Ask The Professional

What Is Herpes Simplex 2?

I have an inquiry of a sensitive nature.  What is Herpes Simplex 2?  As a doula and childbirth educator I would like to be more informed on this subject for my clients. 
Thank-you ! Elizabeth Lugmayer

Thanks for asking about this, Elizabeth. Herpes is much more common than is generally known. Many of my home birth clients had it.  Groups of people you least expect will carry it.

The following composition compiles current information that includes diagnosis and remedies.  Hopefully it's easy for the novice as well as the experienced clinician to embrace.   ~Susan Oshel~



What Is Herpes?

There are two strains of the HSV (Herpes Simplex Virus), 1 and 2. They are both from the herpes virus family, herpesviridae, which causes infections in humans.

Oral herpes (HSV-1) causes cold sores around the mouth or face.

Genital herpes (HSV-2) affects the genital area.

Herpes is one of the most common viral infections known to man, affecting more than 80% of the population at one time or another, including more than 20% of pregnant women.

Herpes Simplex Virus 2 is transmitted primarily by contact with genital secretions. Public Health studies show that within the United States, 10 to 40 million people carry the HSV-2 virus. Many genital infections also carry a mixture of HSV-1 and HSV-2.

HSV interacts with epithelial or neuroepithelial cells and neurons. The incubation period is between 2 and 4 weeks. During the initial infection, HSV migrates to one or more sensory nerve ganglia, where it remains latent and dormant indefinitely. An intact immune system cures the infection at the portal (place of entry on the skin where the fluids touched). The primary infection involves mucocutaneous cells; recurrent infection involves stratified epithelial cells.

HSV is diagnosed by cytologic testing and microscopic examination. A papanicolaou smear of the lesion shows multinucleated giant cells with ground-glass nuclear appearance and cervical dysplasia. A wet-mount preparation of lesion secretions reveals polymorphonuclear leukocytes.

In many instances, your healthcare professional is able to make the diagnosis of herpes from physical appearance of the lesions and no tests are required. If your healthcare professional is not 100% certain, however, then fluid from the blisters can be removed and tested for the herpes simplex virus. This can be done through viral cultures which is very accurate but generally takes 2 to 3 days to get the results and make an official diagnosis. Another more immediate, but less accurate, approach is to do a Tzanck test of the skin lesions. This involves taking a sample of fluid from the blisters, staining the fluid with a dye, and examining the stained fluid under the microscope looking for a characteristic appearance of the virus. Finally, there is a blood test that may be helpful for making a diagnosis, especially if herpes simplex is suspected but no symptoms are present or if a distinction between HSV-1 and HSV-2 is needed.

HSV infections may involve external genitals, the vaginal canal and cervix. Symptoms are more pronounced with first infections of HSV. Painful blisters form, rupture, and then drain, leaving shallow ulcers that crust over and disappear after 2-6 weeks. A vaginal discharge is seen if the cervix or vaginal mucosa is involved. The woman may have fever, malaise, anorexia, painful inguinal lymphadenopathy (disorder of the lymph nodes or vessels in the groin), dysuria (painful urination), and dyspareunia (an abnormal condition of painful intercourse for women).

Some people have no symptoms. Others get sores near the area where the virus has entered the body. They turn into blisters, become itchy and painful, and then heal. The virus can be dangerous in newborn babies or in people with weak immune systems.

Most people have outbreaks several times a year. Over time, you get them less often. Medicines to help your body fight the virus can help lessen symptoms and decrease outbreaks. Correct usage of latex condoms can reduce, but not eliminate, the risk of catching or spreading herpes.

Once you have herpes, it is likely to recur. In between herpes outbreaks, the virus lies dormant (like it is hibernating or sleeping) in nerve cells. Recurrent HSV-1 infections on the lip are often mild and are commonly referred to as cold sores or fever blisters. HSV-2 lesions tend to recur more often and to be more severe than HSV-1 infections.

The virus can be reactivated due to "stressor stimuli's" such as fever, another infection and the effects of other illnesses such as cold and influenza, intercourse, menstruation, emotional and physical stress, exposure to bright sunlight, gastric upset, fatigue or injury, consequently resulting in the appearance of surface sores. Repeated occurrences may result in keratitis (inflammation of the cornea), encephalitis (inflammation condition of the brain), and possible cervical carcinoma. These possibilities are rare. Most recurrences tend to be milder and shorter in duration.

