Clinical Guides
Genital Herpes
A clinically focused Indian clinical guide to genital herpes diagnosis, antiviral choices, recurrence and suppression, pregnancy and neonatal safety, HIV, partner communication, stigma and suspected resistance.
MedNext Academy | 14 min read
Genital Herpes
A clinically focused Indian clinical guide to genital herpes diagnosis, antiviral choices, recurrence and suppression, pregnancy and neonatal safety, HIV, partner communication, stigma and suspected resistance.
Summary
Genital herpes is a lifelong infection caused by herpes simplex virus type 1 or type 2. It may produce painful grouped vesicles, erosions or ulcers, but classic lesions are absent in many patients and clinical diagnosis alone is unreliable. When a compatible fresh lesion is present, swab the base for a type-specific nucleic acid amplification test, usually PCR. Typing matters because genital HSV-1 generally recurs and sheds less often than HSV-2. A negative lesion test does not exclude infection when the lesion is old, healing or intermittently shedding.
Systemic acyclovir, valacyclovir or famciclovir shortens symptomatic episodes but does not eradicate latent virus. Treat every first clinical episode. Recurrent disease can be managed with early patient-initiated episodic treatment or daily suppression after shared decision-making about frequency, severity, distress, transmission goals, cost and adherence. Topical antiviral treatment offers little benefit. Transmission can occur without visible lesions; avoiding sex during lesions or prodrome, consistent condoms, disclosure and selected suppressive therapy reduce but do not eliminate risk.
Pregnancy changes urgency. New acquisition late in pregnancy carries the highest neonatal transmission risk, and lesions or prodrome at labour require immediate obstetric assessment. An exposed or unwell neonate needs specialist evaluation because neonatal herpes can be fatal. Severe, disseminated, neurological or ocular disease, urinary retention and persistent lesions in immunocompromise require urgent escalation. Genital herpes is common and manageable; diagnosis does not prove infidelity or identify when or from whom infection was acquired. Care must be confidential, non-judgmental and linked to testing for HIV and other indicated STIs.
How Common Is It?
HSV infection is common worldwide and is often unrecognised. WHO’s May 2025 fact sheet, based on 2020 modelling, estimated that 520 million people aged 15 to 49 had HSV-2 and that 205 million people in that age range experienced at least one symptomatic genital-herpes episode in 2020. These are global modelled estimates, not measured Indian clinic prevalence, and they should not be used to predict an individual patient’s infection probability. HSV-1 also causes a substantial and increasing proportion of genital infection in some populations.
Most infection is asymptomatic, mildly symptomatic or mistaken for another condition. Consequently, clinic attendees represent only a fraction of people carrying HSV, and absence of a remembered outbreak does not exclude transmission. After a symptomatic first HSV-2 episode, recurrences are common and asymptomatic shedding continues intermittently. Genital HSV-1 usually recurs less often and shedding declines more quickly, making viral typing useful for prognosis and counselling. The first recognised episode is not necessarily newly acquired infection; symptoms can emerge long after transmission.
Indian burden estimates vary with population, setting, assay and selection into STI services. Antenatal, HIV, dermatology and community studies are not interchangeable. NACO’s service framework is more useful clinically than asserting an unsupported single national prevalence. Barriers such as stigma, cost, privacy concerns, distance from a Suraksha Clinic and self-treatment may suppress attendance. The commonness of HSV should be explained without minimising pain, recurrent symptoms, relationship strain, HIV interaction or pregnancy risk.
Risk Factors
HSV spreads through contact with infected oral, genital or anal skin, mucosa, lesions or secretions. Transmission is most likely during an outbreak but can occur during asymptomatic shedding. Genital HSV-1 may follow oral-genital contact; HSV-2 is predominantly sexually transmitted. Risk rises with an infected partner, new or multiple partners, inconsistent barrier use and sexual contact during prodrome or lesions. Condoms reduce risk but do not cover every shedding surface. Neither a patient’s appearance nor a partner’s lack of symptoms establishes absence of infection.
Biological and clinical factors affect severity. A first episode can be prolonged and systemic. People living with HIV, especially with advanced immunosuppression, and recipients of transplants, chemotherapy or other immunosuppressive treatment may have extensive, deep, atypical or slowly healing lesions. HSV-2 is associated with increased HIV acquisition risk, so a genital-herpes presentation should trigger a confidential offer of HIV testing and assessment for other STIs. Friction, intercurrent illness and stress may accompany recurrences, but trigger avoidance cannot eliminate latent-virus reactivation.
