Herpes outbreak while on suppressive therapy (daily Valtrex 500mg)

[zelec]

Hi,
I’ve been diagnosed with genital HSV2 in January 2010 and I’ve been on non-stop outbreaks till I started a suppressive therapy in Jannuary 2011. I’ve been outbreak free for almost two years. For the first time since then, I had an outbreak on my thigh. It didn’t disappear yet and another one appeared today on my testicule.

My question is, since I’m already taking 500mg Valtrex daily, can I increase the dosage when I have an outbreak? If yes, should I go for 1g daily and for how long?

Also, if my outbreaks reoccur, should I consider increasing the dosage of my suppressive therapy for ever?

I’m currently away from my country of residence (Canada) where I have my doctor and won’t be able to get there before one year. That’s why I’m asking you.

Thanks in advance


Background:

Jannuary 2010:
First diagnosis: took generic Valacyclovir for the first 3 outbreaks, didn’t seem to have a strong effect so I stopped taking it. I had non-stop outbreaks despite taking supplements / topical (olive leaf extract, zinc, lysine, tea tree oil, kelp… )
My outbreaks occured in the pubic area around the base of the shaft except two that were on the penis. I took some pictures; my doctor said it was impressive when he saw them.
Psychologically, it was devastating, it caused me depression. I’m currently seeing a psychologist which helps a lot.


Jannuary 2011:
After seeing an ID specialist, I started a suppressive therapy (500mg Valtrex daily). No more outbreaks (except one on my lip), but the skin was red and had often secretions in the genital area. I always felt that it meant that I was still contagious and went to another specialist who explained to me that I wasn’t contagious. He even took a swab that came back negative for HSV.

December 2012:
First genital outbreak since I started suppressive therapy. It was in an unusual area (on my right thigh near my testicule). It progressed for 15 days, and other blisters appeared today on my right testicule.

[H. Hunter Handsfield, M.D.]

Welcome back to the forum.

I would be interested in knowing more about the basis for the diagnosis of HSV-2.  What direct tests for the virus (PCR or culture from the lesions) and/or what blood tests have you had?  If blood tests were done, tell me the exact results, i.e. the numerical values for both HSV-1 and HSV-2.  Did a health professional diagnose it in person, or is photograph the only time one of your doctors saw the actual lesions?

If indeed you have HSV-2, I'm not convinced that it was the cause of many (most?) of the symptoms you had in the first few months:

1) You "took generic Valacyclovir for the first 3 outbreaks, didn’t seem to have a strong effect...."  It is exceedingly rare for valacyclovir to have no effect at all on herpes symptoms.

2) You "had non-stop outbreaks" for some time after that.  Herpes rarely if ever behaves that way. Recurrent herpes outbreaks, whether oral or genital, due to either HSV-2 or HSV-1, don't lasts more than 2 weeks; recur no more often than once every 4-6 weeks; and between outbreaks there are no symptoms.

3) The location is wrong.  Initial herpes rarely involves the pubic area.  It can happen, but so can folliculitis -- which certainly can cause symptoms and lesions that look a lot like herpes.

4) Recurrent herpes usually causes lesions in pretty much the same anatomic area every time, give or take an inch or so.  A new lesion on your thigh at this time would be quite atypical, as would lesions now appearing on the scrotum.  And as already implied above, multiple locations is rarely for recurrent outbreaks; and the duration also is against herpes.  Can you tell me more about exactly what the thigh and scrotal lesion looks like?  How many lesions are there?  What has been the time course since symptoms started?

Having said all that, the fact that your symptoms finally cleared up on suppressive doses of valacyclovir tends to support the diagnosis.  And breakthrough recurrent outbreaks are not at all rare.  Valacyclovir and related drugs reduce but do not totally prevent outbreaks.  So leaving aside the location of the lesion(s), this could well be a herpes recurrence despite valacyclovir suppression.  It wouldn't mean the infection is resistant to the drug, and there would be no need to increase the dose to speed healing; it would be unlikely to make any difference.

In summary, I'm not all that skeptical you have HSV-2 (after all, 10-20% of the US population has postive blood tests for it) -- but I am suspicious that HSV has not been the main cause of your symptoms either initially or now.
If you would like to return with answers to my questions about diagnostic tests etc, I'll be happy to comment further.

Regards--  HHH, MD

[H. Hunter Handsfield, M.D.]

As discussed above, I have no doubt you had gential herpes at the time your viral test was positive.  However, your current symptoms may not be due to herpes at all.  As you say, outbreaks in two separate locations is unusual; and recurrent herpes almost never lasts a whole month, even without treatment.  And herpes lesions don't bleed.

My advice is that you stop taking valacyclovir, and make arrangements with your doctor or clinic to be seen promptly (within a day or two) of any and all suspicious outbreaks, to determine whether they really are herpes.  Most likely most of what you are having is something else.

Please return after one or more of these episodes have been professionall evaluated to let me know the outcome.  Until then I won't have any further comments or advice.

[zelec]

Hi,
It's been a month now, the blisters on my right side groin almost cleared and the itching stopped.
However, 3 days ago and for the 1st time, I felt a light but consistent tingling on the tip of my penis and since yesterday, I felt a burning sensation in the urethra (1/2" deep from the tip) while urinating that persists a few minutes after as well. I also noticed obvious traces of blood on the paper when I wiped my penis and on my underwear.
Is it another herpes outbreak (I'm still taking 500mg of Valtrex daily)?
If it is the case, why is the virus outbraking in new locations (thighs then urethra)

[H. Hunter Handsfield, M.D.]

