Strange question

[nsns]

Dr. I want to ask a strange question. I have herpes and my soon to be wife does not, at least that we know of. Theoretically speaking couldn’t I take a Q-tip the next time I have an OB and rub I on one of my blisters then take the Q-tip and purposely infect say the bottom of my soon to be wife’s foot?

I know it sounds strange, but based on everything I have read on this site, it seems to me that this would prevent her from getting the virus on her genitals.

Lets face it, EVERYONE with genital herpes would much rather have an OB on the bottom of there foot if they were given the choice, plus she wants to have a child and if this would work it would insure that she could have a natural birth without the fear of a neonatal herpes problem.

I am currently in Costa Rica and I highly doubt they offer the herpes select test, so what other test can determine if she already have herpes?

Thanks a bunch!

[H. Hunter Handsfield, M.D.]

Dont' go there.  I definitely do not recommend intentional infection with HSV-2 at any body site.  There are risks of other complications from HSV-2 (meningitis, a serious skin rash called erythema multiforme, and others).  Transmission to pregnant women and newborns can be easily prevented without such a drastic measure.  Cesarean section to prevent HSV transmission to newborns is uncommon these days; even if she has or develops herpes, with proper management she can expect a vaginal delivery.

I agree with your alternate implication (last sentence) that the first thing is to determine whether or not your wife already is HSV-2 positive; as the spouse of an infected partner, there is at least a 50% likelihood she is.  I suspect you are wrong about availability of proper HSV blood tests in Costa Rica, which is a medically sophisticated country, or so I understand.  At a minimum, there must be providers and labs that can send specimens to Quest Diagnostics, LabCorp, or other laboratories in the US.

Good luck--  HHH, MD

[Englishman]

Back to the toe theory. This has been answered by the doc before, though he did not mention the consequences of purpose infection of HSV-2 (since I presume that herpetic encephalitis is caused by oral HSV-1 because of the close promxity to the spinal column at the bottom of the brain). If HSV-2 does not potentially cause herpetic encephalitis and prior infection with HSV-2 give some immunity (10%, 50%, 90%???) then the toe thoery still stands?

[Englishman]

If a patient turns out to be HSV-2 positive and a long term relationship is being formed, will the partner not eventually become infected anyway? So would it be better to have HSV-2 of the genitals or toe? I guess from a legal point of view a doctor could never recommend this anyway? Although some doctors recommend encouraging children to be infected with chicken pox to offer protection for adult life despite the fact that chicken pox may lead to more severe complications (though rare).

[Lunker1]

Since we are asking questions, here's one for everyone.  If a mother has HSV2, will her child have HSV2 antibodies, or is that not how it works?  If true, could this explain why some people have antibodies but no symptoms?

[apollo13]

Sorry Doc.  I question your objectiveness with respect to this recurring question.  Each time it is presented, you say it is possible in theory, but recommend against it.  The ostensible basis for your recommendation is that the intentionally infected person will experience some remotely possible condition such as meningitis, a serious skin rash called erythema multiforme, or herpetic encephalitis.  I realize doctors take a Hippocratic oath, but not an oath of hypocrisy.  On the one hand, you consult folks that herpes is common, manageable, and more of a nuisance and stigma than a serious medical condition.  On the other hand, you strongly discourage folks from self-immunization on the basis of some remote conditions that make up less than .05% of all herpes cases?  You do not seem to be open minded to the potential benefits of this theory.  Yet, one of the major herpes web sites expressly states that passing HSV-2 antibodies to the fetus is a positive thing.

I suspect your legal and ethical obligations, along with some hubris, are preventing an objective analysis of the issue.  Maybe you never want to be the doctor responsible for even hinting about the potential viability or benefits of the "big toe" theory.  Maybe your conclusion will turn out to be correct even after an objective analysis, but isn't it for the patient to decide?  Shouldn't the patient be able to decide the cost/benefit analysis?  Is there a medical paper on this issue?  If not, there should be an objective FAQ on this web site.

My 2 cents.

[H. Hunter Handsfield, M.D.]

Hubris?  Hypocracy?  Lack of objectivity?  Closed mindedness?  Pretty heavy duty charges, thank you very much.

In humble honesty, I never give advice based on a medicolegal, CYA mentality.  And I reject the charge of lack of objectivity.  The opposite is true, i.e. those promoting the notion of intentional nongenital HSV-2 are the ones lacking in objectivity.  You are reacting to the psychological impact of genital herpes and inflated perceptions of how bad the disease is.  The psychological impact is real, but 90% of that impact is in fear of the unknown.  90% of infected people come to the realization that it's mostly not so bad, and that their pre-infection, or early infection, fears were not realized.  So in this analysis, I put the psychological impact aside and look at the risks and benefits of the proposed strategy and compare them with the probability and consequences of getting genital HSV-2.