Pregnancy is a special risk context. The greatest neonatal danger occurs when genital infection is first acquired near delivery because protective maternal antibody has not developed and shedding may be high. Recurrent infection present before pregnancy usually carries a much lower transmission risk, though it still requires antenatal documentation and a delivery plan. Ask about genital and oral HSV in the pregnant person and partner without implying blame. Adolescents, sexual-minority patients and people facing violence or coercion may need safeguarding, consent support and private access to care.
Diagnosis
History
Ask about pain, burning, itching or tingling before lesions; vesicles, ulcers, dysuria, urethral or vaginal symptoms, discharge, fever, myalgia, headache, tender nodes and urinary retention. Record lesion onset, site, healing, previous similar episodes and prior antiviral use. Take a confidential sexual history covering oral, vaginal and anal contact, partners, barriers, known HSV or other STIs, pregnancy possibility and HIV risk. Do not infer recent acquisition from a first recognised episode. Ask about immunosuppression, neurological symptoms, eye symptoms and psychosocial distress.
Examination
With consent and a chaperone according to policy, inspect external genital, perianal and relevant oral sites in good light. Fresh grouped vesicles may have progressed to shallow painful erosions or atypical fissures. Note lesion distribution, tenderness, discharge, lymphadenopathy, secondary infection and features of syphilis, chancroid or inflammatory disease. Examine the cervix, vagina, rectum or urethral opening only when clinically indicated and within competence. Check temperature and general state. Neurological examination is required for headache, photophobia, meningism, radicular pain or bladder dysfunction. Avoid unroofing lesions destructively when a vigorous swab of a fresh base will suffice.
Investigations
Send a fresh lesion swab for type-specific HSV PCR or another validated nucleic acid amplification test; PCR is more sensitive than culture. Viral culture can be useful where PCR is unavailable and is needed for phenotypic susceptibility testing when resistance is suspected. Type-specific serology has selective roles after negative lesion testing with recurrent atypical symptoms, an unconfirmed clinical diagnosis or an affected partner, but low-positive results can be false and require assay-specific confirmation. Routine population screening is not recommended. Offer HIV testing and perform syphilis and other site- and risk-directed STI testing. Pregnancy testing is considered before treatment or when relevant to planning.
Differential Diagnosis
Syphilis must be actively excluded because a primary chancre can be atypical or painful and coexist with HSV. Chancroid classically causes painful ragged ulcers and tender nodes but clinical distinction is imperfect. Lymphogranuloma venereum may begin with a small transient lesion followed by lymphadenopathy or proctocolitis. Donovanosis causes slowly progressive, friable, beefy-red ulcers and remains a relevant though uncommon Indian differential. Mpox, traumatic erosions, fixed drug eruption, aphthosis, Behcet disease, erosive lichen planus, autoimmune blistering disease and malignancy may resemble genital herpes.
Painful grouped lesions support HSV but are not diagnostic. Vulvovaginal candidiasis can cause fissuring and soreness; bacterial folliculitis, scabies and contact dermatitis produce different primary lesions but may be excoriated. A solitary persistent ulcer, induration, bleeding, pigment change or failure to heal needs biopsy or specialist assessment rather than repeated empirical antivirals. Genital ulcers may have more than one cause, particularly with HIV. Secondary bacterial infection can add discharge or crust without explaining the initiating lesion.
Neurological symptoms broaden the frame to HSV meningitis, encephalitis, transverse myelitis or sacral radiculitis. Dysuria may reflect urine contacting external ulcers rather than cystitis, but urinary infection and urethritis remain possible. Severe lower abdominal pain or pregnancy symptoms require a separate pelvic and obstetric differential. A positive HSV antibody without compatible disease does not prove that a current lesion is herpetic. Conversely, a negative PCR from a late crusted lesion does not rule out HSV. Diagnostic humility protects both medical care and relationships.
