Preventing Outbreaks of Genital Herpes
People with genital herpes fall into two broad categories: Those who have outbreaks and those that do not. Interestingly, probably 90% of people with genital herpes infections remain undiagnosed. This is probably because most of them have very few symptoms, though Wald et al showed recently that most people who have genital herpes do have symptoms that, if they were trained to look for them, might lead them to think that they might have an infection. These symptoms include skin redness, itching, burning, tingling, vaginal discharges that were thought to be yeast infections, leg pain, and so on. So, the “great 90%” of undiagnosed patients probably often have some symptoms, but they are rarely aware of them. Thus, this 90% of people can continue to spread genital herpes through intimate relations to unsuspecting partners. MY OPINION: ROUTINE TESTING OF ADULTS HAVING INTIMATE CONTACT SHOULD BE THE RULE, NOT THE EXCEPTION. So, of the category of those who do not have symptoms, these people either have been diagnosed and don’t have outbreaks OR they are infected but have never been diagnosed.
Many millions of people with genital herpes have symptoms. A recent estimate I found was that as many as five million Americans have regular outbreaks of some nature. Some people rarely have symptoms, perhaps once every year or two. People who have picked up type 1 genital herpes usually have few outbreaks, for example. The average number of outbreaks for a person with genital type 2 herpes is around four to six outbreaks per year. Sometimes the outbreaks are mild, showing little more than some skin redness and tenderness. Sometimes the outbreaks can be really severe, with many blisters leading to ulcers which can be very uncomfortable.
Preventing outbreaks has two essential parts: Lifestyle matters, and medicine. Lifestyle is so important. Over the last four years I have corresponded with many thousands of people on the website. I have heard so many stories about romance, stress, fatigue, and anxiety. I see a definite undercurrent of stress, fatigue, and anxiety running through the people who write it. It could be members of a relationship who don’t get along. It could be a mother fearful for her children. It could be someone in near financial ruin, who has little resources. Whatever the case, fear – what I call “deep fear” – unsettles the unconscious roots of our psychological trees, bringing us to our emotional knees spritually if not physically.
If you are being troubled with frequent outbreaks, then I ask that you look at the circle of your life to see if there are some stresses that you are either aware of or not aware of that may really be eating away at you. Financial stress can be one of the worst, of course. If somebody feels that the end of the rope is near financially, this can cause such mental stress that depression, early morning awakening, sleeplessness, and despair can occur. If such deep stresses are inducing outbreaks, then to control the outbreaks, you have to work on the sources of the stress. Moreover, if these stresses are affecting your immune system such that frequent outbreaks are occurring, then the stresses are likely affecting you in other ways: Making you more susceptible to cancer or heart disease; causing depression; affecting the quality of your life.
I also believe very strongly that frequent outbreaks tell a person a lot about how life is going for that person. Immune systems are often able to control infections in most diseases: Not always, but most of the time. So, most people with genital HSV have almost no symptoms, we think. Does this mean that they have less stressful lives, or that they control stress better? I don’t know the answer to that, but I do know that the converse is true. People who let stresses affect them very deeply often have a much harder time keeping outbreaks under control. Listen to the infection. If frequent outbreaks occur, then make sure that there are not other issues in your life that may need to be addressed as well.
If you would like for me to talk one day more about controlling stress, contact me here, and I will work on it.
Controlling Outbreaks through Medication
There is no doubt that prescription antiviral medication helps control the incidence of outbreaks. It has been documented now since the eighties that acyclovir taken regularly can keep outbreaks down to a minimum, as few as once or twice a year. The outbreaks while on medication tend to be very mild. Valtrex, which achieves blood levels of acyclovirFOUR HUNDRED PERCENT GREATER than generic acyclovir or Zovirax, has been a tremendous addition to the armamentarium of treating herpes outbreaks and preventing disease from recurring. Also, Valtrex can be taken once a day in most people, unlike acyclovir which might be taken from twice to five times per day or Famvir which is taken twice daily. So, there is real value to be found in achieving higher blood levels through better absorption.
Some people take antiviral medication daily, every day, which is called “daily suppression therapy”. Some people take the medication only when they have symptoms, which is called “episodic therapy”. Which is right for you? Generally we think that if someone has outbreaks more often then four to six times per year, then a person is a candidate for daily suppressive therapy. Does this mean that a person that begins daily suppressive therapy will be on the medication for the rest of that person’s life?
The best answer to that is how the person responds after a period of time of being on suppressive therapy. Some people, after six months of suppressive therapy, have allowed their immune systems sufficient time to recover so that they seem to then be able to control their outbreaks. These people might consider coming off of medication for a period of time. Some people, though, after six months of therapy, continue to have frequent outbreaks if they come off of medication. These people would benefit from continuing on medication for a long period of time: Perhaps years.
It has been said about genital herpes infections that outbreaks tend to become less frequent as people get into their middle aged years. If that is in fact true, I suspect that it is so because, as people age, they get better control of their lives: The mortgage is paid off, the kids are out of college, and the essences of relationships are solidified. So, stress is less. This would make perfectly good sense. Research indicates that the frequency of HSV outbreaks tends to fall for the first four years of infections and then to settle in from there. My take home message for this is that someone who has an infection should work hard to control stresses in life and shoule consider being on antiviral suppressive therapy if frequent outbreaks occur.
