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Constant Tingling post-initial HSV1 genital outbreak
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Constant Tingling post-initial HSV1 genital outbreak

Dr. Handsfield,
I contracted HSV1 genitally from my husband.  I had the flu-like symptoms, the swelling of my lymph nodes, & the outbreak of blisters on my vagina.  My ob/gyn took a culture which came back positive for herpes.  My husband was tested and came back positive for HSV1, expected given he gets cold sores on his lips. I took 2000 mg Valtrex for this initial outbreak. I had 3 days where all felt fine & then began the zapping electrical currents and tingling, with occasional itching and pinching, not on my vagina, instead, around my anus & thighs. Very occasionally, I will feel the tingling run from my anus to my vagina.

Since that time, I have experimented with various amounts of Valtrex. Currently, I am taking between 6 to 8000mg a day lessening the tingling/zapping feeling but not alleviating it. As of today, I have been feeling these "symptoms" for 8 weeks, not counting the 3 weeks of true prodrome/outbreak.  My health otherwise, is excellent.

Multiple questions then:
1. Is the constant tingling/zapping, light itching nerve damage (post herpetic neuraligia) or a prodrome?
2. Is the constant tingling/zapping, light itchign an indication that an outbreak is imminent/pending?  That is, is there viral shedding so that I should not have sex with my husband?
3. What dose of Valtrex should I be taking, if any?  Should I stop it altogether and see what happens?  That is, do I need to suffer full-blown outbreaks to build a coping immunity for this?
4. I am on the west coast (working in Southern California, maintaining my home in the Puget Sound area).  Do you know of any medical experts in either location that I could consult in person?

I am just at a loss about what's going on and where to turn to for help.

Thank you,
ELPD


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Dr. Handsfield and I share the forum.  You got me.  FYI, the reason we share the forum is because we have worked together for nearly 30 years and while our verbiage styles vary, we have never disagreed on management strategies or advice to clients.

Before I address your specific questions, a few comments in general about genital HSV-1.  Genital HSV1 represents a minority of genital herpes episodes.  In the studies of  genital HSV-1, when compared to HSV-1, HSV-1 tends to have fewer recurrences and a larger proportion of persons with genital HSV-1 who never have a recurrence is far larger than for HSV-2.  That said, these are generalizations and as such there are exceptions.  While  all of us who have seen a lot of persons with GH have seen a few persons who have frequent and severe genital recurrences, how to manage such persons is a function of experience rather than based on large studies since there are fewer patients to study, making definitive answers more difficult.  For your specific problems living in the Puget Sound area there are two great resources which might be helpful to you.  In the Portland Area Terri Warren, who heads up the Herpes Expert Forum (link on the left) runs an excellent private STD clinic, the Westover Heights Clinic with great expertise in GH.  Alternatively, in the Seattle area, the Seattle-King County STD Clinic provides superb care and when appropriate can also refer patients to the Univ. of Washington Herpes Clinic which is one of the premier HSV clinics on earth.  Now on to your questions.

1.  The tingling that you describe may be neuropathic pain.  Such pain can arise from a long list of things and be influenced by confounding factors such as anxiety.  We get many questions about possible post-herpetic neuralgia on the forum.  Unfortunately, in discussions with STD and specifically HSV experts, we know of no one who has seen patients who they are convinced has had post-herpetic neuralgia due to HSV-1 or HSV-2 ( It certainly does occur with herpes zoster [the chicken pox virus] but this is an entirely different virus.).  While such neuralgic syndromes MAY occur due to GH, if this is the case it is very rare and is more appropriately cared for by a neurologist than an infectious disease person as the discomfort is unlikely to represent active infection.  I can tell you from sad experience that antiviral therapy seems to have little impact of most instances in which this situation arises,

Herpetic prodromes do frequently (about 25-30% of the time) occur in persons with both HSV-1 and HSV-2 and can be a warning of a forthcoming outbreak.  They rarely last longer than a 6-12 hours before an outbreak and occasional "false prodromes" lasting a similar period but not followed by outbreaks may occur as well.  Continuous symptoms are not a prodrome.

2.  See above regarding the relationship of prodromes to outbreaks..  If you and your husband both have HSV-1, there is no reason to worry about spread to one another.  Once both have the infection the virus does not regularly spread to each other (you don't become "more infected") due to the immune response to infection.

3.  There are no studies of the most appropriate therapy for genital herpes due to HSV-1 because the course tends to be so very benign.  I realize that does not help you.  In treating and/or suppressing genital herpes, does of 500mg -1.0 gram have been used.  Somewhat higher doses are thought to be needed for treatment of cold sore (oral HSV-1) but there is no clear reason why doses in excess of 2.0 grams per day should be needed.  Whatever therapy is used, it should be used on a regular schedule.

4.  See comments above.

Hope this helps,  EWH
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