Herpes Simplex (HSV), oral and genital

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If there is a question of diagnosis, do a Tzanck smear (see technique below).  While oral or genital HSV is usually painful, this is not always the case.  Be suspicious, especially with penile erosions and ulcers.

Treatment should be individualized.  Topical acyclovir ointment is useless.  Tea bag soaks are quite helpful to dry out the blisters.  Have the patient make a cup of tea, squeeze out the teabag, and then apply the bag to the lesions after it has cooled.  The residual tannic acid in a tea bag is a surprisingly effective drying agent.  

(a)  Acyclovir

Oral acyclovir is effective only if given EARLY in the herpetic episode.  In addition, it is not useful for the patient who gets only the occasional mild episode.  Acyclovir is helpful for patients with an initial outbreak.  They are frequently systemically ill and in pain.

For patients with recurrent disease, acyclovir should be reserved for those patients whose outbreaks are frequent, very painful, or have associated systemic findings (fever, painful adenopathy, malaise, etc.)  The dose for treatment of an acute episode is 200 mg five times a day for 5 days.  The use of 200 mg TID to 400 mg BID is useful for suppression in patients with frequent recurrences.

(b)   Valacyclovir

This drug is a pro-drug of acyclovir.  Its mechanism of action is identical to acyclovir.  The advantage is that the medication needs to only be used twice a day instead of five.  The dose for recurrent HSV is 500 mg BID for 5 days.  The use of 500 mg QD is useful for suppression.

(c)  Famcyclovir The dose is 125 mg BID for 5 days.

(d)  Other Considerations

In the case of genital HSV, evaluation for concomitant STD should be strongly considered on an initial visit.  STDs are a chummy group and are frequently transmitted in twos or threes.  Look for them!

Although patients are most infectious when they have active lesions, they may continue to shed virus (albeit at a smaller rate) between outbreaks.  As such, barrier contraception (e.g. condoms) is recommended at all times unless a couple is trying to conceive.

A couple trying to determine "who gave what to whom and when" is engaged in a hopeless and psychologically destructive task. Either partner may have had a dormant infection for weeks, months or even years.  While serologic testing for antibodies to HSV I and II is available, a positive result is of little clinical utility because over 90 percent of adults will test positive due to previous exposure to oral or genital HSV.

Instructions for performing a Tzank Smear

  • Open an intact vesicle at the edge using a surgical blade. If no intact vesicles, gently soak off the crust.

  • Scrape the base of the vesicle (or the advancing border from an erosion/ulcer after crust soaked off) and smear on slide. Do not scrape to the point of bleeding, it makes the slide difficult to interpret.


  • Tzank Smear

    Fix the slide using heat or 20 seconds in absolute alcohol.

  • Stain using Wright, Wright-Giemsa, Pap, etc. stains following the lab's standard operating procedures manual.

  • Dry the slide using gentle blotting motions of a paper towel and air movement.

  • Place 2 small drops of immersion oil on slide and then mount a cover slip.

  • Scan under 10-X for presence of multinucleated giant cells.

Written and revised by CAPT Dennis A. Vidmar, MC, USN, Department of Military and Emergency Medicine, and Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, MD (1999).

Additional images provided by CAPT Vidmar in June, 2000, subsequent to the initial publication of this manual.

Preface  ·  Administrative Section  ·  Clinical Section

The General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C., 20372-5300

This web version of The General Medical Officer Manual, NAVMEDPUB 5134 is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy version, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense. All material in this version is unclassified. This formatting © 2006 Medical Education Division, Brookside Associates, Ltd. All rights reserved.

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