after a few days.
The first genital manifestation, presents with genital soreness, itching and discomfort. After a few days, blisters, erosions, and swelling appear, which may extend even to the root of the thighs and pubis. Often because of the pain there is also retention of urine. Resolution is spontaneous and occurs in 2-3 weeks.
Although traditionally HSV-1 is considered the cause of cold sores and HSV-2 the cause of genital herpes for women, in 60% of cases genital herpes is due to HSV-1. The cause would seem to be related to oral intercourse (e.g., a person with HSV-1 transmits it genitally to his partner). In 90% of heterosexual couples in which the woman has genital manifestations, the male partner has only a personal history of cold sores. Finally, in women the manifestations are more violent than in men.
There is, then, neonatal herpes, which, however, is rare but potentially very serious. It can develop if the mother contracts herpes for the first time during late pregnancy or near delivery. In only 10% of cases does it result from the infant's contact with relatives with active cold sores.
Recurrent infections
- Olabial herpes: manifests with the appearance of blisters preceded shortly before (hours) by localized discomfort to the area. Lesions may extend to the nasal cavity or even affect only the nose, sparing the lips. It tends to resolve naturally in 1-2 weeks.
- Genital herpes: manifests with genital ulcerations, and women especially are susceptible to recurrent forms of the virus. If the primary infection was caused by HSV-2, recurrences tend to be more frequent. However, as already specified, HSV-1 infection is also more frequent at the genital level. The presence of genital herpes can promote the occurrence of bacterial vaginitis due to a matter of imbalance of the local flora. Genital herpes is considered a sexually transmitted disease.
- Herpetic paterecium: a rare manifestation, often confused with bacterial paterecium (vulgarly, giradito) that appears almost regularly at the same site in each subject, that is, at one end of a finger of the hand. It can be an occupational disease found in medical and health personnel.
- herpes gladiatorium: occurs when there is massive and prolonged contact with infected individuals during sports activities such as rugby, wrestling, American football.
Diagnosis is mainly clinical but direct microscopic examinations, antibody assays or search for viral DNA by PCR technique can be used.
Treatment is determined by the dermatologist, attending physician or pediatrician depending on the extent of the disease and/or symptoms. It is critical to know that creams and other topical antiviral products are of little or no use. Instead, oral and possibly even intravenous treatments based on antivirals are essential.
How the virus behaves
.When we first come into contact with the virus, if our skin (oral region or genital region) has small breaks in continuity, the virus enters and multiplies inside the skin cells. Then, once the primary infection is resolved, the virus hides inside the nerve ganglia, the crossroads of nerves, (at the oral or sacral level) and remains there until the next manifestation. The secondary manifestation may not appear, appear regularly (example in menstruating women) or only at certain times of stress or sun exposure.
In fact, it is good to know that after the first infection herpes remains inside our body, nesting in the ganglia. But with good instructions from the dermatologist, you can make it less annoying and frequent as possible.
HHV-3 or VZV (varicella-zoster virus)
It has many similarities with HSV-1 and 2: it loves the skin and nerves, occurs in a primary form (chickenpox) and in itsrecurrence (shingles).
Varicellais an exanthematous disease typical of childhood and young adulthood.
It usually does not occur until 6 months because each of us inherits during pregnancy protective antibodies against chickenpox that remain in our blood for about 6 months after birth, precisely.
The infection occurs via droplets (saliva droplets) from an infected person. It has an incubation period of 14 days. Prior to the vesicular manifestations on the body, the subject may be completely asymptomatic or report the appearance of sore throat and fever for 2-3 days.
The disease is transmitted through droplets.
The disease manifests as blisters on reddened skin that rapidly evolve into pustules and then crusts. Typically they are observed at the tronchus and then extend to the face and scalp, while the palm-plantar region is generally spared.
The subject is contagious from 2 days before the appearance of the blisters to 5 days after their appearance. Over a period of 5 to 25 days, the scabs fall off.
There can be complications: pneumonia, bacterial overinfection of the crusted/ulcerated lesions on the skin, encephalitis, and meningitis. In adults, there may be a risk of follow-up hepatitis or porpora. Finally, in immunodeficient individuals there may be massive involvement of internal organs in the so-called "malignant varicella" picture. Like herpes simplex, varicella is serious if it develops in pregnancy because it can lead to even very serious consequences for the fetus.
The treatment is symptomatic.
Treatment is symptomatic: one should avoid treating fever with acetylsalicylic acid but use only paracetamol. Rest and proper hydration are essential. In severe forms, vein antiviral therapies and hospitalization may also be used.