In that analysis, I conclude that, in general, genital HSV-2 simply is not sufficiently serious or important to go to the trouble, and the risk of other morbidity--which although infrequent can be severe.  (Your 0.05% figure--or 1 in 2000 cases--probably is randomly selected, so I don't hold you to it as your definitive belief.  But the actual rate of serious outcomes is far higher than that.)  In the case of nsns's original question, it assumed incorrectly that neonatal herpes cannot otherwise be easily prevented.  In fact, the risk of neonatal herpes in a properly managed infected pregnant women, or in a couple in whom the male partner is infected, is very low.  In that circumstance, neonatal herpes is nearly 100% preventable, even with--as apparently is important to nsns and his partner--of a vaginal vs cesarean delivery.

Are there scientific papers on this notion?  Of course not.  But based on my analysis of the available data, I gave my advice.  Of course the patient ultimately decides; I never dictate herpes management, only give my best judgment.   nsns will intentionally infect his wife's foot or not.  Presumably he will factor in my opinion, otherwise he wouldn't have asked the question.  That doesn't mean he will follow either my reasoning or my advice; it's up to him.

In response to Englishman's question:  No, the uninfected partner will not necessarily become infected eventually.  The available data suggest that about half the partners ultimately are infected--perhaps higher if the couple is unaware of the infected partner's infection, but nowhere near 100%.

HHH, MD

[t1234]

Yes, my understanding is the child will have antibodies to HSV2 via the placenta.  They will eventually go away as the body will
not produce them absent infection.

I also understand the newborn baby would test positive
via an antibody test. Of course after time the test would
become negative as the antibodies go away.

[apollo13]

Doc.  There are two components of intentional infection (ie "big toe" theory).  The threshold question is can it be done?  If not, the issue is moot.  If yes, the second component is risk management.  Namely, what are the chances that intentional infection will lead to serious health risks?  Also, what is the probability that a positive partner will infect a negative partner over a lengthy period of unprotected sex?  Risk management is a decision that the couple should make under medical advice.

The folks here have not promoted the big toe theory.  We've asked questions.  This is because logically it makes sense and could save loved ones from the biggest grief - the psychological stigma (legitimate or not).  There is no lack of objectivity, just questions.  I agree that herpes is not a big deal for most (especially if 90% don't know they have it).  But that was not until I discovered I was an asymptomatic carrier.  Before then, I was paranoid and feared it like the plague.  

Until the medical community changes the name "herpes," the psychological impact of having genital herpes will be real and substantial.  Isn't it logical that someone would want to protect their loved one from this burden?

You say of course there are no scientific papers on this notion.  Why?  This corroborates my point about the legal and ethical dilemmas a doctor might face.  Should nsns infect his wife's foot if they decide the risk management weighs in favor of intentional infection?  Or should a doctor help them?

[Englishman]

Thanks for the reply doc I fully understand you perspective and appreciate the time taken to answer. Personally, if I knew for a fact that I had met the woman of my dreams (easier said than done!) AND there was around around a 50% of being eventually infected AND infection of the toe offered high levels of immunity I would offer my toe up for the sacrifice. Not sure about the bottom of the foot since this is in contact with the ground and would be worse during an outbreak. I think the top of my foot would get it.

There should be scientific papers on this - whether on humans or animals. It sounds like a very simple animal experiment and I imagine quite a few people would volunteer for this investigation too. Not sure on the legal complications for the human volunteers.

I think the "big toe" theory needs to be studied further. Could the principle work with HPV infection? I would quite happily have recurrent outbreaks on my toe to offer better genital immunity.

I understand that there is a psychological element here. But I do value each part of my body differently. I would quite happily sacrifice my penis (!!!) for my eyes (if such a bizarre situation arises). When it comes down to it, I value the little toe on my foot the least important both cosmetically and functionally.

[Englishman]

Sorry, but more valid questions spring to mind....


According to eMedicine, herpetic whitlow of the finger/toe can be caused by both HSV-1 and HSV-2.

Are patients with a HSV-2 Whitlow protected from acquiring gential HSV-2?

There must be a research paper on this. There are people out there now who could be studied and would not have to be purposely infected.

[t1234]

My understanding is that you would.  Of course there
would be period between the date of infection and the
time the antibodies "built up" that you would not be.

But otherwise, I think you would have significant levels
of protection at least that's my understanding

[t1234]

Correction to my prior post--I was referring to Herpes Whitlow.

I also agree more studies need to be done.  The reason given is lack of funds, but I've often suspected it has in part something to do with the financial interest of the parties.

For example, I don't think any drug manufactor can be expected to fund a study that could adversely affect his product.

Also it appears to me the research community is closely tied with drug manufactors etc. via lecture fees, consulting fees, or clinical trial contracts which needs to be better disclosed.  For example, if a person agrues in a healh care periodical for generalized HSV2 testing they should disclose any relationships they may have with the test manufactor.