Management
Explain the diagnosis in neutral language: HSV persists in sensory ganglia, may reactivate, and cannot currently be eradicated, but symptoms and transmission risk can be reduced. Offer systemic antiviral treatment to everyone with a first clinical episode, ideally without waiting for results when suspicion is high. Provide analgesia, saline bathing or plain warm-water soaking, loose clothing, hydration and advice for painful urination. Severe pain, urinary retention, disseminated lesions, inability to take oral medicine or neurological, hepatic or ocular involvement needs hospital-level care and intravenous therapy.
For recurrences, episodic therapy works best when started during prodrome or within a day of lesion onset. Give an agreed prescription or supply with clear start criteria rather than requiring a delayed clinic visit for every episode. Daily suppression is an alternative for frequent, severe or distressing recurrences and for some people seeking to reduce HSV-2 transmission. Review benefit, adherence, renal function when relevant, pregnancy, cost and patient preference periodically. Suppression reduces outbreaks substantially but is not a cure and does not make transmission impossible. Evidence for preventing genital HSV-1 transmission through suppression is lacking.
Counselling is treatment. Advise no oral, vaginal or anal sex during lesions or prodrome; consistent condoms reduce but do not eliminate risk. Discuss disclosure to current partners and before future sexual contact in a practical, safety-aware way. Partners with symptoms need assessment; selected asymptomatic partners may be offered type-specific HSV-2 serology, but antiviral post-exposure prophylaxis is not established. Offer HIV and indicated STI testing. Address shame, anxiety, relationship fears and pregnancy plans directly, and arrange follow-up after acute pain settles when information is easier to absorb.
Prescribing Information
Acyclovir, valacyclovir and famciclovir are effective systemic options. India’s NACO guideline should determine the locally recommended regimen; international schedules must not be copied without verifying formulation, kidney function, age, pregnancy, interactions and service policy. CDC’s 2021 reference schedules include acyclovir 400 mg orally three times daily, valacyclovir 1 g twice daily or famciclovir 250 mg three times daily for 7 to 10 days for a first episode, with extension if healing is incomplete. These examples support learning, not self-prescribing. Topical antiviral monotherapy provides little benefit and should not replace systemic treatment.
Episodic recurrent regimens are shorter and require very early initiation. Suppressive options use daily acyclovir, valacyclovir or famciclovir; selection depends on recurrence frequency, dosing convenience, cost and evidence. Dose-adjust acyclovir and valacyclovir in renal impairment, maintain hydration where appropriate and review nephrotoxic co-medication. Headache, nausea and gastrointestinal effects are usually mild; neurotoxicity or kidney injury is a concern with excessive exposure, renal dysfunction or intravenous use. Pregnancy treatment and suppression require obstetric coordination, even though acyclovir has extensive reassuring experience.
Persistent lesions during adequate adherent treatment, particularly in advanced HIV or transplantation, raise resistance. Obtain viral culture for phenotypic susceptibility testing and involve infectious-disease or specialist STI services. Acyclovir-resistant strains are also resistant to valacyclovir and often famciclovir. Foscarnet or cidofovir can be nephrotoxic and require monitored specialist use; they are not primary-care rescue prescriptions. Antivirals do not eradicate latency, episodic therapy does not prevent every future recurrence, and no established vaccine or antiviral PrEP is available for an uninfected partner solely to prevent HSV acquisition.
When to Refer
Seek urgent hospital or specialist assessment for severe or disseminated lesions, uncontrolled pain, urinary retention, inability to drink or take oral therapy, marked immunosuppression, rapidly progressive disease or suspected bacterial superinfection with systemic illness. Headache with photophobia, meningism, confusion, seizure, focal neurology or sacral radicular symptoms requires emergency neurological evaluation. Eye pain, photophobia or visual change needs same-day ophthalmology because herpetic keratitis threatens vision. Fever with hepatitis, especially in pregnancy, raises rare disseminated HSV and warrants emergency treatment.
Any first episode in pregnancy needs prompt obstetric or sexual-health review. Acquisition in the second half of pregnancy, particularly near term, requires maternal-fetal medicine and infectious-disease input where available. Lesions or prodromal symptoms at labour require immediate delivery-team assessment; a routine outpatient plan is unsafe. A neonate exposed during birth or showing vesicles, fever, poor feeding, lethargy, seizures, respiratory illness or hepatitis needs urgent paediatric infectious-disease or neonatal care, even if the mother had no recognised herpes history.
