The first outbreak usually occurs in or around the genital area between three days and two weeks after exposure to the virus. If there is a long duration between the initial infection and the first outbreak of symptoms, the episode may be quite mild because the immune system has produced antibodies to the virus by that time. Also, such primary infections are less transmissible, heal faster, and produce fewer symptoms.
In about 80% of initial outbreaks of genital herpes, patients develop diffuse symptoms (e.g., flu-like discomfort and fever). The virus sheds for about 3 weeks. Symptoms in men and women are very different from each other.
In women, the pattern of a first infection is often more complicated and severe than in men with some or all of the following events:
In addition to general flu-like discomfort, women may experience nerve pain, itching, lower abdominal pain, urinary difficulties, and yeast infections before or during the eruption of the skin blisters.
When the outbreak occurs, blisters form raw sores (ulcers) almost immediately. Later they become crusted and fill with a grayish-white fluid. A new crop often occurs during the second week and is accompanied by swollen lymph glands in the groin. The symptoms may last as long as 6 weeks.
Lesions commonly appear around the vaginal opening, on the buttocks, in the vagina, or on the cervix. If lesions occur inside the vagina, they are not visible and pain may be minimal. Such women, then, may be unaware that they have genital herpes. In such cases, the blisters produce a discharge that is still highly infectious.
Lesions develop in places other than the genital region in 10% to 18% of primary HSV-2 infections. In most of these cases, outbreaks occur in the urethra (the channel that carries urine) where they can cause painful burning during urination. Inflammation of the internal reproductive organs, including the uterus lining (endometrium) and the fallopian tubes, is rare.
In men, about 6 to 10 blisters typically develop on the head or shaft of the penis. They rarely occur at the base. In some cases, they can occur on the buttocks, around the anus, or on the thighs.
Valacyclovir. Valacyclovir (Valtrex) is converted to acyclovir in the intestine and liver. It provides a higher concentration of acyclovir in the bloodstream without added toxicity and therefore requires less frequent dosing. It is available in a one-day regimen for oral herpes, a once-daily dose to suppress genital herpes, and a three-day treatment for recurrent herpes. Valacyclovir is most effective if taken within 24 hours of the first signs of an outbreak.
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