Herpes Information

[HomeRunDerby]

I am involved in a near year long relationship with a woman. We are married, however, not to each other. My friend gets random cold sores. The last was about 6 months back. We kiss very often and do engage in oral without condoms. We are careful to watch for any sign of a cold sore and refrain when one is present Approximately 10 days back we engaged in lengthy kissing and oral sex. Approximately 6 days later I noticed a red pimple type spot near the base on the shaft of my penis. There are no signs elsewhere or on my lips. She does not have any visible signs or symptoms of a cold sore.

I saw an internist 2 days later and he was confident it was an inflamed follicle. He examined it and also felt for enlarged lymph nodes in the groin and they were normal. The internist did not recommend medication. I also spoke with a friend who is a family physician. He didn't examine me. Rather, he suggested valtrex for 10 days as a precaution and consider a blood test in 6 weeks. The spot is now beginning to fade. It had a small white head which is now gone. It looks like a red pimple around a hair follicle. It doesn't hurt and there was never any puss.

I am concerned for obvious reasons and want advice and information. Here are my specific issues:

1. Does this sound like an initial HSV1 infection;

2. We kissed often yet no symptoms on my mouth. Does this make HSV1 a less likely diagnosis

3. Should I take valtrex either short or long term;

4. It is my understanding that if this is HSV1, there is still a relatively low rate of recurrence/shedding with a genital HSV1 infection. Should I reduce this risk further by taking valtrex;

5. In the event this isn't HSV1, how much risk is there by continuing to engage in kissing and oral when there are no symptoms of a cold sore. My wife doesn't have HSV1 so there are obvious implications.

We recognize the complexity of the situation. The straight forward information on this site is most appreciated

[Edward W Hook, MD]

It is thought that asymptomatic shedding becomes less common with the pasage of time.  EWH

[HomeRunDerby]

Dr Hook:

A final issue of relevance

I read in a recent thread 10/25/10 that you estimate the risk of exposure to HSV1 during aysmptomatic shedding in the range of 1 in 10,000 and describe it as low

I realize this is only an estimate. I would like to know whether a person has less asymptomatic shedding of oral HSV1 when the virus has been present from childhood. In other words does the fact that my partner has experienced cold sores from the time she was a child reduce the chance I was exposed to asypmtomatic shedding

I will post when I have test results to report. Much appreciation for your time and the information

[Edward W Hook, MD]

Genital to genital transmission of HSV-1 is rare (IF you have it which, as I have said, is unlikely).  When it occurs, it is more likely to occur with recently acquired infection than infection which has been present for more than a year.  Further, recurrences of genital HSV-1 infections are many times less common than recurrences of HSV-2.    

As I also mentioned before, a blood test will be of little use unless you have had one before.  It is more likely than not that you already have HSV-1 but don't know it, like most people.  Further, a blood test, if positive will tell you nothing about the location of your infection (oral, genital, other).  EWH

[HomeRunDerby]

I again appreciate your information and the opportunity to rephrase my issue of concern

I am very much trying to handle this concern in an appropriate manner. The relationship I am involved in is non traditional, however, it is very close and personal. We both knew of the potential for moments such as this and discussed it openly on a sophiticated level

Nonetheless, the potential reality of the situation is more stressful than anticipated

I realize the limitations of visual inspection are magnified (no pun intended) over the Internet. Thus I don't think there is more to offer with descriptions other than to say that on day 5 it is a red base around one of the hair follicles we all have down the shaft of the penis

I think I am really looking for advice moving forward. I realize a blood test is an option down the road. I think the time frame is 6 weeks. I will likely request one at my next physical.

The issue I am attempting to convey is more one of risk management. I would like your view on risks to my wife moving forward. I have read much conflicting information. I would appreciate your view on the risk of genital to genital HSV1 infection, including the likelihood of future outbreaks and/or asymptomatic shedding in the event this is an initial symptom. I realize this is only an assumption. We use condoms for birth control.

Please know your time is most appreciated

[Edward W Hook, MD]

Your lesion really does no sound like HSV.  I agree with your internist.  

Regarding symptoms, sorry.  While I agree that infection could have occurred orally or genitally, and that oral infection is somewhat more likely, it still could  have occurred in either location.  

Most people with herpes do not know that they have herpes however this is not because they are asymptomatic but, in most cases, because most people attribute their HSV symptoms to other causes, due in part to denial and in part to the fact that people expect the symptoms of inital HSV to be severe when in fact that is not the case.

I hope this answers your quesitons.  If not, please re-state them

EWH

[HomeRunDerby]

Dr Hook:

I appreciate the information. Your comments provide much assistance. I respectfully request you permit this one folllow up post

I am concerned because I have read many times that visual examination isn't a reliable diagnostic tool. Nonetheless, I have confidence in the internist. I acknowledge that I am nervous and this might be impacting my thought process

The spot is now close to gone and today is 5 days from the time it appeared. It is now flesh colored and looks like an enlarged bump on top of a hair follicle. There has never been puss other than the small white head on the first day. Does this sound like what an initial HSV1 would look like on the 5th day

I think you might have misunderstood my reference to oral symptoms. I am thinking that a genital HSV1 diagnosis is less likely because I would have suffered oral symptoms rather than only genital. Does this logic hold

There are many sources that imply transmission in the absence of symptoms is very common. The numbers you cite speak to the contrary. Given our circumstances please advise what precautions you suggest and testing you recommend

I will follow your advice and be guided by your suggestions

[Edward W Hook, MD]

Welcome to the Forum.  I have reviewed your interchanges on the Community site and agree with the advice Grace has given you. If the lesion you describe is a first episode of genital HSV it is a bit atypical in that such an outbreak would more typically be a group of small blisters (medical term is vesicles).  Further, from what you describe of your precautions, the risk of infection is rather low.  Does this mean that this in not HSV- no, but it IS unlikely.  The only way to be sure would be to have a culture or PCR test.   Further, I disagree with the advice your physician friend has given. The lesion is already going away and there is no evidence that taking antiviral therapy would benefit you in any way.  With this as background, let's work through your questions:

1.  No, not really.  You have been examined and the physician diagnosed folliculitis. That is what it sounds like to me as well.

2.  Infection following the sorts of exposures you describe essentially chance events.  I suppose it would be more likely for you to get an oral infection but could not say so with 100% confidence.

3.   I would not recommend antiviral therapy of any sort.  Hard to know how it might benefit you.  

4.  You are correct about the lower rate of recurrence with genital HSV-1. There is no evidence that antiviral therapy would further reduce the risk for recurrence.

5.  In the absence of a lesion, the risk of acquisition of HSV through the activities you mention is in the neighborhood of 1 in 10,000, IF you do not have HSV-1 already. There is a better than 50/50 chance that you already have HSV-1 however, unless you have a type-specific blood test which tells you that you do not.  

Hope these comments help.  EWH