Refer persistent, atypical, indurated or recurrent PCR-negative lesions for dermatology, venereology or gynaecological assessment and possible biopsy. Failure to heal during adequate antiviral treatment in immunocompromise requires resistance testing and specialist therapy. Refer when diagnostic confirmation, partner testing, HIV care or complex STI management is unavailable locally. Significant anxiety, self-harm thoughts, relationship violence or coercive disclosure requires mental-health or safeguarding support. The receiving pathway in India may be a NACO-supported Suraksha Clinic, medical college, district service or qualified private specialist; confirm privacy, affordability and follow-up.
Red Flags
Neurological red flags include severe headache, photophobia, neck stiffness, altered behaviour, reduced consciousness, seizure, focal deficit, new leg weakness, saddle sensory change and bladder dysfunction. These features can indicate meningitis, encephalitis or radiculomyelitis and are not managed as routine genital lesions. Ocular pain, redness, photophobia or reduced vision is another emergency. Disseminated vesicles, respiratory compromise, jaundice, very high transaminases, haemodynamic instability or sepsis require admission and intravenous antiviral consideration.
Pregnancy and neonatal red flags deserve explicit repetition. A first genital outbreak late in pregnancy, new lesions or prodrome near labour, fever with unexplained hepatitis, or uncertain primary versus recurrent infection needs immediate obstetric coordination. A neonate with vesicles may already have disseminated or central nervous system disease, but neonatal herpes can initially present without skin lesions. Poor feeding, temperature instability, lethargy, seizures, respiratory deterioration, coagulopathy or hepatitis in the first weeks of life demands urgent evaluation and empiric treatment under neonatal protocols.
Clinical red flags also include urinary retention, inability to maintain hydration, extensive necrotic or hypertrophic lesions, rapidly worsening pain and non-healing ulceration. A persistent ulcer may be syphilis, malignancy, inflammatory disease or resistant HSV. In advanced HIV, appearances can be atypical and long-lasting. Psychological danger matters: panic, severe shame, coercion, threatened violence or suicidal thinking after disclosure requires immediate safety assessment. Do not use a herpes diagnosis to assign blame, date transmission or allege infidelity; those unsupported conclusions can cause serious harm.
Indian Clinical Context
NACO’s 2024 National Technical Guidelines on STI and RTI provide the principal Indian programme context for genital-ulcer assessment, treatment, HIV integration and referral. Services may be delivered through Suraksha Clinics, district hospitals, medical colleges, integrated HIV facilities and trained private clinicians. PCR and type-specific serology are not uniformly accessible; syndromic treatment may therefore be necessary, but it should not become permanent diagnostic certainty. Where tests are available, lesion PCR and syphilis testing improve accuracy and reduce unnecessary or incomplete treatment.
Confidentiality, consent and non-discrimination are essential. Ask about partners, sexual practices, gender identity and HIV risk only to guide care, in a language the patient understands. Do not require partner attendance as a condition of treatment. Disclosure counselling should consider personal safety; forced disclosure can expose a patient to violence, abandonment or housing and financial harm. Provide written information that states HSV is common, may have been acquired long before symptoms and does not identify a source partner. The NACO helpline and locally verified services can support linkage, but availability should be confirmed rather than assumed.
Affordability affects antiviral choice and adherence. Generic acyclovir may be less expensive but more frequent dosing can be difficult; valacyclovir is convenient but may cost more. Renal testing, pregnancy care, HIV services and resistance testing can require referral. Avoid presenting imported transmission estimates or US screening policy as Indian prevalence. Use NACO guidance for the national pathway, local formulary for prescribing and current laboratory capability for test selection. Document the clinical state, counselling, consent, tests offered, treatment, partner plan and exact follow-up arrangements.
NMC Competency Mapping
The most direct NMC Dermatology and Venereology links are DR10.1, which addresses rational syndromic STI management, and DR10.3, which covers the clinical features and appropriate diagnostic tests for non-syphilitic genital ulcers including herpes genitalis. Genital herpes teaching also integrates Microbiology, Obstetrics and Gynaecology, Paediatrics, Internal Medicine and AETCOM rather than belonging to a single isolated fact list. The learner should recognise vesicular and ulcerative morphology, take a confidential sexual history, construct a genital-ulcer differential, choose a lesion specimen, interpret HSV PCR and understand the limits of serology. Microbiology integration includes HSV latency, reactivation, type-specific prognosis, asymptomatic shedding and the difference between viral detection and timing of acquisition.