The infection may not show symptoms for a long time, and then become activated by the aforementioned stressors and weakened immune system. Most people have outbreaks several times a year. Over time, you get them less often. Medicines to help your body fight the virus can help lessen symptoms and decrease outbreaks. Correct usage of latex condoms can reduce, but not eliminate, the risk of catching or spreading herpes.

Women who have a history of genital herpes often wonder whether or not it is safe for them to deliver their baby naturally. The good news is most women with genital herpes will be able to deliver their baby safely without the need for a cesarean section, provided their disease is long standing and they do not have any active lesions at or near term.

The pregnancy effects of a primary genital herpes infection (the first incidence of an outbreak  in pregnancy) include miscarriage, preterm labor, and intrauterine growth retardation (IUGR). The likelihood of problems increase with a “first outbreak” occurring later in pregnancy. The frequency and severity of recurrent infection also seem to increase with gestational age.

The route of HSV from mother to baby is via an infected birth canal during birth. The risk of maternal-infant transmission is greater during a primary infection than during a recurrent episode. Cesarean birth is no longer recommended for all mothers with HSV because transplacental infection can occur. Only those mothers with clinical evidence of active lesions should give birth abdominally.

Babies of mothers with long-standing herpes infections have a natural protection against the virus. Herpes antibodies in the mother's blood cross the placenta to the fetus. These antibodies help protect the baby from acquiring infection during birth, even if there is some virus in the birth canal. That's the major reason that mothers with recurrent genital herpes rarely transmit herpes to their babies during delivery. Even women who acquire genital herpes during the first two trimesters of pregnancy are usually able to supply sufficient antibody to help protect the fetus.

If you are pregnant and know you have genital herpes, that fact alone gives you a significant advantage in protecting your baby. Studies show that most cases of neonatal herpes occur in babies whose mothers don't have any idea they are infected.

Although genital herpes is common, the risk of your baby being affected by neonatal herpes is low particularly if you contracted genital herpes before the third trimester of pregnancy. In the USA one in 1800-5000 live births are affected, in the UK one in 60 000, in Australia and France one in 10 000 and in the Netherlands one in 35 000 are affected. This means that the majority of women with genital herpes give birth to healthy babies.

For the babies who do contract the disease, fetal and neonatal effects can be serious. Microcephaly, mental retardation, retinal dysplasia, patent ductus arteriosus and intracranial calcification are sequelae. The signs include lethargy, poor feeding, jaundice, bleeding, pneumonia, convulsions, opisthotonus, bulging fontanelles, and skin and mouth lesions. Neonatal infections with disseminated disease results in 82% mortality. Survivors have CNS (central nervous system disorder) or ocular problems in the first 5 years of life.

Neonatal herpes is not a reportable disease in most states, so there are no hard statistics on the number of cases nationwide. However, most researchers estimate between 1,000 and 3,000 cases a year in the United States, out of a total of 4 million births. To put this in greater perspective, an estimated 20-25% of pregnant women have genital herpes, while less than 0.1% of babies contract an infection. "Neonatal herpes is a remarkably rare event", says Zane Brown, MD, an expert on neonatal herpes and a member of the Department of Obstetrics and Gynecology at the University of Washington. "Compared to all the other possible risks in a pregnancy, the risk of neonatal herpes is extremely small."

"I think it's perceived to be more of a problem than it is", says Scott Roberts, MD a researcher in the Department of Maternal Fetal Medicine at the University of Kansas. "The rate of neonatal herpes is very low, even though the prevalence of genital herpes in our country is quite common."

Herpes can also be spread to the baby in the first weeks of life if he or she is kissed by someone with an active cold sore (oral herpes). In rare instances, herpes may be spread by touch, if someone touches an active cold sore and then immediately touches the baby. Babies who contract herpes neonatally can become very ill. It is a greater risk in the first three months after birth. A newborn baby can be infected from both forms of herpes 1 and 2. Therefore, caution in handling the newborn is important even if you only have a mouth sore, HSV 1. If a baby contracts HSV 1 from a sore that the mother or father has (which can be transmitted by kissing), the effects are seen after an incubation of 7 days. The baby will have painful, swollen, reddened, sometimes bleeding gums with tiny blisters on it's tongue, gums, lips and around it's mouth leaving sores that heal within a week. They can also have a low grade fever, be irritable and loose their appetite. Breastfeeding becomes very difficult and often these babies are supplemented because they cannot nurse due to pain in their mouths and depressed appetites. If a baby contracts HSV 2 in the first three months after birth, pneumonia also becomes a risk.