But that's just my opinion.

[Englishman]

Inclined to agree after trying to find follow up work based on the work of Fred Klenner and his treatment for many diseases with mega-vitamin therapy. Very little work done on his amazing discoveries. They were dismissed without proper research. I fear that drug companies would not want to fund research into mega-vitamin therapy because vitamins can not be patented. Similar debate exists with the work of Linus Pauling - a very very intelligent doctor.

[nsns]

It was just a thought, and I have to make a comment about people who say herpes is not a big deal. It's not a big deal if you only have a few OB a year or are asymptomatic, but put yourself in my shoes where I spend over $2,000 a year on Valtrex and still get 6 Ob's, not to mention if I am not on Valtrex try 12 to 15 Ob's a year, that around 120 days or so of not being able to have sex with your partner, THAT IS A HUGE DEAL, not to mention always having the worry of passing it along. So for all you lucky people who only have 2 Ob's a year, you are LUCKY unlike me.

Any recommandations Dr. I just started getting my 3rd OB in 2 months this morning and I have been on 500 my Valtrex for the last 6 months straight.

I wish I had it on my big Toe!

[Englishman]

Your thought was perfectly valid. I came up with a similar suggestion a few weeks back. This issue is still not fully resolved and I feel it will crop up again.

Nsns, I wish you the best of luck with whatever decision you choose and hope that you have a happy future with the woman you love.

[Englishman]

Given the severity and frequency of Nsns outbreaks is it not accurate to presume that his wife is much more likely to aquire the infection? I think that Nsns is very thoughful about his potential to transmit to his partner and bearing in mind the new information he has given, the original question is far from answered.

[H. Hunter Handsfield, M.D.]

nsns, you have more outbreaks than most people--if you really are having recurrent herpes.  Such frequent outbreaks are very atypical while on antiviral therapy.  You need to see a provider for confirmation, and to have a viral culture to see if you are infected with a strain resistant to antiviral drugs (uncommon, but it happens).

But remember that most infected people develop no symptoms at all or such mild ones they don't even know they are infected; and most people with recurrent outbreaks have 3-5 episodes per year. Only a few percent (probably under 2-3%) of people with genital HSV-2 have the frequency you are experiencing.  General recommendations for prevention have to be based on the usual expectations, not infrequent atypical case.

Englishman:  Among HSV-2 discordant couples aware of the infection, taking care to avoid sex with symptoms, using suppressive therapy, and having sex a few times a week, the overall rate of transmisison is around 3% each year.  It might be higher in with more frequent outbreaks, but probabaly still not all that high.  With care, Mrs. nsns will likely remain herpes free for years.  (She still should have a blood test to see if she is already infected.)

I will add that it would be unethical for any health care provider to recommend a form of therapy that is clearly experimental, without writing a research protocol and getting institutional review board approval, developing written consent forms, etc.  Don't hold your breath; I doubt that research ever will be done.  And I will recommend against such personal trials of intentional inoculation until/unless such research is done.

This is my last comment on this thread.

HHH, MD

[Englishman]

Appreciate the response. I propose a very simple research investigation.

"Do people with HSV-2 Whitlow ever develop genital HSV-2?"

There is no ethical debate here, just a simple questionnaire and data analysis.

If it is proved that Herpetic Whitlow HSV-2 does provide immunity to genital HSV-2 then the ethics of purposeful infection comes in to play.

As Apollo13 said the threshold question is "Does it work?". Since this has not been answered anywhere in this forum I am starting to suspect that it indeed does.

It is a shame that the medical community will not explore such possibilities as there are potentially very clear benefits:

1. Less stress and potentital guilt in relationships.
2. Discordant couples could engage in unprotected sex more  often. Indeed, in Nsns case, he clearly states the number of days in a year when he can not have sex because of HSV-2.


Science is about answering the questions, however, having friends (a GP and psychologist) who have worked in the medical community, I am told that the pursuit of the truth is sometimes hindered by the profits or political goals of a pharmaceutical company.

I bet 50 quid that Valtrex will not sponsor an investigation like this!

[H. Hunter Handsfield, M.D.]

OK, I have to respond.  But this really will be my last comment.

Absolutely research is influenced by profits, politics, and other nonscientific issues.  And I agree that no drug company would fund the research you suggest.  But not for the reason you assume.  Such research would be extraordinarily expensive, definitely not "just a simple questionnaire and data analysis".  An investigator would have to recruit many people with herpetic whitlow known to be due to HSV-2 (hard to find, since the bulk of cases are due to HSV-1); select for those whose sexual behavior puts them at risk for new HSV-2 infection; then follow those people with repeated examinations, blood tests, and behavioral questionnaires, probably for several years.  At typical HSV-2 acquisition rates, for scientifically valid results, such a study would require hundreds of subjects (if not thousands) at a cost of many millions of dollars.  Even a preliminary, pilot trial would be a few million.

