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CONTINUING MEDICAL EDUCATION: SEXUALLY TRANSMITTED INFECTIONS
Genital ulcers caused by herpes simplex virus
Úlceras genitales por virus herpes simplex
Manuel Parra-Sánchez
Molecular Diagnostics Deparment, Vircell Microbiologists, Parque Tecnológico de la Salud, Granada, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction&#58; microbiology of HSV</span><p id="par0005" class="elsevierStylePara elsevierViewall">Genital herpes is a sexually transmitted disease caused by herpes simplex virus type 1 &#40;HSV-1&#41; and type 2 &#40;HSV-2&#41;&#44; which belong to the herpesviridae family of DNA viruses&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The herpes viruses have a well-defined structure&#44; being composed of an icosahedral capsid surrounded by a tegument containing 15&#8211;20 proteins&#46; The tegument is then in direct contact with the envelope&#44; which is made up of numerous glycoproteins&#46; The genome is a single linear double-stranded DNA molecule 152&#8211;155<span class="elsevierStyleHsp" style=""></span>kbp in size&#46; These two viruses share up to 40&#37; homology in their genome structure&#44; reaching up to 83&#37; in the coding regions&#44; which largely explains their antigenic cross-reactivity&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The herpesviridae family is divided into three subfamilies&#58; alpha&#44; beta and gamma &#40;based on biological and genomic similarities&#41;&#46; The alphaherpesviruses include HSV-1&#44; HSV-2 and varicella zoster virus &#40;VZV&#41;&#46; Humans are the only known reservoirs&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">HSV-1 is a large&#44; neurotropic virus which causes mainly oral infections ranging from minor lesions&#44; such as cold sores&#44; to severe lesions&#44; such as meningoencephalitis&#46; HSV-2 is very similar&#44; but it causes anogenital infections or neonatal herpes&#46; In recent years&#44; these data have varied as a consequence of oral sex practices&#44; with HSV-2 manifesting in labial lesions and an increase in the prevalence of HSV-1 in anogenital infections&#46; In the light of these changes&#44; we need to break with the traditional assumptions that HSV-2 means genital herpes and that HSV-1 is limited to orolabial infections with non-sexual transmission&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">HSV lesions continue to be the most common cause of vulva ulcers in the sexually active population &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A continuous increase in HSV infection has been detected in recent years&#44; due in part to sociocultural changes and risky sexual practices&#46; The majority of these infections are asymptomatic&#44; which favours transmission&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a> Recent studies in sexually active people aged from 14 to 49 in the United States indicate that the prevalence of HSV-1 is 47&#46;8&#37;&#44; while that of HSV-2 is 11&#46;9&#37;&#59; both prevalences increase with age&#44; and are higher in women than in men&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">5&#44;6</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">WHO data estimate that&#44; worldwide&#44; 11&#37; of the population aged from 15 to 49 is infected with HSV-2&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">7</span></a> Meanwhile&#44; we have to consider the potential for morbidity and mortality in the newborn due to the risk of transmission during pregnancy&#44; and as a cofactor in the transmission of HIV&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Pathogenesis</span><p id="par0035" class="elsevierStylePara elsevierViewall">The infectious cycle of the virus starts after contact with the oral or genital mucosa&#44; through abrasions or micro-cracks in the host&#39;s skin &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Replication begins in the epidermis and penetrates sensory nerve endings in the skin&#46; Through the axon of these nerves it is transported to the nucleus of the neurons in the sensory ganglia in the spinal cord &#40;spinal or trigeminal&#41;&#46; HSV can replicate within sensory ganglion neurons or remain dormant for months and even years&#44; and reactivate spontaneously or in response to various stimuli &#40;solar radiation&#44; stress&#44; fever&#44; certain medications&#44; acute diseases or immunosuppressive processes&#41;&#46; This ability of the latent virus to reactivate is defined as recurrent HSV disease&#46; When the virus is reactivated&#44; it descends through the sensory nerve to the surface of the initially infected dermatomes &#40;orolabial or vulva&#41;&#46; Replication continues in the epidermal cells and can cause asymptomatic excretion in oral or genital secretions&#44; or obvious clinical recurrence&#44; resulting in vesicles and inflammation of local lymph nodes&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">9&#44;10</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical manifestations</span><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical signs and symptoms of genital herpes vary&#44; depending on the type of HSV&#44; gender&#44; age&#44; immune status of the patient and previous exposure to the virus&#46; Episodes in patients with no evidence of previous HSV infection &#40;primary infection&#41; may be more severe on average than in patients with previous infection &#40;non-primary first-episode genital herpes&#41;&#46; However&#44; more commonly&#44; we find asymptomatic primary infections&#44; meaning that most people with either genital or oral herpes are unaware of their infection status&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In the case of primary genital herpes we find that 7&#8211;50&#37; of cases are caused by HSV-1 infection&#44; while 50&#8211;93&#37; are due to HSV-2&#46; These proportions vary according to geographical location and socioeconomic status&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a> The incubation period is about 4 days &#40;it can range from 2 to 12 days&#41;&#46; In most cases&#44; clinically visible lesions are preceded by a prodromal phase &#40;2&#8211;24<span class="elsevierStyleHsp" style=""></span>h before the lesions appear&#41;&#44; which can manifest with fever&#44; malaise&#44; headache&#44; myalgia&#44; stinging or itchiness in the anal&#47;genital area&#44; abnormal vaginal discharge and pain in legs&#44; buttocks or genitals&#46; In immunocompetent women&#44; lesions &#40;blisters that can progress to ulcers&#41; develop in areas of infection &#40;vulva&#44; cervix&#44; vagina&#44; perineum and&#47;or urethra&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">12&#44;13</span></a> causing urethritis and&#47;or painful inguinal lymphadenopathy&#46; The most common complications derive from extragenital skin lesions&#44; central nervous system involvement and opportunistic fungal infections&#46; Less frequently&#44; sacral radiculomyelitis with urinary retention&#44; transverse myelitis and neuralgia may occur&#46; Complications are more common in women than in men&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">9&#44;11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Both local and systemic symptoms are less severe and resolve more quickly in non-primary first-episode genital herpes than in primary infections&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The average duration of viral shedding is 12 days in primary disease and 7 days in non-primary disease&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Recurrent genital herpes is one of the main problems of this disease&#44; as it depends on the type of virus&#44; the intensity of the first episode and also the host&#46; Most cases of recurrence occur in the first year after primary infection &#40;80&#8211;90&#37; for HSV-2 and 20&#37; for HSV-1&#41;&#46; There is a great deal of variation in the number of flare-ups&#44; the severity and the natural course of recurrences&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Skin manifestations tend to be in the same area of the first episode and are sometimes nonspecific and barely perceptible&#44; such as fissures and cracks&#44; which can lead to mistaken diagnosis&#46; Occasionally&#44; there may be no lesions&#44; making it difficult to diagnose the recurrences&#46; Systemic symptoms are rare and less severe&#44; although they can be more painful and prolonged in women&#46; The recurrence rate increases during pregnancy&#44; but the course and duration are similar&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Diagnosis</span><p id="par0070" class="elsevierStylePara elsevierViewall">A clinical diagnosis is enough to start early empirical treatment and this improves the symptoms and shortens their duration&#46; However&#44; the diagnosis should always be confirmed with laboratory tests in order to deliver a prognosis and choose the optimal treatment&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Physical examination involves external and internal examination of genitals&#44; and checking for lymphadenopathy &#40;hard&#44; mobile&#44; bilateral and very painful&#41; and location of the virus in other areas &#40;mouth and eyes&#41;&#44; along with the patient&#39;s medical history&#46; The initial lesion is one or more grouped vesicles on an erythematous base&#46; These vesicles subsequently open up and lead to shallow ulcerations&#46; In the area around the labia and rectum the vesicles often burst before they are noticed&#44; and crusts may appear &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; In primary genital infection&#44; the pain tends to last 10 days and the lesions heal in 2&#8211;3 weeks&#46; They are less painful and of limited duration&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The most commonly used diagnostic techniques are&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Tzanck smear&#44; from an unbroken vesicle&#46; Cheap and quick tool&#44; but requires experienced staff and is limited to this type of