Symptoms:

Symptoms vary depending on whether the outbreak is initial or recurrent. The first (primary) outbreak is usually worse than recurrent outbreaks. However, most cases of new herpes simplex virus infections do not produce symptoms. In fact, studies indicate that 10 - 25% of people infected with HSV-2 are unaware that they have genital herpes. Even if infected people have mild or no symptoms, they can still transmit the herpes virus.

Symptoms of Genital Herpes

Primary Genital Herpes Outbreak. For patients who do experience symptoms, the first outbreak usually occurs in or around the genital area within 1 - 2 weeks after sexual exposure to the virus. The first signs are a tingling sensation in the affected areas, (genitalia, buttocks, thighs), and groups of small red bumps that develop into blisters. Over the next 2 - 3 weeks, more blisters can appear and rupture into painful open sores. The lesions eventually dry out and develop a crust, and then heal rapidly without leaving a scar. Blisters in moist areas heal more slowly than others. The lesions may sometimes itch, but itching decreases as they heal.

About 40% of men and 70% of women develop other symptoms during initial outbreaks of genital herpes, such as flu-like discomfort, headache, muscle aches, fever, and swollen glands. (Glands can become swollen in the groin area as well as the neck.) Some patients may have difficulty urinating, and women may experience vaginal discharge.

Recurrent Genital Herpes Outbreak. In general, recurrences are much milder than the initial outbreak. The virus sheds for a much shorter period of time (about 3 days) compared to in an initial outbreak of 3 weeks. Women may have only minor itching, and the symptoms may be even milder in men.

On average, people have about four recurrences during the first year, although this varies widely. Over time, recurrences decrease in frequency. There are some differences in frequency of recurrence depending on whether HSV-2 or HSV-1 causes genital herpes. HSV-2 genital infection is more likely to cause recurrences than HSV-1.

Symptoms of Oral Herpes

Oral herpes (herpes labialis) is most often caused by herpes simplex virus 1 (HSV-1) but can also be caused by herpes simplex virus 1 (HSV-2). It usually affects the lips and, in some primary attacks, the mucous membranes in the mouth. A herpes infection may occur on the cheeks or in the nose, but facial herpes is very uncommon.

Primary Oral Herpes Infection. If the primary (initial) oral infection causes symptoms, they can be very painful, particularly in small children.

• Blisters form on the lips but may also erupt on the tongue.
• The blisters eventually rupture as painful open sores, develop a yellowish membrane before healing, and disappear within 3 - 14 days.
• Increased salivation and foul breath may be present.
• Rarely, the infection may be accompanied by difficulty in swallowing, chills, muscle pain, or hearing loss.

In children, the infection usually occurs in the mouth. In adolescents, the primary infection is more apt to appear in the upper part of the throat and cause soreness.

Recurrent Oral Herpes Infection. Most patients have only a couple of outbreaks a year, although a small percentage of patients experience more frequent recurrences. HSV-2 oral infections tend to recur less frequently than HSV-1. Recurrences are usually much milder than primary infections and are known commonly as cold sores or fever blisters (because they may arise during a bout of cold or flu). They usually show up on the outer edge of the lips and rarely affect the gums or throat. (Cold sores are commonly mistaken for the crater-like mouth lesions known as canker sores, which are not associated with herpes simplex virus.)

Recurrence Course, Triggers, and Timing

Course of Recurrence. Most cases of herpes simplex recur. The site on the body and the type of virus influence how often it comes back. The virus usually takes the following course:

• Prodrome. The outbreak of infection is often preceded by a prodrome, an early group of symptoms that may include itching skin, pain, or an abnormal tingling sensation at the site of infection. The patient may also have a headache, enlarged lymph glands, and flu-like symptoms. The prodrome, which may be as few as 2 hours or as many as 2 days, steps when the blisters develop. About 25% of the time, recurrence does not go beyond the prodrome stage.
• Outbreak. Recurrent outbreaks of herpes simplex virus (HSV) feature most of the same symptoms at the same sites as the primary attack, but they tend to be milder and briefer. After blisters erupt, they typically heal in 6 - 10 days. Occasionally, the symptoms may not resemble those of the primary episode but appear as fissures and scrapes in the skin or as general inflammation around the affected area.

Triggers of Recurrence. It is not completely known what triggers renewed infection, but several different factors may be involved. These include sunlight, wind, fever, physical injury, surgery, menstruation, suppression of the immune system, and emotional stress. Oral herpes can be provoked within about 3 days of intense dental work, particularly root canal or tooth extraction.

Timing of Recurrences. Recurrent outbreaks may occur at intervals of days, weeks, or years. For most people, outbreaks recur with more frequency during the first year after an initial attack. During that period, the body mounts an immune response to HSV, and in most healthy people recurring infections tend to become progressively less severe and less frequent. The immune system, however, cannot kill the virus completely.