Herpes simplex – herpes simplex or vesicular lichen has been known to mankind since ancient times, and the name “herpes” is of Greek origin – “crawl”, “sneak up”, which fully corresponds to the clinical manifestations of diseases caused by the herpes simplex virus (HSV). Due to the typical clinical picture, the diagnosis of herpes simplex is a fairly simple task. In doubtful cases, a study of the discharge of herpetic vesicles is carried out. Treatment of herpes simplex is reduced to local or systemic administration of antiherpetic drugs based on acyclovir, if necessary, immunomodulatory therapy is carried out.
Diseases caused by the herpes simplex virus are quite common, some complications of infection end in death. Data from the Center for Disease Control in the United States register about half a million cases of herpes infection per year, hence it can be assumed that carriers of herpes infection are from 2 to 20 million Americans. In England, the increase in the incidence of genital herpes infection exceeds other sexually transmitted infections. In the Scandinavian countries, herpes simplex is found in about 8% of women who have turned to a venereologist. There are no statistics on the incidence of herpes in our country, but herpes infection is widespread everywhere, this is indicated by data from private surveys on the carrier of the herpes simplex virus.
A relapse of herpetic infection occurs in the case of reactivation of the virus, this is possible after hypothermia, overheating, with reduced immunity, in particular, herpetic infection is a specific complication in HIV infection. Rashes caused by herpes virus serotype 1 are usually localized in the nasolabial region, the virus also manifests itself as keratoconjunctivitis, and rashes caused by HSV-2 are localized in the genital area. But, given the peculiarities of sexual behavior, the localization of rashes can be exactly the opposite. Therefore, herpes requires serological studies to establish the serotype.
Etiology and pathogenesis
The group of herpes viruses includes 4 viruses similar in morphology: HSV (herpes simplex), varicella-zoster virus – the causative agent of shingles and chickenpox, Epstein-Barr virus and cytomegalovirus; in 1962, it was revealed that the herpes simplex virus has two serotypes – serotype 1 and serotype 2. Serological studies confirm that by the end of 18 months of life, almost every person was in contact with with VGP-1, the entrance gate is usually the respiratory tract. After that, the virus penetrates into the ganglion cells of the trigeminal nerve, but during life it may never cause clinical manifestations of infection.
With HSV-2, the first contact usually occurs during puberty at the beginning of sexual relations. At the same time, after external manifestations, which may not be, the virus also goes into an inactive form and is able to persist for a long time in the cells of the sacral ganglion.
Herpes simplex, especially the second type, has oncogenic properties, which is of great importance, given the prevalence of infection. The incidence of herpes infection is approximately the same in all age groups and is equally common regardless of gender. Clinical manifestations also depend on the localization and size of the lesion, as well as on the general state of the immune system.
Manifestations of herpes
Herpes simplex is most often localized around the wings of the nose, the corners of the mouth, the red border of the lips and in the genital area, that is, around the natural openings. In one, less often in two or three places, small bubbles appear against the background of limited hyperemia; each focus contains from two to ten or more. The bubbles are arranged in a group and filled with a transparent exudate, which becomes cloudy after a few days. In some cases, single bubbles merging form several multi-chamber bubbles that have an uneven scalloped edge and reach up to 1.5 cm in diameter.
When the process is localized, blisters on areas of the skin that are not subject to maceration and friction shrink into a yellowish-gray crust, which disappears independently after 5-7 days. And in place of the bubble remains a pigmented area, after some time acquires a normal color.
On the mucous membranes, as well as on those areas that are subject to maceration or friction, the bubbles open, resulting in erosion of a polycyclic outline with a bright red bottom. Rashes are accompanied by burning, pain and a tingling sensation, if there are a lot of rashes, there is swelling of nearby tissues. The general condition of the patient with an infection caused by the herpes simplex virus does not suffer, but in some cases there may be chills, muscle pain and subfebrile temperature. In general, the process takes 10-14 days, with the addition of a secondary infection, the duration of the disease increases.
The herpes simplex virus can cause herpetic stomatitis, the clinical manifestations of which are lesions of the mucous membrane of the mouth, lips, cheeks, gums and palate. Small groups of small bubbles appear on the swollen and hyperemic mucous membrane. The bubbles are opened in the first few hours, leaving erosions that have fine-grained outlines due to fusion. After 2-4 days, the erosions are covered with a delicate fibrous film, and then epithelized. Herpetic stomatitis, not complicated by other infections, lasts 6-14 days, the general condition of the patient is satisfactory, but there is soreness in the oral cavity and hypersalivation.
In younger and preschool children, the herpes virus most often causes acute aphthous stomatitis. During a short prodromal period, there is general malaise, weakness, loss of appetite and a slight increase in body temperature. The oral mucosa is sharply edematous and hyperemic, and aphthoid-like rashes are localized everywhere. Unlike simple stomatitis, rashes have the form of aft with a necrosis site in the center and a pronounced inflammatory rim along the periphery, the diameter of single rashes is up to 1 cm. As the process progresses, the aphthae merge and form extensive erosive-ulcerative areas with uneven edges. Hypersalivation, loss of appetite, fever and severe soreness are noted.
