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Non genital lesions, genital shedding?
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Non genital lesions, genital shedding?

Hello Dr.,

My girlfriend has thigh herpes, type 2, diagnosed by blood and PCR.  She got it through dry humping with her past boyfriend.   She's never had any vaginal issues connected to the herpes.   Her doctor indicated that this can happen and that avoiding sex during an outbreak is the only precaution necessary because the ano-gential area is not affected in her specific case.   Or so we thought……we were later given this article from the herpes community about her issue: http://www.ncbi.nlm.nih.gov/pubmed/17012458

The article states that when non-genital lesions are present (in the absence of genital lesions) the genital region will shed, on average, 7% of the time.

However, the article does not quantify the amount of genital shedding occurring in between non-genital lesions.  This might, in fact, mean that even less occurs, on par with genital HSV 1. Let me explain:

If genital shedding takes place 7% of the time in the presence of non-genital lesions (as indicated in the research study), this is not a bad situation altogether in terms of transmission, markedly better than if someone has solely genital lesions.  

Let's do an example:  A person has only buttock recurrences (no concurrent genital lesions), 10 outbreaks per year, let's say--which is a high estimate as the article indicates that non genital lesions occur less frequently than genital ones.  Only 7% of this entire outbreak time will s/he shed genitally.  Let's say each buttock outbreak is 7 days in duration.  That's 70 days of outbreak time per year, only 5 (7%) of those days will s/he shed genitally.  I assume genital shedding without lesions would be even less, on scale with HSV1 shedding, in fact.  Let's say that it's the same amount of shedding without lesions as with lesions.  This totals around 10 days per year of genital shedding with or without lesions.

Any thoughts on my calculations?

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Welcome back to the forum.  I read your discussions on this and the herpes community forums.

You have done a lot of research and learned a lot.  But you are over-interpreting the available data and, most important, do not understand one crucial issue.  The fact is that nobody has ever done any research to answer your questions.  In essence, the main issue boils down to this:  If an initial HSV-2 infection occurs in the general area of the genitals ("boxer shorts" distribution) but not on the genitals per se, what nerve roots are likely to be sites of persistent viral infection?  And where can recurrent outbreaks and asymptomatic shedding occur in such situations?  We simply do not know and the available data don't even allow confident prediction.

In his original reply to your question, Dr. Hook accepted the reasonable likelihood that in such a circumstance, genital asymptomatic shedding and outbreaks are unlikely.  In the subsequent discussion on the community forum, you heard the more conservative viewpoint:  in the absence of clear data, it it safest to assume that genital shedding can occur and that people like your girlfriend could transmit HSV-2 by genital intercourse.  Neither view is clearly right or wrong; that's what happens when there are no data.

For the most part, the research paper you cite is irrelevant.  (FYI, the investigators are close friends and professional colleagues of both Dr. Hook and me.  I often say that 90% of what I know about genital herpes has been learned from Drs. Corey and Wald.)  The patients studied had recurrent buttock HSV-2 lesions, but few if any acquired their infections on the buttocks or extra-genital areas.  Probably all or nearly all had truly genital initial infections.

So the available data do not provide any basis for the shedding/transmission estimates in your last paragraph.  I will not even speculate about the frequency of asymptomatic genital shedding in your girlfriend or the potential for transmission to you.

My final advice parallels that of gracefromHHP on the community forum.  You seem overly concerned about genital herpes and your risk of infection.  If your relationship with your girlfriend is strong, committed, and likely to continue, then her herpes should be a minor concern.  Romance and love are too important to be so affected by an impersonal bit of DNA that happened to evolve to exploit human intimacy for its genetic survival.  That's not to say you should be cavalier about herpes, and reasonable steps to prevent transmission make sense.  Among other things, your girlfriend could take suppressive therapy and you could use condoms consistently.  If you get infected, effective treatment is available to limit symptoms.

I hope this helps put things in perspective.  Good luck--  HHH, MD  
7 Comments
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Avatar_n_tn
Thanks Dr.,

Great information.  Certainly a lot of gray area on this issue.  Do you anticipate any such research on this issue?

Just a quick point of clarification:  I wasn't the original poster to Dr Hook on this issue.  I only cited that particular post to the Herpes Community because it bears similarity to our situation.  I've only ever posted on the Herpes Community and then today on the STD forum.

You are absolutely right about the relative unimportance of herpes in relation to romance etc.  You might find this hard to believe but its actually my g/f who's more concerned and what drove this most recent message to you.  Of course I'm concerned but have always viewed herpes as cold sores down south....

Thank again...
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239123_tn?1267651214
Thanks for the clarification.  Actually, I understood you weren't the original questioner to Dr. Hook -- just forgot as I wrote my reply.  I doubt this area will be a main topic of future research.  The problem is not a common one.  But maybe someday we'll know more.

It's good to learn you aren't all that concerned about catching herpes.  Maybe you'll show this discussion to your partner, to help her understand that it won't be a big deal if you become infected someday.
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Avatar_n_tn
Thanks, again, Dr.,

You certainly are one dedicated doctor.  

One final question I neglected to ask:  In the research study I cited, it found that in genital HSV1,  20% of initial infections involve both the genital and non-genital sites concurrently, whilst this occurs in only 2% of HSV2 cases.  Any reason for the very vast difference?

Good luck in your future research.  Best regards.  
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239123_tn?1267651214
Probably two factors.  First, transmission of HSV-1 generally requires oral sex, so simultaneous acquisition of HSV-1 both genitally and orally probably almost always follows an exposure that involved both genital and oral sex, as well as kissing.  By contrast, many HSV-2 transmissions probably result from genital intercourse without an oral sex event.  Second, there are differences in inherent predilection for each virus for various exposed sites.  The mouth probably is less susceptible to HSV-2 then genital tissues are to HSV-1.
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Avatar_n_tn
Thanks for the information.  My g/f wants me to ask one very final question to you based on the research study cited:  in 9% of primary HSV 2 outbreaks, the legs or buttocks are simultaneously involved with the genitals, both with lesions.  Yet, in those who have a non-primary initial outbreak the lesions are solely genital--none had buttock or leg lesions.  Why the difference?  Feel free to ignore this question if we've exceeded the limitations.  Thanks again for your insights.
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239123_tn?1267651214
This will have to be the last one.

Are you clear on definitions?  Primary means a person's first infection with either HSV-1 or 2. Nonprimary initial is first HSV-2 in someone with prior HSV-1.  Primary infections generally have more severe, prolonged, and more widespread slesions and symptoms than non primary initial.  That in turn goes along with a higher rate of nongenital involvement in primary cases.
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