The Five Stages of a Genital Herpes Outbreak

It can be difficult to feel in control of genital herpes infections if it’s not understood which stage the infection is currently in. Learning the stages of a HSV-2 infection and understanding the process of an outbreak, as well as levels of contagion and appropriate treatment will make controlling the outbreak much more manageable.

What is genital herpes?

The Herpes Simplex Virus is a viral infection that can take two different forms - HSV-1 which causes oral herpes, also known as cold sores and HSV-2, which causes genital herpes. Genital herpes, or HSV-2, is a sexually transmitted infection that can be passed on through skin-to-skin contact during sexual intercourse ^[1].

How many people have genital herpes?

Both types of Herpes Simplex Virus are very common globally. It’s estimated that 491 million people worldwide aged between 15 and 49 years old (13%) have the HSV-2 infection ^[2]. Most of the people with an infection are unaware of their status, as they experience no symptoms, making them asymptomatic.

How do you develop a HSV-2 infection?

As mentioned previously, genital herpes is a highly contagious sexually transmitted infection (STI), meaning it can be spread through skin-to-skin contact that can take place during vaginal, oral or anal sexual intercourse, as well as other forms of contact like kissing.

As HSV-2 can be spread through skin-to-skin contact, it’s important to keep in mind that you can spread the virus to other areas of your body by touching an infected area and then touching another region.

HSV-2 can also be spread through asymptomatic shedding, meaning that even if an infected person is displaying no symptoms, they still have the potential to spread the virus and infect another person. For this reason, it’s extremely important to do the following:

• Take necessary precautions if having sexual intercourse
• Be open with your sexual partners about the status of your infection
• See a GP immediately if you think you may have been infected with HSV-2

What are the stages of genital herpes?

When someone is infected with HSV-2, they may be asymptomatic so show no symptoms, or their infection could begin to cycle through a series of stages - from the initial infection to the healing of the genital herpes sores. The outbreak stages are outlined below:

1. Primary infection stage

The primary infection is the first outbreak of genital herpes you will experience after you have been infected with the Herpes Simplex Virus. This typically happens around 2-3 weeks after being infected and is more severe than recurrent outbreaks ^[3].

At first, you may experience symptoms that are synonymous with the flu, such as:

• A fever
• Fatigue
• Joint pain
• Headaches
• Body aches
• Lymph node swelling around the groin, arms or throat

The skin around your genital area may appear red, itchy and inflamed, and you may feel a burning sensation whilst urinating. As this stage progresses, it is likely that blisters will develop on the skin around your groin, genitals, anus, upper thighs and buttocks. If scratched, the blisters can seep fluid, resulting in painful sores.

2. Latent stage

During this stage, symptoms disappear as the Herpes Simplex Virus travels away from the skin and to the base of the spine into a bundle of nerves. The virus stays dormant until there’s a trigger that awakens the virus, progressing it to the prodrome stage. The Herpes Simplex Virus is still in the body, meaning you are still infectious despite having no symptoms. This means you can still transmit the virus to others if you do not take precautions.

3. Prodrome stage

This stage involves the Herpes Simplex Virus being triggered, awakening it from its dormant state, where it travels from the spine up the nerves to the skin layer ^[4]. Potential triggers that could ‘wake’ the virus include:

• Hormones, such as those that occur during the menstrual cycle
• Weakened immune system, for example those whose immune systems have been weakened by chemotherapy or HIV
• Sexual intercourse
• Stress
• Vitamin deficiency
• Surgery
• Alcohol consumption
• Smoking

Around 50% of people infected with genital herpes experience symptoms during the prodrome stage of each recurring outbreaks. These symptoms include redness, itching, tingling and pain around the genitals, buttocks, upper thighs and anus.

This stage can last from a few hours to several days before the virus progresses to the next phase - the blister stage.

4. Blister stage

Once the virus reaches the surface of the skin, it can cause blisters to form. Herpes blisters appear as small red bumps that fill with fluid. Their appearance can resemble pimples or ingrown hairs, but unlike those, they are contagious.

The herpes blisters go through their own individual phases, similar to that of a cold sore. These stages are:

1. Red, itchy bumps begin to form on the skin around the genitals, as well as the buttocks, groin and upper thighs.
2. The bumps begin to turn into fluid-filled blisters.
3. The blisters burst and ooze a white, cloudy fluid. As a result, painful ulcers and sores form in their place.
4. After a duration of time, the sores begin to dry out and scab over, protecting the infected skin.

5. Healing stage

During this stage, the scabs that have formed on the blisters eventually fall off, leaving red or irritated skin. It is important to protect areas where blister scabs have fallen off, as the skin will be highly sensitive and may be irritated by tight clothing. Once this stage is complete and the sores have healed completely, the HSV-2 infection will become dormant again, entering the latent stage again, until a trigger causes the virus to awaken.

How to treat genital herpes:

Many outbreaks clear up themselves without any treatment required. If you are looking to reduce the frequency of outbreaks, or ease symptoms, there are treatments available, including:

• Aciclovir - this is an oral antiviral medication that treats outbreaks by controlling and suppressing the infection. It does this by stopping the virus from multiplying, which also means the duration of the infection is reduced.
• Valaciclovir - this is the precursor for aciclovir, meaning that once consumed, this oral medication converts into aciclovir in the body. This allows it to stay in the body longer, requiring less dosing.
• Valtrex - this treatment is the medical equivalent, branded version of valaciclovir.

Other ways to soothe symptoms:

Aside from medication, there are other steps you can take at home to ease the severity and impact symptoms of HSV-2 have on your day-to-day life. These include:

• Applying an ice pack (wrapped in a flannel) to the site of the blisters
• Urinating whilst pouring water over your genitals
• Keeping the area of blisters clean by washing with plain or salt water to prevent infection
• Applying Vaseline (or other petroleum jelly) to the blister area, but make sure to wash hands before and after applying
• Avoiding tight clothing as this can irritate the sores
• Taking over-the-counter pain relief medications such as paracetamol or ibuprofen

What stage of genital herpes is most contagious?

Each stage of a genital herpes outbreak carries some risk of contagion, however, the primary infection stage and the blister stage typically have the highest risk of spreading HSV-2 to others. Therefore, any form of sexual contact during these stages should be avoided.

The latent stage of a genital herpes outbreak is typically when the infected person carries the lowest level of contagion. There is still a potential risk of spreading HSV-2 to another person, so necessary precautions should still be taken.

How frequently do outbreaks occur?

The frequency of recurrent outbreaks occurring varies from person to person, but on average, people tend to experience 4 to 5 outbreaks each year. A 1994 study also found that men who are infected with HSV-2 experience about 20% more recurrences in outbreaks compared to women ^[5].

Is genital herpes curable?

There is currently no cure for the Herpes Simplex Virus, however it’s important to remember that in most cases people are asymptomatic and if they are not, their symptoms from outbreaks are only temporary. Outbreaks can be effectively managed through medication, although often symptoms will clear up on their own without any treatment necessary.