No chance; it will never happen.  And it would be a low priority; genital herpes simply isn't important enough.  If I were research czar and had several million dollars to spend, I could think of a hundred things of higher public health priority.

HHH, MD

[Englishman]

http://www.emedicine.com/EMERG/topic754.htm


It appears that most HSV-2 Whitlows are from auto-innoculation from a genital infection.

Indeed all Whitlows are supposedly from auto-innoculation which suggests that prior infection of HSV in one site does not offer protection to another body site.

It is not known if having a Whitlow first offers genital protection, but from the logic outlined earlier I would assume not.

It appears that the "Big Toe" theory has probably reached its end.

Nsns I suspect that purposely infecting your wifes foot might do nothing other than give her a sore foot a few times a year and stop her catching HSV-2 of the foot in the future (which never happens anyway). Probably best to leave her foot alone.

I now find myself asking questions about the nature of herpes itself. The blood antibodies appear to be useless in controlling infection to a new body site but do protect the same body site. This makes me think that antibodies in the blood have nothing to do with immunity. The immunity must be specific to the infected area - it must be antibodies in a non-fluid tissue. I never did microbiology and am now stumped. Anyone else got any idea?

[Englishman]

Cheers doc. I will leave this one alone now. Thank you for your time and patience. Thankyou to other forum users, it has been an interesting discussion.

[t1234]

My understanding is as follows:

Auto innoculation most often occurs during initial infection before the body has a chance to build up anti-bodies.  Once the
infection is established , transferring it to another part of the body is unlikely.  Think about it.  If that weren't true,
people would have HSV1 or HSV2 infections routinely all over
their bodies from auto innoculating themselves over time.

I saw the webmd stuff, but Herpes Whitlow is common amoung
medical personnel who carelessly touch a herpes sore on an
infected patient.

Those guys may be right, I don't know (seen info that might contradict their conclusions), but they said most not all were
autoinnoculations from gentital infections.

But if you get Herpes Whitlow from HSV2 and that was the source
site,  after the antibodies built up you would have substantial immunity to subsequent HSV2 infections on other parts of the body.

Great discussion

Maybe Dr. HHH will comment.

[Englishman]

But Whitlows are usually on the fingers because:

1. You are most likely to touch a HSV sore with your finger (obviously).
2. The skin around the finger nails commonly has trauma (just looking at my fingers now, I can be stratches and abraded skin).


It is less likely that you would autoinnoculate the rest of your body because generally it is free from minor trauma. Intact skin is generall very protective against nearly all infections (that is one of its main functions).

Also people are advised to not touch there eye if they have herpes sores because of auto-innoculation of the eye.

The existence of auto-innoculation provides very good evidence that the "Big toe" theory would not work. I wonder why the doc didn't use these examples to dispel the theory ages ago?

- Now I am thinking there is something in it again!!!!!

[Englishman]

I suppose maybe the doc doesn't know much about Whitlows because they are not really an STD.

What if you finger a woman who has HSV-2, I guess you could get a Whitlow, so they are potentially an STD?

I should retrain in the field of medicine, I find it fascinating.

[nsns]

I just wanted to thank you for taking the time to always explane your input.

Just one more thing if possible? I am currently on 500 mg of Valtrex and my friend told me that alott of doctors don't even mess around with prescribing that dose to people who have more then 3 or 4 Ob's a year, they just put them on the 1000mg because the 500 is usually not enougph.

The problem is that the montly cost of 1000mg Valtrex daily is $300 and living in Costa Rica you would think it would be less but it's not at all!

I want to know if I can take acyclovir because as you know it's a 10th of the price and I don't have a problem taking something a few times a day since it ends up being the same once it is in your system I figure why not?

I just don't know what the equal dose would be due to the diffrence of bioavailibity.

1000mg Valtrex = ? acyclovir split into ? doses.


Once again thanks for all that you do!

[apollo13]

Very interesting discussion here that warrants further research to get a somewhat definitive answer.  I agree that a direct study of the Big Toe Theory will not happen for the reasons Doc stated.  However, couldn't scientists test Big Toe anecdotally with those infected with HSV-1?  In other words, do people with genital HSV-1 infect their partners who have oral HSV-1?  The upside is that oral HSV-1 is so common that finding people should be easy. The downside is that you would never really know the location of the HSV-1 infection (even with cultures).  Could HSV-1 exist in both areas of the body but only be symptomatic in one?  If Doc's comments about antibodies and immunity are correct, it should be difficult for people with oral HSV-1 (half the population) to get genital HSV-1 right?

Doc, Englishman's flip flop is further evidence of our objectivity.