lesion&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">15&#44;16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">Viral culture&#58; although isolation in cell culture is relatively simple and fast compared to other viruses&#44; the yield is higher in the presence of vesicles &#40;80&#37;&#41; and when the samples are taken in the first two days after they appear&#44; and lower in the crust phase or in recurrences &#40;25&#8211;50&#37;&#41;&#46; It is a sensitive and specific&#44; but lengthy&#44; method&#46; The characteristic cytopathic effects tend to appear within 12&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">17&#44;18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Direct&#47;indirect immunofluorescence techniques&#58; fast&#44; cheap techniques&#44; many of them available fully automated or semi-automated&#44; with a sensitivity-specificity of 85&#8211;99&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">19&#8211;23</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Type-specific serology for specific anti-HSV IgG antibodies&#58; relevant in patients with a history of undiagnosed atypical genital lesion&#44; suspicion of partner infection with infected patient and pregnant women at risk of transmission to the newborn&#46; These are also fast&#44; inexpensive techniques&#44; many of which are fully automated or semi-automated&#46; However&#44; the limitation is that the antibody for the viral glycoprotein is detected from 6 to 8 weeks and approximately 5&#37; of the patients may have undetectable levels&#46; They have high sensitivity &#40;93&#8211;96&#37;&#41; and specificity &#40;80&#8211;98&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">24</span></a> but their use is not recommended in asymptomatic patients&#44; given the high rate of false positives in the low-risk population&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">A negative serology result may indicate both the absence of previous contact with HSV and absence of immune response&#44; either due to initial phase of infection &#40;primary infection&#41; or alterations in the patient&#39;s immune system&#46; In contrast&#44; the presence of total antibodies is evidence of herpetic infection&#46; A negative IgM indicates a non-active infection at the time of analysis&#44; while the presence of IgM shows an evolving infection &#40;not always a primary infection&#44; as in some recurrences significant amounts of IgM may be detected&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">25&#44;26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">PCR&#58; use of PCR in clinical practice is booming thanks to the multiplex PCR technique that enables the simultaneous detection of the main organisms present in infectious ulcers of sexual origin &#40;<span class="elsevierStyleItalic">Treponema pallidum</span>&#44; <span class="elsevierStyleItalic">Haemophilus ducreyi</span>&#44; <span class="elsevierStyleItalic">Chlamydia trachomatis L serovar</span>&#44; which causes lymphogranuloma venereum&#44; and HSV 1&#8211;2&#41;&#46; This technique has a high sensitivity and specificity &#40;both close to 100&#37;&#41;&#44; it is fast&#44; its cost is decreasing and&#44; combined with the fact that it is automated&#44; it enables access for an increasing number of laboratories&#46; Mainly because of its high sensitivity &#40;even in cases with low viral load&#41; it is useful for detecting viral shedding in asymptomatic patients and diagnosing lesions which were negative in the culture&#46; The biggest drawback is the cost and the requirement for laboratories and specialised staff&#46; Commercial kits are now available for the simultaneous determination of several STIs or exclusively herpes simplex infection which can differentiate between HSV types 1 and 2&#44; something that a culture cannot do&#46; For all these reasons&#44; PCR has progressively displaced performing a culture as the diagnostic method for HSV infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">27&#44;28</span></a></p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">The most commonly used molecular targets are conserved sequences of the genes encoding the surface glycoproteins gD and gB&#44; or the enzymatic proteins DNA polymerase and thymidine kinase&#44; with differences in their sequence which enable discrimination in the detection of HSV-1 and HSV-2&#44; such as those approved by the FDA for the detection of HSV in genital lesions&#58; IsoAmp HSV Assay &#40;BioHelix Corporation&#41;&#44; Multi-Code-RTx Herpes Simplex Virus 1 &#38; 2 Kit &#40;EraGen Biosciences Inc&#46;&#41; and BD ProbeTec Herpes Simplex Viruses HSV 1 &#38; 2 &#40;HSV QxAssays&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">29&#44;30</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Treatment</span><p id="par0120" class="elsevierStylePara elsevierViewall">The WHO recommends &#8220;empirical&#8221; or &#8220;syndromic&#8221; treatment&#44; as the results of the diagnostic tests are not available at the time of the first consultation&#46; Such early treatment can lead to faster healing&#44; relief