Clinical competence includes assessing pain, hydration, urination, pregnancy, HIV risk, immunosuppression and neurological or ocular complications. The learner should formulate first-episode, episodic and suppressive strategies; reconcile renal function and pregnancy; and explain why topical therapy or indiscriminate antibiotic use is inadequate. Obstetric integration requires recognising the high neonatal risk of late maternal acquisition, asking about lesions and prodrome at labour, and escalating an exposed or symptomatic newborn. HIV integration includes consent-based testing, atypical disease, immune reconstitution and suspected resistance.
Communication is a core safety skill. Counselling must distinguish lifelong infection from lifelong symptoms, explain residual transmission risk, support voluntary disclosure and avoid blame. Learners should address stigma, reproductive fears and partner safety while maintaining confidentiality. Examination and specimen collection require consent, privacy and an appropriate chaperone. Reading a guide does not certify independent genital examination, neonatal management, intravenous acyclovir prescribing or resistance treatment. These need supervised clinical teaching, skills assessment and local protocol knowledge.
Key Exam Pearls for NEET PG
HSV is an enveloped double-stranded DNA virus that establishes latency in sensory ganglia. HSV-2 is the classic genital type, but HSV-1 increasingly causes genital disease and generally recurs less often. Painful grouped vesicles progressing to shallow ulcers, tender nodes, dysuria and systemic symptoms support a first episode, yet absence of classic lesions does not exclude infection. PCR or another nucleic acid amplification test from a fresh lesion is preferred; viral culture sensitivity falls as lesions heal. Tzanck smear cannot type HSV and is not sufficiently sensitive or specific for modern diagnosis.
Treat every first clinical episode with a systemic nucleoside analogue. Recurrent episodic treatment works best during prodrome or within one day of lesion onset. Daily suppression markedly reduces HSV-2 recurrences and can reduce, but not abolish, transmission in selected discordant couples. Antivirals do not eradicate latent virus. Condoms reduce risk incompletely because uncovered skin can shed virus. Avoid sex during prodrome and active lesions. A first recognised episode does not prove recent acquisition.
Always test for or offer assessment of syphilis and HIV as indicated. Advanced HIV can cause chronic, extensive or atypical ulcers. Persistent disease during adequate acyclovir suggests resistance; culture for phenotypic susceptibility and specialist foscarnet-based management may be required. New maternal infection near delivery carries the greatest neonatal risk. Lesions or prodrome at labour prompt obstetric assessment for caesarean delivery, while exposed or symptomatic neonates require urgent systemic acyclovir protocols. HSV encephalitis classically affects temporal lobes; genital HSV-2 more often features in aseptic meningitis questions.
Frequently Asked Questions
Can genital herpes be diagnosed reliably just by looking at an ulcer?
No. Classic grouped painful vesicles are helpful but many lesions are atypical, and syphilis or other ulcer causes can coexist. Swab a fresh lesion base for type-specific HSV PCR when available and test for syphilis and other indicated STIs. A negative late-lesion result does not fully exclude HSV, so clinical context and follow-up remain important.
Does suppressive antiviral treatment completely prevent transmission to a partner?
No. Daily suppression can substantially reduce symptomatic recurrences and lowers HSV-2 transmission in some studied discordant couples, but asymptomatic shedding and residual risk remain. Combine it with avoiding sex during prodrome or lesions, consistent condoms, informed disclosure and partner-centred counselling. Evidence is limited for preventing genital HSV-1 transmission and asymptomatic HSV-2 transmission.
Why does genital herpes require special planning during pregnancy?
Acquisition near delivery carries the highest risk because maternal protective antibody has not developed and viral shedding may be substantial. A pregnant person with a first episode needs prompt obstetric review; lesions or prodrome at labour need immediate delivery-team assessment. An exposed or unwell neonate requires specialist evaluation because neonatal herpes can progress without obvious skin lesions.
What should be done when genital herpes lesions persist despite acyclovir?
First reassess the diagnosis, dose, adherence, absorption, kidney adjustment and immune status. In an immunocompromised patient with persistent or recurrent lesions during adequate treatment, suspect resistance, obtain viral culture for phenotypic susceptibility and involve infectious-disease or specialist STI services. Foscarnet and cidofovir are toxic monitored therapies, not empirical community alternatives.
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