There is also a varicella vaccine that is given to newborns.
Shingles is the recurrence of VZV and occurs mostly in adults, especially if they had chickenpox in the first 4 years of life and/or if they had a form of chickenpox with few lesions and few symptoms. In these situations, the immune system would not have developed enough antibodies to protect against reactivation of the virus.
The disease mainly manifests itself at the level of the chest (its name, zoster, comes from the Greek, belt because herpetic vesicles are observed arranged in a band, like the middle of a belt), but lesions can also appear on the face, arms, legs, and lumbosacral region.
It is characterized by severe, unbearable pain (in fact, it is also referred to as Shingles) and must be treated immediately and as best as possible to prevent it from persisting even after the manifestations on the skin have healed.
Special cases do exist and are represented by ophthalmic zoster, which develops when the virus also affects the cornea and uvea (collaboration between dermatologists and ophthalmologists is essential), and zoster of the external auditory canal (Ramsay-Hunt II syndrome: appearance of vesicles in the ear area, possible hearing loss, dizziness and facial nerve paralysis with the appearance of alteration of normal facial symmetry, difficulty eating, drinking and speaking. In some cases, there may, even, be all neurologic symptomswithout skin changes.
Treatment is antivirals by mouth or by vein in special cases, but also pain relievers and B-complex vitamins to preserve the myelin sheaths of nerves.
The vaccine for the prevention of shingles exists and is currently offered to at-risk patients and/or individuals >50 years old.
HHV-4 or EBV (Epstein Barr Virus)
.Very often results in asymptomatic infection: it affects up to 90% of the world's population
It is present in saliva and genital secretions.
As in the other cases, the infection results in the persistence of the virus in our cells for a lifetime.
Typically it hides in B lymphocytes and cells of the oropharyngeal epithelium.
HHHV-4 is an etiologic agent of various diseases: mononucleosis, Burkitt's lymphoma, carcinoma of the oropharynx but also hypersensitivity reactions to the virus (Gianotti-Crosti syndrome), very severe ano-genital ulcers (Lipschutz ulcer) or tongue changes in HIV-infected individuals (oral villous leukoplakia).
Monucleosis is typical of young adults between 18 and 25 years of age; it is also called kissing disease because saliva can be a vehicle for infection. It is manifested by the appearance of short-lasting redness (rash) on the body, especially on the trunk and arms. It is associated with pharyngitis, tonsillitis and lymphadenopathy. Skin healing occurs without sequelae but persistence of tiredness for several months after healing is possible. Often no treatment is necessary.
In the case of mononucleosis, if it is not recognized as a disease but mistaken for a bacterial pharyngitis and, for this reason treated with antibiotic (ampicillin), a skin rash may appear.
HHV-5 or CMV (Cytomegalovirus)
.It is transmitted by urine, saliva, blood, breast milk and genital secretions.
As with EBV, in most cases the infection is asymptomatic.
The virus remains within lymphocytes, endothelial cells (cells that form blood vessels) and bone marrow stem cells.
It too can result in mononucleosis and genital ulcers very similar to those from EBV, but its main danger is in case of immunodeficiency (it can result in reactivation of the virus with general involvement that can lead to death) and pregnancy (if the mother gets infected for the first time before the 6th month, the fetus can suffer severe malformations).
HHV-6
Etiologic agent of the sixth disease or exanthem subitum affecting infants from 4 months of age and children up to 2 years of age. After an asymptomatic incubation, the child develops a fever high (39°, 40°C) without changes in general condition, and then, after 2-3 days, a pale pink rash appears on the trunk, neck and then on the extremities with the appearance of spots also on the soft palate. The whole rash disappears in about 2-3 days without the need for treatment.
.Often, the HHV-6 virus, is implicated in paraviral eruptions, that is, skin manifestations not related to the virus itself but to the anti-viral inflammatory reaction set up by our body against it, such as Gibert's pityriasis rosea.
HHV-7
He has no specific cutaneous manifestations. When they occur, they are similar to those of HHV-6, especially the paraviral manifestations.
HHHV-8 (or Kaposi sarcoma-associated herpes virus or KSHV)
.Virus sequences have been isolated in endothelial cells involved in Kaposi's sarcoma in patients with HIV.
In addition to Kaposi's sarcoma, herpes virus is associated with Castelman's disease in HIV-infected individuals.
Sources:
Saurat JH et al, Dermatology and sexually transmitted diseases Elsevier Masson 2017, 6th edition
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