Managing (solving?) HSV related facial outbreaks

[BetsyM]

Background: I have been diagnosed with HSV2 since 1986. The original diagnosis was genital herpes (lesions were located on my labia). Outbreaks were infrequent initially, and genital. After ~1993, I developed HSV2 (not HSV1) related facial lesions (small bumps, becoming sores, etc). I treated them with acyclovir 5 day treatment, and topical zovirax to manage the facial oozing. Outbreaks were associated with stress, infrequent sunburn, or illness (if i was fighting off infection). In the past few years, the outbreaks have been increasing to a minimum of 4 per year. Last month, I had a record 2 outbreaks, just 2 weeks apart. Each outbreak is facially located, rotating (no pattern)to the same spot(either base of chin, or below my mouth). From 1997-1999 under physician care, I took a daily low dose of acyclovir to manage the outbreaks, but was concerned about developing resistance, so I tapered off to no daily prophilaxis with acyclovir; replacing it with good diet, yoga, daily doses of Lysine and E vitamin. Acyclovir(pill and topical) in the event of outbreak. In the past 3 years, I have observed an increase of outbreaks. My questions: 1) I am seeing quite a bit of facial scarring and want to take care of this---what are the dermatological options for skin repair? 2)how do I reduce these facial outbreaks? Must I be on a daily dose of acyclovir? if so, what are the dangers of resistance, and what should my dosage be?  As I age (I am 37) I am seeing a pattern of recurrence, and am worried about this.  Thanks very much.

[Alan Rockoff, MD]

I hope you will forgive me for expressing some skepticism about the diagnosis.  Not that you don't have herpes--certainly yo do.  Rather, I question whether all your outbreaks are indeed herpes, but instead are nondescript bumps which you perhaps traumatize out of concern that they're herpes.  My skepticism arises from your description--"small bumps, becoming sores"--as herpes starts as blisters.  Small bumps generally become sores when you rub or scratch them.

Also, it is very uncommon for the frequency of herpes to increase over time.  Finally, scarring is very uncommon from herpes on the face.

I therefore urge to to arrange with your dermatologist to see you at the first sign of your next apparent outbreak, so examination and culture can settle the issue definitively.  If my skepticism is misplaced and these are indeed all herpes, you needn't be afraid of side-effects or drug resistance if you take oral acyclovir or valacyclovir as suppressive therapy.

Take care.

Dr. Rockoff

[BetsyM]

Correction: when describing my outbreaks...they are small blisters (not bumps), breaking out into sores, then resolving in the usual time period (before about 10 days).

[Alan Rockoff, MD]

Nevertheless.  And if they are herpes, then you should indeed consider chronic suppressive therapy.

Dr. Rockoff

[Terri Warren, RN, Adult Nurse Practitioner]

And I would add to this very insightful response that the literature (all of it) strongly supports that HSV 2 orally has a recurrence rate of .01 times per year.  Even if you had HSV 2 cultured from a lesion at some point, that does not mean that all of your recurrences are HSV 2 or even herpes.  However, you could do daily home swabbing with PCR and find out for sure, you could get an antibody test and see if you might be positive for HSV 1 as well, and you could go on daily suppressive therapy.  

Terri Warren