Irritated skin / Healing wound

[hemsky111]

Hi Dr Hook and HHH.,
I know this is a bit theoretical, but I couldn't fid an answer to it on the boards and I'm sure others have similar questions. I know an open wound/cut/skin break is required for transmission though skin typically, but what about simply irritated skin that was unbroken? I had a sore perianal area that was licked, so theoretically speaking, that would not pose a risk still, correct (as the skin, while a bit sore and irritated, was not bleeding at all). At what point is there a risk with skin? I know intact skin is a great barrier against HIV, but what about a VERY tiny healing cut that has stopped bleeding (say an hour before)?
Also, if one had an anal fistula, would it no longer hurt half an hour later, or do fistulas normally take a while to hurt and take a while to heal (or at least to pose a risk they do).

[H. Hunter Handsfield, M.D.]

Yes, your questions are theoretical, and there are no data to answer them with anything other than common sense.  HIV cannot pentrate intact skin, but it probably can penetrate the lining of the rectum, even without anal lesions -- which is why anal sex is the most risky of all sexual practices.  Logically a  "VERY tiny healing cut" on the anus would be less risk than a larger lesion or one that was fresh (not healing), but nothing mroe can be said.

You might be confusing anal fissure versus fistula.  Fissures can appear and heal in a few days, and often might start with minor trauma.  Anal fistulas are abnormal anatomic connections from higher in the rectum, leading to an opening on the skin near the anus. They are relatively major medical problem and don't heal on their own, but typically require surgery plus antibiotics.  

I hope this helps.  Best wishes--   HHH, MD

[H. Hunter Handsfield, M.D.]

I meant to say that herpes is also a common explanation for anal lesions, especially in men who have sex with men.  That would especially be a consideration if the problem is a recurrent one.  And syphilis can also cause anal sores.  It is an important issue, because either herpes or syphilis of the anus would significantly increase the risk of HIV if exposed to an infected partner.  If you have any doubt about your STD risks, see provider for STD evaluation.

[hemsky111]

Thanks Dr. HHH. Yes, I was mixing up fissure with fistulas. I know I'm thinking about this too in depth, but  "intact" skin for all logical purposes of HIV risk includes open wounds/cuts/breaks in the skin such as healing wounds. I believe I read a while ago that you stated that in reference to skin (not rectal mucosae, because logically it's a risk anyways) that typically to pose a risk it would have to be an open fresh wound (ie bleeding, such as why fingering is no risk since logically people don't finger with fresh, open wounds).
I am not too sure what was wrong with my anal area, but it burnt a bit and was sore -around- the anus. I do not remember noticing any blood while wiping and I checked for blood/sores around that time and couldn't find any. I did have a little "lump" that was not discoloured around the area of my sphincters and I have suffered from hemmorhoids in the past. I am almost 100% sure I don't have anal herpes or syphillis (no canchre - I checked at the time quite and none of the symptom dates would line up at ALL) and  didn't notice any herpetic lesions of any type (I'm assuming lesions would be required to increase my risk). In addition I haven't suffered from any symptoms of either (and I've read quite a bit). Indeed, my only pot. exposure was VERY brief rimming (3 licks) (receptive).

So I guess here's my questions (I'll try to keep them brief):
1) While irritated/sore skin that has not visibly broken may be slightly "damaged" on a cellular level, the keratin should not be too broken, and thus it would not really pose a risk correct (or in my situation someone licked the irritated skin, so that's no risk too, correct)?
2) Typically a lot of fluid transfer is needed for hiv transmission, correct (ie in the case of rimming logically 3 licks by someone to you with no reported blood in thier mouth is about as zero risk as can be, correct)?
3) The area around my anus was red and a bit sore (not too bad), but I'm not too sure what caused this. I did see a bit of a protrusion inside the anus (not a sore, but a lump), and no blood was noticed. I'm assuming this would likely be either a case of a) not cleaning the anal area well enough) or b) hemmorhoids? Indeed, an anal fissure would cause bleeding to occur (or at least any fissure that would be a risk).
I should also note that this was all at LEAST 45 minutes before being licked.
4) Is it not logical to assume that given the WORST case scenario that there was a small nick/tear in my anal canal, that after 45 minutes (and with no blood), that the wound would have clotted and not at least been an "open wound" and that any miniscule fluid contact should be of no worry anyways?
Thanks again!

[H. Hunter Handsfield, M.D.]

Yes, you are over-thinking it.  There no clear answers to your follow-up quesitons, only common sense assumptions.

1,2) I haven't a clue whether there was enough break in natural barriers to increase the risk if infection, if exposed.  If so, the effect was small.  A protruding bump suggests a hemorrhoid.

2) The greater the volume of fluid exchange, probably the higher the risk of transmission.

4) I suppose that makes sense.

You don't describe the risky episode(s) or behaviors that concern you.  Those are what is important in avoiding HIV through rectal exposure -- whether or not you have had unprotected receptive anal sex with someone with HIV (or at risk).  Whether or not there is a minor anal lesion of some sort makes little difference.

Time to end this thread.  I won't have any further comments.