of symptoms and a reduced risk of transmission&#46; It is recommended in patients with genital ulcers suggestive of HSV infection&#44; but has the disadvantage of potentially being inappropriate treatment&#46; It is therefore essential to follow up patients to assess their treatment response and diagnostic tests results and to reassess treatment decisions&#44; if necessary&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In the <span class="elsevierStyleItalic">first episode of genital herpes</span>&#44; antivirals should be used for the first five days from onset of the episode&#44; or during the formation of new lesions&#46; The treatment of choice is oral antivirals&#44; aciclovir&#44; valaciclovir and famciclovir&#44; which reduce the severity and duration of the episode &#40;level of evidence Ib&#44; A&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">31</span></a> Topical treatments are not recommended&#44; as they are less effective than oral treatments and can generate resistance &#40;IV&#44; C&#41;&#46; The only indication for the use of intravenous therapy is when the patient cannot ingest or tolerate oral treatment&#46; The recommended regimens for 5&#8211;10 days are as follows&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Aciclovir 400<span class="elsevierStyleHsp" style=""></span>mg three times a day&#44; or aciclovir 200<span class="elsevierStyleHsp" style=""></span>mg five times a day&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Famciclovir 250<span class="elsevierStyleHsp" style=""></span>mg three times a day&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Valaciclovir 500<span class="elsevierStyleHsp" style=""></span>mg twice a day&#46;</p></li></ul></p><p id="par0145" class="elsevierStylePara elsevierViewall">As treatment support measures&#44; saline baths and the use of analgesics are recommended&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In cases of <span class="elsevierStyleItalic">recurrent genital herpes</span>&#44; the choice of treatment is made according to the severity of the symptoms and the time of recurrence&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">There is a range of treatment regimens&#44; including the following&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Short therapy &#40;Ib&#44; A&#41;&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Aciclovir 800<span class="elsevierStyleHsp" style=""></span>mg three times a day for two days&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Famciclovir 1<span class="elsevierStyleHsp" style=""></span>g two tablets in a single day&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Valaciclovir 500<span class="elsevierStyleHsp" style=""></span>mg twice a day for three days&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Five-day treatment&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Aciclovir 400<span class="elsevierStyleHsp" style=""></span>mg three times a day for 3&#8211;5 days&#44; or aciclovir 200<span class="elsevierStyleHsp" style=""></span>mg five times a day&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Valaciclovir 500<span class="elsevierStyleHsp" style=""></span>mg twice a day&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Famciclovir 125<span class="elsevierStyleHsp" style=""></span>mg twice a day&#46;</p></li></ul></p></li></ul></p><p id="par0200" class="elsevierStylePara elsevierViewall">In special situations&#44; such as HIV-positive patients&#44; there are no clinical trials for the duration and treatment&#44; so some clinicians opt for 10 days of treatment with twice the dose of any of the above oral treatments &#40;IV&#44; C&#41;&#46; In pregnant women&#44; treatment regimens and treatment management vary according to the trimester of virus acquisition&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">31&#44;32</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Suppressive therapy</span> is recommended in patients with more than six episodes per year&#44; and can reduce flare-ups by up to 70&#8211;80&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">31</span></a> This treatment regimen aims to reduce the number of recurrences and the risk of transmission to sexual partners&#46; The recommended doses are&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Aciclovir 400<span class="elsevierStyleHsp" style=""></span>mg twice a day for five days&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">Valaciclovir 500<span class="elsevierStyleHsp" style=""></span>mg a day &#40;if fewer than 10 recurrences&#47;year&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Valaciclovir 1<span class="elsevierStyleHsp" style=""></span>g a day &#40;more than 10 recurrences&#47;year&#41;&#46;</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">Recent studies indicate that topical microbicides&#44; such as the 1&#37; tenofovir or 3&#37; SPL7013 gels&#44; may be a promising option&#44; having achieved a 51&#37; reduction in the risk of HSV-2 infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">33&#44;34</span></a> Another