Keep in mind that there are precautions that can be taken to lower the risk of transmission from mother to baby. It is mainly the "unknown" infections that are transferred.

"The vast majority of babies born to mothers with genital herpes are healthy, happy babies." American Social Health Association, 1996
 

Treatments

The following allopathic medications (as well as natural remedies) carry various risks. Each will be a treatment of choice for some people and not for others. Weighing the risk of the condition with the risk of the treatment is important. In my walk as a midwife over the past 30 years, I grew in the knowledge that "one size does not fit all".  I learned that we break all the rules! Though I reverently question the side effects of medications, the side effects of the disease are sometimes far more severe and should be judged on an individual basis. Following is a full spectrum of treatments for herpes.
 

Prescriptive Treatments:

Antivirals

Antivirals are the most commonly prescribed medication for treating herpes. Antivirals can be topical (applied to the skin) or taken internally to help suppress future outbreaks. Antiviral medications are generally used to shorten the length of an outbreak and reduce the number of outbreaks a person will experience. Antiviral therapy can be taken as “episodic treatment” or as “suppressive therapy.”  Following are antiviral prescriptive medications:

Valacyclovir
A newer drug, valacyclovir (brand name Valtrex®), actually uses acyclovir as its active ingredient. This medication delivers acyclovir more efficiently so that the body absorbs much of the drug, which has the advantage of taking the medication fewer times during the day. It is the most commonly recommended drug for pregnant women.

Acyclovir
The oldest antiviral medication for herpes is acyclovir. Acyclovir is available as a generic drug and is also sold under the brand name Zovirax®. It has been available since 1982 in a topical form (as an ointment) and sold since 1985 in pill form. Acyclovir has been shown to be safe in persons who have used it continuously (every day) for as long as 10 years.

Famciclovir
Famciclovir (brand name Famvir®) utilizes penciclovir as its active ingredient to stop HSV from replicating. Like valacyclovir, it is well absorbed, persists for a longer time in the body, and can be taken less frequently than acyclovir.

Numerous studies suggest that treatment of genital herpes infections during pregnancy with the antiviral acyclovir is safe even during the first trimester. There have been long term studies that suggest the long term use of acyclovir during pregnancy is safe. Thus this drug may be used in certain circumstances to prevent a break out during pregnancy.

Following is a study done by the Department of Obstetrics and Gynecology, University of Washington, Seattle, USA.

OBJECTIVE: The purpose of this study was to assess the efficacy of acyclovir in the reduction of herpes simplex virus culture and polymerase chain reaction positivity and cesarean delivery. STUDY DESIGN: Women with recurrent genital herpes simplex virus were randomized to acyclovir 400 mg three times daily or placebo from 36 weeks of gestation until delivery. A subset of daily specimens for herpes simplex virus culture and DNA polymerase chain reaction was self-collected. Analyses used chi(2), Fisher exact, and Mann-Whitney U tests. RESULTS: Lesions occurred at delivery among 11 of 78 women (14%) who received placebo and 4 of 84 women (5%) who received acyclovir. Herpes simplex virus culture and polymerase chain reaction positivity near delivery occurred in 7% and 34% women in the placebo group and 0 and 2% in the acyclovir group. Cesarean delivery for herpes simplex virus occurred in 8 of the women (10%) in the placebo group and in 3 of the women (4%) in the acyclovir group. Despite reductions in herpes simplex virus detection, 6% of the women who received acyclovir had herpes simplex virus detected by polymerase chain reaction on >20% of days. Neonatal outcomes were similar between groups.

STUDY CONCLUSION: Acyclovir significantly reduced, but did not eliminate, herpes simplex virus lesions and detection in late pregnancy.

Vaccine research

Herpevac, a vaccine for HSV-2 is currently (as of February 2007) undergoing clinical testing in women in the United States and Canada. Previous studies have determined that this vaccine is approximately 70% effective in women, but does not prevent the disease in men.

