Vulvar herpes: clinics and therapy

Most young people with erosive-ulcerative-genital lesions (“Genital Ulcer Disease”) have genital herpes (prevalence 5-40%), sometimes associated with syphilis or other sexually transmitted diseases, with a significant risk of co-infection with HIV.
Also transmissible in asymptomatic (virus shedding) or “undiagnosed” due to mild, atypical symptoms (fissures, erythema, neuralgia), or hidden localizations, the primary infection of vulvar herpes (HSV2-1) has classic acute manifestations: pain, burning (sometimes sciatica, cruralgia, antalgic urinary retention), cluster vesicle- pustules on erythematous-edematous areas that evolve into confluent-polycyclic erosions, often ulcerative-aphthous-like; satellite lymphadenitis, fever sometimes high. In 1-3 weeks they heal (completely the erosions; ulcers with scars); after weeks or months of latency the secondary herpes relapses on average 5-6 times a year, with variable duration (on average 1 week). Relapsing symptoms and signs, similar to primary-Herpes, are more localized and attenuated, except in immunosuppressed, who manifest chronic, severe-ulcerative, disabling, hypertrophic-pseudo-tumor, generalized-varicelliform forms. Possible cause of fetal malformations, neonatal morbidity and lethality, herpes in pregnancy is effectively treated with systemic acyclovir. Sometimes it justifies caesarean-section. According to European-guidelines (2017), the diagnosis is clinical (when possible supported by PCR); topical antiviral-therapy offers few advantages (except foscarnet 1% in case of resistance and imiquimod 5% effective in HIV-associated pseudotumoral-forms) compared to local soothing-antiseptic and anti-inflammatory (including cortisone) therapy. Acyclovir (ACV), since its discovery (Elion_G.B.1978) the best systemic antiherpetic, is effective both with “episodic-therapy” (average adult dose: ACV tbl 200-800mg 3t./die for 7-10 days in primary-Herpes, for 2-5 days at each relapse) both with “continuous-suppressive-therapy” (if>6 relapses a year a.a.d.:ACV400mg 2t./die or similar: Famciclovir FCV 250mg 2t./die, Valaciclovir VLC 500mg 1t./die; replaceable in case of resistance with Foscarnet 40mg / kgI.V./8-12h.).