On this forum we normally don't examine posted photographs.  Our view is that it comes too close to practicing medicine from a distance.  No online forum is intended or can serve as a substitute for in-person medical care.

But I broke our own rule and glanced at your images. They are all very nonspecific -- i.e. not sufficiently typical for herpes or anything else for me to be confident in guessing at a diagnosis.  So this doesn't change my opinion or advice as as above:  my best judgment remains that you probably don't have genital herpes.

I have deleted the comments with the photo links, to preclude second guessing by other forum users.

[zelec]

Hello,

I unfortunately can't see my Dr for culture anytime soon, I hope the outbreak will end and I would return to normal condition soon.
I forgot to inform you that the first ID specialist I saw in early 2011, asked me to take tests (blood and urine) to check my immune system because he found the outbreaks too frequent, long and visually impressive (they weren't painful though, only itchy). The results (a three page report) came back perfectly normal.

I uploaded some pictures of the outbreak that started 3 weeks ago after being outbreak free for almost 2 years:

[url=http://postimage.org/image/dys7g7quz/][img]http://s9.postimage.org/dys7g7quz/zelec_dec_08_02_pubic.jpg[/img][/url]
[url=http://postimage.org/image/cs226jbbf/][img]http://s1.postimage.org/cs226jbbf/zelec_dec_09_03_thigh_groin.jpg[/img][/url]
[url=http://postimage.org/image/lfs83vh0x/][img]http://s8.postimage.org/lfs83vh0x/zelec_dec_20_05_thigh_groin.jpg[/img][/url]
[url=http://postimage.org/image/5kmqfmthz/][img]http://s7.postimage.org/5kmqfmthz/zelec_dec_21_07_thigh_groin.jpg[/img][/url]
[url=http://postimage.org/image/7dgej4oa9/][img]http://s8.postimage.org/7dgej4oa9/zelec_dec_23_08_thigh_testicle.jpg[/img][/url]
[url=http://postimage.org/image/qpev5iw9v/][img]http://s13.postimage.org/qpev5iw9v/zelec_dec_26_12_thigh.jpg[/img][/url]



It started with some red spots in the usual area where I get outbreaks (in the pubic area around the penis), it disappeared the next day and it appeared on my right thigh, then the testicle and a new starting blister started on my thigh again before even the healing of the first one. It reminded me of the pre-suppressive period were I was seeing outbreaks overlapping.

Please let me know if these pictures suggest any useful info that might help explaining this atypical reaction to HSV.

Thanks

[H. Hunter Handsfield, M.D.]

Thanks for clarifying.  False positive viral tests are rare, so the initial diagnosis is confirmed.  However, your GP has some misunderstandings about genital herpes.  With the rising frequency of oral sex, in the past 20 years about half of all initial infections are due to HSV-1.  And there is no difference in severity between initial infections with HSV-1 or 2.

The distinction is important, and the virus type should be determined in all people with genital herpes.  Genital HSV-1 recurs much less frequenly and has a lot less asymptomatic shedding than HSV-2, with markedly lower potential for sexual transmission.  Half of all with GHSV-1 never have a recurrent outbreak, and most of the rest have only 1-2 more recurrences over 2-3 years.  For these reasons, where as suppressive therapy often is important for GHSV-2, most people with GHSV-1 don't need and do not benefit from it.

Accordingly, you should follow through on the ID specialist's advice to promptly (within a couple days of onset) have another viral test -- preferably PCR -- if and when you have another suspected recurrent outbreak.  You could consider stopping valacyclovir in the "hope" of a recurrence that can be tested.  Whether or not this is practical, you should also have an HSV antibody test, which will tell which type(s) you are infected with.  If your travels have taken you to an industrialized country (and many developing ones), probably you can find a doctor or clinic that do the viral and/or antibody tests.

Having said all that, I'm still skeptical that your initial problem was herpes alone.  Given the prolonged duration and non-response to valacyclovir, even if it started with herpes, the main problem might have been a secondary bacterial infection.  I'm also skeptical that your current problem is recurrent herpes, and hope you'll visit a doctor for diagnosis; this could well be folliculitis or some other skin infection.  If so, given its duration so far, you might need an antibiotic prescription.

[zelec]

Thank you for your prompt response.
I’m sorry for the lack of detail, I will try to clarify the points you mentioned.

When I got my first symptoms (blisters in the pubic area around the base of the penis with bad smelling secretion), 3-4 days after a fully protected sexual intercourse, I went to a GP, she immediately recognized herpes after examining my lesions and she also took a culture from lesions that came back positive, I never knew if it was HSV1 or HSV2. My GP thinks that it should be HSV2 because HSV1 affects rarely genitals and if it does not cause such strong symptoms.
I also took Gonorrhea/Chlamydia tests and my GP prescribed antibiotics before even getting the results. They were negative anyway.
Regarding the severity of my symptoms, the ID specialist I saw, told me that they looked impressive when he saw pictures of them. Is there a way can send them to you so you have a better idea?
More over, location of lesions was more or less in the same area excepts that last one on my thigh/testicule.
Finally, the last ID specialist I saw, asked me to go to his office for a culture as soon as I have lesions. Unfortunately, I’m away now and cannot see him before one year.

Thanks again