Non Prescriptive Treatments:


Nutrition and Dietary Supplements

Lysine

Although the research to date is not entirely conclusive, lysine supplements have been used to help treat or prevent mouth and genital lesions caused by herpes. Supplementation of Lysine has demonstrated the ability to reduce the duration of infection through inhibiting the replication of the HSV. Taking lysine supplements or increasing lysine in your diet (from foods like fish, eggs, and potatoes) may speed recovery time and reduce the chance of recurrent breakouts of the herpes infection. However, consuming foods high in arginine (such as nuts or peanuts) may interfere with the therapeutic use of lysine

Propolis

Propolis, a resin from tree bark and leaves, is loaded with flavonoids (antioxidants that help fight infection and boost immune function). A study of a small number of people with genital herpes compared an ointment made from propolis to acyclovir ointment (a medication outlined above commonly used for herpes). In this research trial, the lesions of those using the propolis healed more quickly than those using acyclovir. Research on larger numbers of people would be helpful. In the interim, it may be worth trying propolis ointment for genital herpes lesions if your doctor approves.

Spirulina

Test tube studies suggest that spirulina, also known as blue green algae, has activity against certain viruses including herpes. Whether this laboratory finding will prove beneficial for people in treating herpes infections is not known. More research is needed before a recommendation can be made.

Vitamin C and herbs

Tinctures of echinacea, siberian ginseng and reishi mushroom combined 1-2 droppersful every 2 hours; vitamin C and zinc to body's tolerance; lots of fluids to flush the system

Zinc

Topical preparations of zinc have shown benefit in relieving symptoms and preventing recurrences of oral herpes lesions.

Herbs

The use of herbs is a time-honored approach to strengthen the body and treat disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care and only under the supervision of a practitioner knowledgeable in the field of herbal medicine.

Teas
Lemon balm (melissa) tea, also chamomile tea, hops, passionflower, st. john's wort...tension tamer are all teas that calm the nerves.  I've heard some people using chamomile tea bags topically too.

Aloe ( Aloe vera )
Preliminary evidence suggests that aloe gel used topically may improve the symptoms of genital herpes. Whether this same use of aloe will apply to oral herpes lesions is not known, but it may be worth trying in order to reduce the length and severity of your symptoms. 

Lemon Balm ( Melissa officianalis )
Some studies suggest that topical ointments containing lemon balm may help heal herpes cold sores. In one study of 116 people with HSV, for example, those who applied lemon balm cream to their lip sores experienced significant improvement in redness and swelling after only two days. Although other symptoms (such as pain and scabbing) did not improve, both the participants and their physicians reported that the lemon balm ointment was highly effective. Several animal studies also support the value of topical lemon balm for oral herpes lesions.

Peppermint Oil
In test tubes, peppermint oil has exhibited antiviral properties against a number of infectious agents, including herpes. Whether this would translate into help for relieving herpes lesions is not known at this point.

Sage-Rhubarb Cream
In one Swiss study, a cream made from sage ( Salvia officinialis ) and rhubarb ( Rheum palmatum ) lessened the length of time that herpes lesions were present to the same extent as the medication acyclovir. More research on this topic would be helpful.

Siberian Ginseng ( Eleutherococcus senticosus/Acanthopanax senticosus )
Although not all studies agree, one 6-month study of 93 people with HSV-2 (which, again, generally causes genital herpes lesions) found that Siberian ginseng reduced the frequency, severity, and duration of outbreaks. This herb should not be given to children and should not be taken if you have high blood pressure, obstructive sleep apnea (repeated, prolonged periods when breathing stops while sleeping), narcolepsy (frequent day time sleeping), are pregnant or breastfeeding.

Tea Tree Oil ( Melaleuca alternifolia )
Use of tea tree oil, applied topically in gel form, has some popularity for herpes lesions on the lips. Although more research is needed before definitive conclusions can be drawn, there is some scientific basis for this use. First, in test tubes, tea tree oil has the ability to fight both strains of herpes viruses (HSV 1 and HSV 2). Secondly, there has been one small study comparing use of tea tree oil gel to placebo in those with recurrent oral herpes. The herpes lesions of those who used the tea tree oil healed more quickly than those who used placebo. Studies of larger numbers of people are necessary, however, along with studies that compare tea tree oil to medications used for herpes.