Which medication is best? My opinion is that the drug is Valtrex. The blood levels of acyclovir are the highest, and it has once daily dosing in most people. Many people find satisfactory control of disease with generic acyclovir or with Famvir. A patient needs to discuss these alternatives with a private physician to make the right prescribing decision for that person.
Protecting Uninfected Partners
We know that viral shedding occurs in many people even when they are not on medication. This viral shedding is probably responsible for most new cases of genital herpes. Viral shedding from oral herpes infections occurs readily as well, and this oral viral shedding may be responsible for many of the new cases of genital herpes that occur through oral to genital contact. As many as 30% of new cases of genital herpes are acquired, incidentally, through oral to genital contact.
The Medical Advisory Board of www.herpes.org has determined through researching the peer-reviewed scientific literature that antiviral medications such as Valtrex, when taken as prescribed, suppress viral shedding to a very high degree. We feel that this suppression of viral shedding very likely has a protective effect for the uninfected partners of people with genital herpes. We believe, therefore, that persons who have genital herpes should consider being on antiviral medication in dosages consistent with suppressive therapy dosages if they are having intimate contact with uninfected partners. This suppressive therapy, combined with condoms with spermacidal, likely offers a high degree of protection to the uninfected partner. We don’t yet know just how high this degree of protection is, but it seems to be the best protection that can currently be offered.
I have found that many people don’t know what to do when they feel an outbreak coming on or if they discover that an outbreak has occurred. I want to offer several thoughts about how to take care of an outbreak.
First, get on medication. Take the prescribed antiviral medication in the appropriate dosage. I usually suggest one or two grams of Valtrex daily for the first two or three days, decreasing the dosage to one gram daily until the outbreak has either been suppressed or has proceeded through the blister and scab phase and the skin is now healed. Then the regular suppressive dosage can be resumed, which is usually 500 mg once or twice a day, or even 1 gram taken once a day. The comparable dosages of generic acyclovir are usually 400 mg taken three times a day for two or three days during outbreaks, and then 400 mg twice daily during the healing and suppressive period. Famvir is typically a dosage of 125 to 250 mg taken twice daily.
The herpes lesions should be cleaned will when they occur. I suggest taking showers, using a wash rag to break blisters gently under running water with lots of soap on the skin. The hands should then be washed, and the wash rag and towels whould be run through a hot wash. I suggest placing a bit of tissue on the wound, if it is external, to collect any secretion from the wound site. Showers should be performed twice daily, with the tissue being washed away in the shower. In this way, the wound will not get secondarily infected with bacteria, called impetigo, and will heal as quickly as possible. If you can stand the brief discomfort, it may even be somewhat beneficial to clean the wound with alcohol the first few times that it is cleaned. This may be painful, but it does kill virus particles. Soap and water kills virus, too, though, so if the alcohol is too painful, just stick with the soap and water in the showers.
The herpes lesions can be painful. People with frequent outbreaks should have some pain medication on hand. If no stomach ulcers or aspirin allergies are present, then 400 mg to 600 mg of ibuprofen may be taken with some food in the stomach. If this does not control pain, then a stronger prescription medication such as hydrocodone, prescribed by the doctor, may be taken if the patient is not allergic to hydrocodone or codeine.
Needless to say, fresh clean undergarments should be worn during outbreaks, changed at least twice daily.
Some Summary Thoughts
Understanding and dealing with adversity – life’s difficult stresses and challenges – is part of life. Few people get through life with nothing but smiles and relaxing adventures. Most of us have tough things that happen to us, sometimes terrible things: Divorces, illnesses, accidents, loss of jobs, money problems, family crises. I remember a line from the book “A Canticle for Leibowitz”, by Walter Miller, which is a great read by the way. At the end of the book there is a scene where a man is being asked to lead a group of settlers in a dangerous adventure. He struggles with the decision, feeling that he is not able, and not worthy. He says (forgive the paraphrase), “My mind is screaming!” The leader of the company replies, “Steel screams when it is forged!” That statement has stayed with me – and guided me – for over thirty years.
Going through the difficulty of dealing with herpes – knowing that an infection is there, dealing with outbreaks, having to juggle medication sometimes – is a part of living. All of us – everyone reading this paper – will have to deal with illness one of these days. It could be hypertension, arthritis, cancer, diabetes, or heart disease. When it happens, we have to learn to live with it. Herpes is no different than any other illness, with the single exception that it is necessary to help protect a partner from becoming infected.
But, I want to share just this little thought with you: Having a herpes infection is a “life adversity”, nothing more or less. It is something that people have to learn to live with. It is a preparation for many younger people about dealing with an illness that will be useful training for later in life, when a daily medication for a more serious condition has to be taken. Learning how to become responsible for a medical problem is something that we all have to do.
Nobody wants a herpes infection, of course. But, remember: Steel screams when it’s forged. People with herpes will be stronger for the experience. Never resist the challenges life brings, but instead learn how to manage them…and grow…and move on the next trials to come.