In some patients, relapses of herpes infection are possible depending on the seasonality or without connection with the time of year; with reduced immunity, relapses may occur several times a month. The clinical manifestations of recurrent herpes depend on the localization, the general condition of the patient, but do not differ from the manifestations of herpes simplex.
The basis of the pathogenesis of recurrent herpes are predisposing factors: hypothermia or overheating of the body, common and colds, previously transmitted infectious diseases, as well as all diseases that weaken cellular immunity. In women, there is a connection between periods of the menstrual cycle and exacerbations of recurrent herpes infection.
Diagnosis of diseases caused by the herpes simplex virus is not difficult and in typical cases, clinical manifestations make it possible to make an accurate diagnosis. But when localized in the genital area, herpetic ulcers may resemble a hard chancre. Erosion caused by the herpes virus has polycyclic outlines and there is a tendency to merge small-bubble elements, there is no infiltration specific to the chancre, on the basis of this their differentiation occurs. Herpes simplex, unlike syphilis, is acute and in most cases is recurrent. In doubtful cases, they resort to laboratory diagnostics and test the discharge of erosion for the presence of pale treponema.
Herpes, localized on the oral mucosa and proceeding by the type of stomatitis, should be differentiated from pemphigus vulgaris and from multiform exudative erythema, which has a seasonal course and recurs in spring and autumn. Diagnosis of herpetic stomatitis is based on clinical manifestations. Stomatitis caused by the herpes simplex virus is characterized by swelling and hyperemia of the oral mucosa, the appearance of large blisters prone to fusion. The bubbles are opened within a few hours, and in their place there are erosions with a scalloped edge, covered with a fibrous film from above. If the red border of the lips is affected, then the exudate from serous quickly turns into bloody, the rashes shrink into single bloody crusts. There is a loss of appetite, hypersalivation and soreness when eating. Rashes with pemphigus are usually located singly on the mucosa that is not prone to swelling, epithelialization and the formation of a fibrous film also does not occur, acantholytic cells are detected in smears from the eroded surface, and Nikolsky’s symptom is positive, which is not observed when infected with the herpes virus.
If confirmation of the diagnosis for the presence of the herpes virus is required, then in the first few days from the onset of the disease, cytological studies are most informative. The material is taken by scraping and stained according to Romanovsky-Giemse, after staining, giant multinucleated cells with basophilic cytoplasm are clearly visible. The nuclei inside the cells are crowded, forming layers, and outwardly resemble a single conglomerate. If indistinct staining has occurred, then the nuclei may not have clear outlines, which does not make it difficult to confirm the diagnosis of herpes simplex. Additionally, a PCR study for the herpes simplex virus, an immunofluorescence reaction (RIF) and a study for antiherpetic antibodies by immune-enzyme analysis (ELISA) is carried out.
Treatment of recurrent herpes consists in immunorehabilitation of patients, this helps to reduce relapses or persistent remission. Herpes simplex does not tolerate monotherapy, since it is impractical, it is resorted to only for the treatment of the acute phase of the disease. If you use such therapy as the only method of treatment, then the constant intake of drugs such as acyclovir and valacyclovir, the use of ointments resemble a vicious circle from which it is impossible to escape, and stressful situations only aggravate the patient’s condition.
Comprehensive treatment of infection caused by the herpes simplex virus in a short time allows you to stop the process and lead to persistent remission. In the initial phase of relapse, a course of suppressor drugs is prescribed, for example acyclovir, valacyclovir. Taking these drugs for 5-7 days dramatically reduces the number of herpes viruses in the body. After that, immunotherapeutic drugs are prescribed, in the form of courses of recombinant alpha interferons or / and immunomodulators. The duration of the course depends on the severity of the infection and the state of the patient’s immune system. In severe cases, alpha-interferon is taken for 10 days or more. After 1-2 months after the process is stopped, it is advisable to use a herpetic vaccine, which makes it possible to achieve a stable remission.
The effectiveness of vaccination depends on the state of immunity, on the prescribed regimen and on the frequency of administration of the drug. The vaccine is administered intradermally with the formation of a specific “orange peel” at the injection site. But the lack of timely revaccination significantly reduces the effectiveness of the entire multi-month course of treatment, therefore, revaccination against the herpes simplex virus should be carried out without violating the deadlines.
The independent use of a herpetic inactivated vaccine should be excluded, since, despite all the simplicity, the procedure requires certain conditions and knowledge of medical personnel, and the instructions for use do not contain all the necessary information. The negative opinion about the vaccine is based on the fact that it somewhat increases the possibility of a tumor, but a persistent infection caused by the herpes simplex virus can cause more serious damage to the immune system.
The vaccine includes inactivated HSV-1 and HSV-2 viruses, which, like ordinary herpes simplex serotypes, can transform, which, according to some studies, can induce cervical cancer in isolated cases. But the vaccine and the virus present in the body have the same ability to induce the development of oncological processes, and therefore, for patients who have herpes, vaccination does not carry an additional risk of the development of induced cancer. To prevent the formation of tumors, the use of preventive specific anti-cancer vaccines is a reliable way. Of the physiotherapeutic methods in the treatment of herpes simplex, UFO irradiation, laser therapy, infrared irradiation, etc. are used.