Unkown STD symptom HSV-2?

Last year i was diagnosed with genital herpes HSV-2.  I have had two visible breakouts in that time, however have experienced signifigant prodromes many times without any traditional breakouts.  Is this normal? I get regular dull burning and tingling in my genital area however it isn't necessarily in the area where i had the break out. And a full herpes break out rarely follows these prodromes. I am finding it hard identifying when and when not i may be having an outbreak. I don't at all feel as i am in control of my body.

I have been to two STI clinics and have since started taking 400mg of acyclovir twice daily as a form of supressive therapy.  This has reduced the number of prodrome occurances however i still feel them every couple of weeks for a few hours each time. If i feel these prodromes does that mean that i am at that moment contagious and shedding even if the prodromes don't lead to a traditional breakout?

About a month after my first full break out of HSV-2 i small fissure or scrape/wringle (about one inch) appeared above the area where i had my first breakout, near my circumcision scar. I remember reading that this can sometimes be a symptom of herpes however the mark has not disapeared and is still as visible 6+ months later. The scrape doesn't necessarily tingle, itch or burn, however it does not go away and was not there before i was diagnosed with herpes.  Is this a sign of herpes? does this mean i am constantly contagious??  or could this fissure/scrape be a sign of another STI?

[Edward W Hook, MD]

Good questions with a several part answer.

About 1 in 4 persons with genital herpes will experience prodromal symptoms before they experience an outbreak.  These individuals can also experience so called "false-prodromes" more frequently than actual outbreaks.  This seems to be your pattern.  The fact that your suppressive therapy has reduced their frequency some also supports that these prodromes are herpes related.  There is a possibility that your symptoms might improve with a higher dose of suppressive therapy.  I might suggest going to 400 mg three times daily to see if it reduces things further.  I suspect it might and there is little downside to taking the increased dose.

So, what about whether or not you are contagious?  We know that when lesions are present that virus is present.  It is also likely to be present during prodromes.  Even more important is that you. like everyone with HSV-2 infection are also likely to have asymptomatic shedding of the virus at least 10% of the time.  That is, despite the absence of signs or symptoms of infection, the virus can be present on normal appearing skin.  it turns out that while most exposures to partners with herpes do not lead to transmission of infection, that asymptomatic shedding, because it is so common, accounts for most transmission from one person to another.  Suppressive therapy has been shown to reduce asymptomatic shedding, recurrences and prodromes and transmission to others.  Thus in answer to your question, while you are not always “contagious” to sex partners, it is common and you cannot tell when you are and when you are not.

Finally, as far as the "scrape" you mention, this is unlikely to be herpes.  I cannot tell you what it might be.  I would suggest you go on to see a health care provider who has done may genital exams such as someone in your local STD clinic to sort this out.   A herpes lesion would be expected to resolve over a period of no more than 2 weeks.

Hope these comments are helpful.  EWH