Others

Additional herbs that may be recommended by an herbal specialist for the treatment of either oral or genital herpes include:

Pau d'Arco ( Tabebuia avellaneda )

Although Echinacea (coneflower) has gained some popularity for the prevention of herpes, there is no scientific evidence that it works for this purpose. In fact, despite test tube studies suggesting that Echinacea has the ability to fight the herpes virus, one study of people with herpes did not show any reduction in the number of their outbreaks.

*To try to prevent herpes outbreaks.  Herbalists may also consider remedies that help strengthen your immune system or act as adaptogens (substances that help relieve stress).
* abstaining entirely from sugar, chocolate, caffeine, dairy, alcohol, hot/spicy food, anything processed
* avoiding sex, biking, and other topical irritants and avoiding all forms of stress which further antagonizes the nervous system
* lots of sleep and rest

Acupuncture

Case reports in the scientific literature suggest that acupuncture may help reduce the length of time of a herpes outbreak and decrease your chances for recurrent lesions.  Additional research would be helpful. Acupuncture is used to increase immunity (working to support remission with the liver divergent meridian). You can also use carrot oil on Liver DM points.

Massage and Physical Therapy

Regular massage can help alleviate chronic stress; therefore, in theory, receiving massage on a regular basis may help avoid recurrent outbreaks. Aromatherapy and using essential oils during massage therapy has been evaluated for these purposes and results thus far suggest that this is a useful technique.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the remedies described below for the treatment of herpes based on their knowledge and experience. One study of 53 people with genital herpes did show that the majority experienced improvement in their symptoms and were less likely to have recurrent outbreaks when treated with homeopathy. Participants in this study were followed for up to 4 years.

Before prescribing a remedy, homeopaths take into account a person's constitutional type. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for each individual.

For lesions around the lips and mouth:

Natrum Muriaticum -- for eruptions at the corners of the mouth that occur during periods of emotional stress and tend to worsen in the daytime
Rhus toxicodendron -- for eruptions consisting of many small blisters that itch intensely at night
Mercurius -- for children who drool and may have a fever
Sepia -- for outbreaks that do not improve with other homeopathic remedies; this remedy is most appropriate for individuals who tend to have a lack of energy and don't tolerate cold weather

For genital lesions:

*Graphites -- for large, itchy lesions in individuals who are overweight
*Natrum Muriaticum -- for eruptions that occur during periods of emotional stress and symptoms that tend to worsen in the daytime
*Petroleum -- for lesions that spread to anus and thighs; symptoms tend to worsen in winter and improve in summer
*Sepia -- for outbreaks that do not improve with other homeopathic remedies; this remedy is most appropriate for individuals who tend to have a lack of energy and don't tolerate cold weather

_______________________

Every person will respond differently to both the Herpes Virus as well as the treatments.  I hope this information lifts abit of the mystery surrounding it, if only a little.  We grow in knowledge by continuing to study and studying together builds wisdom!  I can think of more wonderful topics to immerse myself in during this Blessed Christmas season, but it has been ever so interesting! ~Susan Oshel~
 

Bibliography:
Maternity and Gynecologic Care, 4th Ed. Pages 851-859
Maternity & Woman's Health Care, 8th ed. Lowdermilk, Perry Pages 199-210, 1068-1069
Mosby's Medical Dictionary, 3rd ed. Page 893
Taber's Cyclopedic Medical Dictionary, 17 ed. Pages 400, 421, 564, 565, 622, 662, 711
Dr. Sears, The Baby Book Page 710
Dr. Sears, The Pregnancy Book  Pages 290, 296-297

Wikipedia, the free encyclopedia
http://en.wikipedia.org/wiki/Herpes_simplex_virus
National Institutes of Health | Department of Health & Human Services
http://www.nlm.nih.gov/medlineplus/herpessimplex.html#cat27
2007 University of Maryland Medical Center
http://www.umm.edu/altmed/articles/herpes-simplex-000079.htm
International Herpes Alliance
http://www.herpesalliance.org/resources_04.htm
Herpes.com
http://www.herpes.com/pregnancy.shtml
Center For Disease Control and Prevention (CDC Herpes Guidelines 2006)
http://www.cdc.gov/std/treatment/2006/genital-ulcers.htm 
American Social Health Assn
http://www.ashastd.org/herpes/herpes_learn_pregnancy.cfm

Written by Susan Oshel, CPM