alternative is helicase-primase inhibitors&#44; such as ASP2151&#44; for the treatment of recurrent genital herpes&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">35&#44;36</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Therapeutic vaccines are another potential strategy for the management of HSV-positive patients&#44; but few of the earlier trials obtained optimal results&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">32</span></a> New trials focused on the immune response of the host&#44; through the use of HSV peptides &#40;HerpV&#41;&#44; have achieved promising results in phase I and are now in phase I&#47;IIa&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">37&#8211;40</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Prophylactic vaccines have been under continuous development and improvement for years&#44; prominent among which are two containing the HSV-2 glycoprotein D subunit&#44; with a demonstrated efficacy of 73&#8211;74&#37; among women seronegative for both types of HSV&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">41</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Analysis of health service costs related to HSV disease</span><p id="par0240" class="elsevierStylePara elsevierViewall">A recently published study<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">42</span></a> calculated the costs associated with HSV infection in hospital accident and emergency units&#46; In the period 2006&#8211;2013 the cost amounted to 543 million dollars&#44; going from 45 million dollars in 2006 to 91 million in 2013&#44; primarily due to a 24&#37; increase in the number of patients&#46; The study emphasises the need for continuous prevention and patient sex education to avoid new cases&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Level of evidence</span><p id="par0245" class="elsevierStylePara elsevierViewall">For more information and details about levels of evidence and grades of recommendation see&#58; <a id="intr0010" class="elsevierStyleInterRef" href="http://www.iusti.org/regions/Europe/pdf/2013/Levels_of_Evidence.pdf">http&#58;&#47;&#47;www&#46;iusti&#46;org&#47;regions&#47;Europe&#47;pdf&#47;2013&#47;Levels&#95;of&#95;Evidence&#46;pdf</a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0250" class="elsevierStylePara elsevierViewall">The author declares that there are no conflicts of interest regarding the research&#44; authorship&#44; and&#47;or publication of this literature review&#46;</p></span></span>"
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          "titulo" => "Introduction&#58; microbiology of HSV"
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            0 => "Vaginitis"
            1 => "Genital ulcers"
            2 => "Herpes simplex virus"
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            4 => "Diagnosis"
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            0 => "Vaginitis"
            1 => "&#218;lceras genitales"
            2 => "Virus herpes simplex"
            3 => "Epidemiolog&#237;a"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Genital herpes is a sexually transmitted disease caused by herpes simplex virus type 1 &#40;HSV-1&#41; and type 2 &#40;HSV-2&#41; belonging to the alphaherpesvirus family&#44; that includes the varicella zoster virus&#46; HSV infection continues to be the most common cause of vulvar ulcers among the sexually active population&#46; Its incidence increases every year&#46; This review summarises the microbiology of the virus&#44; pathogenesis and infection in genitalia&#44; clinical manifestations and correct identification&#44; the different laboratory diagnostic methods&#44; and choice of the correct treatment according to the first infection&#44; recurrence or special cases&#46; Finally&#44; the cost of routine herpes simplex virus infection is analysed&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El herpes genital es una enfermedad de transmisi&#243;n sexual causada por los virus herpes simplex tipo 1 &#40;VHS-1&#41; y tipo 2 &#40;VHS-2&#41;&#44; pertenecientes&#44; junto al virus varicela zoster&#44; a la familia alfaherpesviridae&#46; La lesi&#243;n por VHS contin&#250;a siendo la causa m&#225;s frecuente de &#250;lcera vulvar entre la poblaci&#243;n sexualmente activa&#44; y su incidencia aumenta cada a&#241;o&#46; En esta revisi&#243;n resumiremos la microbiolog&#237;a del virus&#44; la patogenia y la infecci&#243;n en genitales&#44; las manifestaciones cl&#237;nicas para su correcta identificaci&#243;n&#44; las diferentes t&#233;cnicas diagn&#243;sticas de laboratorio y la elecci&#243;n del correcto tratamiento seg&#250;n sea primera infecci&#243;n&#44; recurrencia o casos especiales&#46; Finalmente&#44; se discute un an&#225;lisis de costes de la enfermedad por VHS&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Parra-S&#225;nchez M&#46; &#218;lceras genitales por virus herpes simplex&#46; Enferm Infecc Microbiol Clin&#46; 2019&#59;37&#58;260&#8211;264&#46;</p>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos