Herpes Viruses - GoFoods

Related Terms

Acquired immunodeficiency syndrome, AIDS, antiviral, B-cell lymphotrophic virus, Bell’s palsy, CFS, chicken pox, chickenpox, chronic fatigue syndrome, CMV syndrome, cold sore, colitis, contagious, corticosteroid, cutaneous, cytomegalovirus, down syndrome, EBV, encephalitis, epidural, Epstein-Barr virus, exanthema subitum, fetal alcohol syndrome, fever blister, fibromyalgia, genital herpes, gingivostomatitis, glomerulonephritis, Guillain-Barre syndrome, hepatitis, herpes labialis, herpetic, herpes zoster ophthalmicus, HHV-2, HHV-4, HHV-5, HHV-6, HHV-7, HIV, Hodgkin’s disease, HSV anterior uveitis, HSV blepharitis, HSV conjunctivitis, HSV infectious epithelial keratitis, HSV keratitis, HSV neonatal infection, HSV retinitis, human herpesvirus type 4, human herpesvirus type 5, human herpesvirus type 7, human herpesvirus type 8, human herpesviruse type 6, human immunodeficiency virus, immunocompromised, immunofluorescence, Kaposi’s sarcoma, Kaposi’s sarcoma-associated virus, KS, latency, lesion, lymphocryptovirus, lymphocytes, lymphoma, lymphoproliferative disorders, lyphotrophic virus, MCD, meningitis, mono, monocytes, mononucleosis, multicentric Castleman’s disease, myocarditis, neuropathy, opcular lesions, oropharyngeal, PCR, PEL, PHN, pneumonia, polymerase chain reaction, postherpetic neuralgia, primary effusion lymphoma, prodromal, pyrexia, Ramsay Hunt syndrome, retinitis, rhadinovirus, roseola infantum, roseola, roseolovirus, sexually transmitted disease, shedding, shingles, STD, steroid, topical, uveitis, vaccine, varicella-zoster virus, vesicle, VZV.

Background

Herpes is a group of viruses that infect humans. Types of herpes viruses include herpes simplex virus types 1 and 2 (HHV-1 and HHV-2 respectively), human herpesvirus type 3 (varicella-zoster virus), human herpesvirus type 4 (including Epstein-Barr virus and lymphocryptovirus), human herpesvirus type 5 (cytomegalovirus), human herpesviruse type 6 (HHV-6, including human B-cell lymphotrophic virus and roseolovirus), human herpesvirus type 7 (HHV-7), and human herpesvirus type 8 (rhadinovirus and Kaposi’s sarcoma-associated virus).
The viruses fall into three categories: Alpha herpes viruses (HSV-1, HSV-2, and varicella-zoster virus), beta herpes viruses (cytomegalovirus, HHV-6, and HHV-7), and gamma herpes viruses (Epstein-Barr virus, lymphocryptovirus, and HHV-8). The viruses are different and cause various conditions with many unique signs and symptoms. However, all herpes viruses share some common properties, including a pattern of active symptoms followed by latent (inactive) periods with no symptoms that can last for months, years, or even for a lifetime. Herpes symptoms may even never reappear. The severity of herpes symptoms depends on the type of virus with which the individual is infected.
Herpes simplex type 1 (HHV-1) is also known as a cold sore or fever blister. Herpes simplex type 2 (HHV-2) is also known as genital herpes. Human herpes virus 3 is also referred to as varicella-zoster or VZV. Herpes varicella is the primary infection that causes chickenpox, and herpes zoster is the reactivation of the varicella virus that causes shingles.
Herpes 1 and 2 infections are generally marked by painful, watery blisters in the skin or mucous membranes (such as the mouth or lips) or on the genitals. Lesions heal with a crust-forming scab, the hallmark of herpes. This is particularly likely during an outbreak, although individuals may shed virus between outbreaks. Although no cure is yet available, antiviral treatments exist that reduce the likelihood of viral shedding. An HSV infection on the lips, commonly known as a “cold sore” or “fever blister,” should not to be confused with a canker sore; canker sores (painful sores on the tongue or oral membranes in the mouth) are not caused by the HSV virus.
Herpes is a contagious infection that spreads when the carrier is producing and releasing (“shedding”) virus. Herpes viruses are transmitted from human to human in different ways. With HSV-1, contact and infection can occur directly from another human (such as mouth-to-mouth, hand-to-mouth contact) or through the use of everyday objects that have come in contact with the virus, including razors, towels, dishes, and glasses. Genital herpes or HSV-2 can only be contracted through direct sexual contact (genital-to-genital, mouth-to-genital, or hand-to-genital; not kissing) with an infected partner. Occasionally, oral-genital contact can spread oral herpes to the genitals (and vice versa). Individuals with active herpes lesions on or around their mouths or on their genitals should avoid oral sex. The varicella-zoster (chickenpox) virus spreads through the humidity in the air when inhaled and mainly spreads during the incubation period, which is just before an outbreak of symptoms.
After an initial or primary infection, herpes viruses establish a period called latency, during which the virus is present in the cell bodies of nerves that innervate (attach) to the area of the original viral outbreak (such as genitals, mouth, and lips). At some point this latency ends, and the virus becomes active again. While active, the virus begins to multiply (called shedding), and becomes transmittable again. This shedding may or may not be accompanied by symptoms. During reactivation, virus is produced in the nerve cell and transported outwardly via the nerve to the skin. The ability of herpes virus to become latent and reactive explains the chronic (long-term), recurring nature of a herpes infection.
Recurrence of the viral symptoms is usually milder than the original infection. Recurrence may be triggered by menstruation, sun exposure, illness with fever, stress, immune system imbalances, and other unknown causes.

Risk Factors and Causes

Herpes simplex virus type 1 (HSV-1, herpes labialis): Everyone is at risk for HSV-1 (herpes labialis or oral herpes). It is easily transmitted and is the most common form of the herpes simplex virus. Oral herpes (cold sores or fever blisters) affects between 15-30% of the entire population, and most people are infected when they are with highest incidence first occurring between six months and three years old. HSV-1 can be spread by close contact with someone who has a cold sore or by using items contaminated with the virus. Kissing someone on the mouth will spread the virus and sharing personal items such as razors, towels, or eating utensils with a person who has oral herpes will increase the risk of getting HSV-1. The virus can also be spread to the genital area of another individual by having oral sex. Individuals with oral herpes should not perform oral sex on their partners. They should also avoid kissing. Infants and young children (up to three years old) have an increased risk of being exposed to HSV-1 due to immune systems that are still not fully developed.
Exposure to sunlight or other ultraviolet light is a common trigger for the formation of cold sores. Stress on the body due to illness or excessive exercise can weaken the body’s immune system and lead to an outbreak of oral herpes. Common examples of stress or illness include infection, fever, a cold, physical injury, dental surgery, menstruation, medications (including steroids), or illnesses such as human immunodeficiency virus (HIV) that suppress the immune system, eczema, excessive exercise, and emotional stress.
It should be noted that HSV-1 is becoming a major cause of genital herpes as well and in some studies it is now a more important cause.
Herpes simplex virus type 2 (HHV-2, genital herpes): Anyone who is sexually active is at risk for genital herpes and it is on the rise. Some reports estimate 31 million cases of HHV-2 or genital herpes occur in sexually active adults annually in the United States. The risk of HSV-2 infection is higher in women than in men. The largest increases in HSV-2 occur in women after their early twenties. Women have an 80- 90% chance of contracting HSV-2 after unprotected sexual activity with an infected partner and are 1.7 times more likely to be infected than men. Men, however, have twice as many recurrent infections as women. Less than one percent of American children younger than fifteen test positive for HSV-2; sexual abuse should be considered in children with HSV-2. Although African Americans are more likely to test positively for HSV-2, Caucasians have a higher risk for active genital symptoms and over the past few years the greatest increase in HSV-2 has been observed in white adolescents.
Varicella-zoster virus (chickenpox): Before the introduction of the vaccine, about four million cases of chickenpox were reported in the United States each year. Between 75-90% of chickenpox cases occur in children under 10 years of age. Since a varicella vaccine became available in the United States in 1995, however, the incidence of disease and hospitalizations due to chickenpox are showing a dramatic decrease. Experts expect the disease to become a rarity in the United States.
The risk of chickenpox is high in late winter and early spring months. Primary transmission of chickenpox includes direct contact with the individual carrying the virus or by inhaling the virus from the air. It can also be transmitted from direct contact with the open sores. However, clothing and bedding do not usually spread the disease.
An individual with chickenpox can transmit the disease from about two days before the appearance of the spots to the end of the blister stage. This period lasts about five to seven days. Once dry scabs form, the disease is unlikely to spread.
Most schools allow children with chickenpox back after ten days of onset to avoid the risk of spreading the infection. Some require children to stay home until the skin has completely cleared, although this measure is not necessary to prevent transmission.
Individuals at a higher risk for developing chickenpox include individuals of any age who have neither had chickenpox in the past nor been immunized against chickenpox, newborns, individuals with a weakened immune system, and individuals who are taking immunosuppressant drugs. Also at risk are individuals who are moderately or severely ill and are not yet fully recovered, individuals who have disorders affecting the blood, bone marrow, or lymphatic system, the elderly, and pregnant women. If an individual is not immune to chickenpox, traveling abroad can increase the risk of contracting the condition.
Males (both boys and men) have a higher risk for a severe case of chickenpox than females. The older the child, the higher the risk for a more severe case. But even in such circumstances, chickenpox is rarely serious in children.
Varicella-zoster virus (shingles): About 500,000 cases of shingles occur each year in the United States. Anyone who has had chickenpox has risk for shingles later in life, which means that 90% of U.S. adults are at risk for shingles. Shingles occurs in about 10-20% of adults who have had chickenpox. The risk for herpes zoster increases as people age, so the overall number of cases will undoubtedly increase as the baby boomer generation gets older. One study estimated that an individual who reaches 85 has a 50% chance of having herpes zoster. The risk for postherpetic neuralgia (PHN, or pain that persists after the outbreak healed) is also highest in older people with the infection, increasing dramatically after age 50. Individuals whose immune systems are impaired from diseases such as those with human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), or childhood cancer have a risk for herpes zoster that is much higher than those with healthy immune systems. In fact, herpes zoster in people who are HIV positive may be a sign of full-blown AIDS. Current drugs used for HIV, called protease inhibitors, may also increase the risk for herpes zoster. Cancer places people at high risk for herpes zoster. At highest risk are those with Hodgkin’s disease (13-15% of these patients develop shingles). About seven to nine percent of patients with lymphomas and between one to three percent of patients with other cancers have herpes zoster. Individuals who take certain drugs that suppress the immune system are at risk for shingles (as well as other infections) including azathioprine (Imuran®), chlorambucil (Leukeran®), cyclophosphamide (Cytoxan®), and cyclosporine (Sandimmune®, Neoral®). These drugs are used in patients who have undergone organ transplantation, but they are also often used for severe autoimmune diseases caused by the inflammatory process. Such disorders include rheumatoid arthritis, systemic lupus erythematosus, diabetes, multiple sclerosis, Crohn’s disease, and ulcerative colitis.
Interestingly, one study suggested that previously infected adults who are exposed to children with chickenpox may receive an extra boost in antibody production that can actually help them fight off herpes zoster. This means that as more children are vaccinated against chickenpox, more adults may be at risk for herpes zoster. There is a vaccine now available that may prevent shingles or lessen its effects (Zostavax®). The vaccine is for people 60 or older who have had chickenpox but who have not had shingles.
Although most common in adults, shingles can also develop in children. One study reported that only five percent of shingles cases occur in those under age 15. Children with immune deficiencies are at highest risk. Children with no immune problems and those who had chickenpox before they were one year-old are at higher risk for shingles. It is still uncommon, however.

Signs and Symptoms

Herpes simplex virus type 1 (HSV-1, oral herpes): Symptoms of cold sores are blisters on or around the lips and the edge of the mouth. The first symptom that may appear during an outbreak of oral herpes or cold sores may include tingling, burning, or itching in the area around the mouth or nose. This first portion of the outbreak is known as the prodromal stage or period. Within a few hours to days, the area may become reddened and develop small fluid-filled blisters called vesicles. Several of these small blisters may even come together and form one large blister. Cold sore blisters usually break open, weep clear fluid, and then crust over and disappear after a few days. The patient may experience symptoms including a sore mouth that makes eating, drinking, and sleeping uncomfortable. Other symptoms include fever, sore throat, and swollen lymph nodes in the neck. Symptoms usually last seven to ten days.
Herpes simplex virus type 2 (HHV-2, genital herpes): Signs of genital herpes (HSV-2) tend to develop within three to seven days of skin-to-skin contact with an infected person. Genital herpes infections look like small blisters or ulcers (round areas of broken skin) on the genitals. Each blister or ulcer is typically only one to three millimeters in size, and the blisters or ulcers tend to occur in groups. The blisters usually form first then soon open to form ulcers. Herpes infections may be painless or slightly tender. In some individuals, however, the blisters or ulcers can be very tender and painful. In men, genital herpes (sores or lesions) usually appear on or around the penis. In women, the lesions may be visible outside the vagina, but they commonly occur inside the vagina. Lesions inside the vagina may cause discomfort or vaginal discharge, but may be difficult to see, except during a doctor’s examination. In any individual, ulcers or blisters may be found anywhere around the genitals (the perineum) and in and around the anus. The first herpes outbreak is usually the most painful, and the initial episode may last longer than later outbreaks. Some individuals develop other signs of herpes infection, particularly with the first episode, including fever, muscle aches, headaches (may be severe), vaginal discharge, painful urination, and swollen and tender lymph glands in the groin (glands swell as the body tries to fight the infection). If the disease returns, later outbreaks generally have much less severe symptoms. Many individuals with recurrent disease develop pain in the area of the infection even before any blisters or ulcers can be seen. This pain is due to irritation and inflammation of the nerves leading to the infected area of skin. These are signs that an outbreak is about to start. An individual is particularly contagious during this period, even though the skin still appears normal.
Varicella-zoster virus (chickenpox): Individuals with chickenpox may notice several symptoms before the typical chickenpox rash appears. Known as prodromal, or early symptoms, they include fever, a vague feeling of sickness, or decreased appetite. Within a few days, a rash appears as small red pimples or blisters. The rash appears in batches over the next two to four days. It usually starts on the trunk and then spreads to the head, face, arms, and legs. Blisters may also be found in the mouth or the genital areas, because the virus can affect mucous membranes. Although some individuals may have only a few blisters, some have 100-300 blisters present. The pimples will progress to red teardrop blisters about five to ten millimeters (1/4-1/2 inch) wide. The blisters mature, break open, form a sore, and then crust over. Most of the blisters will heal within 10-14 days, and usually do not cause scarring unless the blisters become infected.
Varicella-zoster virus (shingles): Shingles usually begins with an unpleasant itching, burning, tingling, or painful sensation in a band-like area. The period of time when these sensations occur without a skin rash is called the prodromal period. During this time, the individual may have symptoms including fever, muscle aches, fatigue, anxiety (nervousness), and discomfort in the skin (usually on one side of the face, torso, trunk, back, or buttocks). The discomfort may feel like numbness, itching, burning, stinging, tingling, shooting pain, electric shock, sharp pain, and extreme sensitivity to even light touch. Symptoms of active shingles includes a rash that begins as a reddish band or individual bumps running in a line and bumps developing with fluid-filled centers. Over the course of seven to 10 days, the bumps begin to dry and crust over. The individual may continue to have pain and/or itching in the area of the rash. The pain may be severe. If the rash develops on the side of the nose or elsewhere on the face, the individual should contact their healthcare provider immediately. This can signal that the eyes may be infected. Although the rash of active shingles usually subsides within a week to a month, some individuals continue to have pain and discomfort well after the rash has healed. This syndrome of pain in the area of the previously infected nerve is called postherpetic neuralgia (PHN), and it can be quite severe and debilitating.
Epstein Barr virus: Epstein-Barr virus can cause fever, a sore throat, swollen lymph glands- especially in the neck, and extreme fatigue or tiredness. Although typically caused by the Epstein-Barr virus (EBV), mononucleosis can also be caused by other herpes viruses including cytomegalovirus (CMV). Infection with EBV during adolescence or young adulthood results in mononucleosis in 35-50% of the cases. The incubation period for the mononucleosis is usually seven to 14 days in children and adolescents. The incubation period in adults is longer; at times it may be 30-50 days. If symptoms of mononucleosis last more than six months, it is frequently referred to as chronic EBV infection. EBV may be linked to chronic fatigue syndrome, a condition of chronic tiredness and exhaustion.
Symptoms of mononucleosis develop slowly, with such mild symptoms initially that it may be mistaken for a cold or the flu. As the condition progresses the symptoms may include a sore throat that lasts two weeks or more, swollen lymph nodes (in the neck, armpits, and groin), a persistent fever, fatigue (tiredness), and malaise (a vague feeling of discomfort). These symptoms can be mild or so severe that throat pain impedes swallowing and fever reaches 105 degrees Fahrenheit. Some individuals also experience a rash, eye pain, photophobia (discomfort with bright light), and a swollen spleen or liver. In most cases of mononucleosis, no specific treatment is necessary as the illness is usually self-limiting. Although the symptoms of infectious mononucleosis usually resolve in one or two months, the EBV remains dormant in cells in the throat and blood for the rest of the person’s life. Periodically, the virus can reactivate and can be found in the saliva of infected persons. This reactivation usually occurs without symptoms of illness, although it may be linked to symptoms of CFS. EBV also establishes a lifelong dormant infection in some cells of the body’s immune system.
Cytomegalovirus (CMV): In people with weakened immune systems (such as those with HIV or AIDS), cytomegalovirus (CMV) can cause any number of infections including retinitis (inflammation of the retina), pneumonia, colitis (inflammation of the colon), encephalitis (inflammation of the brain), mononucleosis, pneumonia, hepatitis, and uveitis. CMV syndrome and fever of unknown origin (known as pyrexia) are complications that may occur. CMV is a common a cause of serious disability such as neural tube defects. Neural tube defects (NTDs) are serious birth defects with symptoms that range from mild to severe impairment. They are caused by incomplete development of the brain, spinal cord, and/or their protective coverings.

Diagnosis

Physical exam: Signs and symptoms associated with herpes viral infections in humans can vary greatly depending upon the specific virus infecting the individual. Healthcare providers diagnose this group of infections by visual inspection and by taking a sample from the sore(s) for testing in a laboratory. Between outbreaks, these herpes infections can be difficult to diagnose. Viral diagnostic tests can also be performed to determine what type of herpes virus is infecting the individual.
Herpes viral infections may be confused with other conditions. Varicella-zoster virus (chickenpox), particularly in early stages, may be confused with herpes simplex, impetigo (bacterial skin infection), insect bites, or scabies (skin infection by mites). The early prodromal stage of shingles can cause severe pain on one side of the lower back, chest, or abdomen before the rash appears. It therefore may be mistaken for disorders, such as gallstones, that cause acute pain in internal organs. In the active rash stage, shingles may be confused with herpes simplex virus, particularly in young adults and if the blisters occur on the buttocks or around the mouth. Herpes simplex does not usually generate severe or chronic pain. A diagnosis may be difficult if herpes zoster takes a non-typical course, such as with Bell’s palsy (a neurological condition involving facial paralysis) or Ramsay Hunt syndrome (a neurologic disorder caused by a varicella zoster virus that infects certain nerves in the head) or if it affects the eye or causes fever and delirium.
Viral culture: A viral culture uses specimens taken from the blister, fluid in the blister, or sometimes spinal fluid. The samples are sent to a laboratory where they are analyzed. It takes between one and 14 days to detect the virus in the preparation made from the specimen. A viral culture is also sometimes used in vaccinated patients to determine if a varicella-like infection is caused by a natural virus or by the vaccine. This test is useful, but it is sometimes difficult to detect the virus in the samples.
Immunofluorescence assay: Immunofluorescence is a diagnostic technique used to identify antibodies to a specific virus. In the case of herpes zoster, the technique uses ultraviolet rays applied to a preparation composed of cells taken from the patient’s zoster blisters. The specific characteristics of the light, as seen through a microscope, will identify the presence of the antibodies. This test is less expensive, more accurate, and faster than a viral culture.
Polymerase chain reaction (PCR): Polymerase chain reaction (PCR) uses a piece of the DNA of the virus, which is then replicated millions of times until the virus is detectable. A sample of the individual’s tissue from a sore is prepared and analyzed in a complicated laboratory test. This technique is expensive but is useful for unusual cases, such as identifying infection in the brain and spinal cord. This type of testing would be used to detect the presence of the herpes simplex virus in those who have genital sores, encephalitis (inflammation of the brain), and in newborns suspected of having neonatal herpes (a rare but serious condition where herpes is contracted during birth). A pregnant woman who has been diagnosed with herpes may be monitored regularly prior to delivery to identify a reactivation of her infection (which would indicate the necessity for a caesarean section to avoid infecting the baby). The primary methods of testing for the virus are the herpes culture and HSV DNA testing.
A positive herpes simplex culture or HSV DNA test from a vesicle scraping indicates an active HSV-1 or HSV-2 infection. A negative test result does not definitely rule out the presence of virus; for instance, the test may not be accurate if the herpes simplex virus was not isolated from the vesicle scraping.

Complications

Herpes simplex virus: Although genital herpes usually causes mild symptoms, some people may experience recurrent painful genital ulcers, which can be especially severe in people with suppressed immune systems. Like other sexually transmitted diseases (STDs), herpes may also increase the risk for transmitting or acquiring the human immunodeficiency virus (HIV).
All herpes viruses can be passed from mother to baby. The chance of giving herpes to the baby is highest if the first infection occurs near the time of delivery. The virus can be transmitted to the fetus while in-utero (inside the womb) or during passage through an infected vagina at birth. First-time infection during pregnancy leads to an increased risk of miscarriage, decreased fetal growth, and preterm labor. About 30-50% of infants who are born vaginally to a mother with first-time infection become infected with the herpes virus. Of babies born to women experiencing recurrent herpes at the time of birth, one to four percent become infected with the herpes-simplex virus.
If a woman is having an active outbreak of genital herpes at the time of delivery, the baby will usually be delivered by cesarean section to prevent transmission of herpes. Of infants infected with herpes at birth, 30-60% die within the first month. Survivors may have long-term complications such as mental retardation and seizures. To prevent transmission of herpes to their babies, pregnant women should discuss any past history of herpes with their healthcare providers and take adequate measures to prevent infection during pregnancy. The risk of herpes can be reduced during pregnancy by avoiding sexual intercourse (vaginal, anal, and oral) during the last three months of pregnancy if the partner is known to have or suspected of having genital herpes and avoiding receptive oral sex during the last three months of pregnancy if the partner is known to have or suspected of having herpes sores on the mouth, tongue, gum, or lips. Infidelity plays an important role in genital herpes transmission.
Herpes simplex viruses (HSV) can also cause several ocular (eye) lesions including HSV blepharitis, HSV conjunctivitis, HSV keratitis, HSV infectious epithelial keratitis, HSV anterior uveitis, and HSV retinitis.
Varicella-zoster virus: Pregnant women and anyone with immune system problems should not be near a person with chickenpox. If a pregnant woman who has not had chickenpox in the past contracts the virus (especially in the first 20 weeks of pregnancy), the fetus is at risk for birth defects. The mother is at risk for more health complications than if she had been infected when she was not pregnant. If the mother develops chickenpox just before or after the child is born, the newborn is at risk for serious health complications. There is no risk to the developing baby if the woman develops shingles during the pregnancy. If a pregnant woman has had chickenpox before the pregnancy, the baby will be protected from infection for the first few months of life, since the mother’s immunity gets passed on to the baby through the placenta and breast milk. Those at risk for severe disease or serious complications may be given varicella-zoster immune globulin (VZIG, a vaccine for varicella-zoster virus) after exposure to chickenpox to reduce its severity. This group of people includes newborns whose mothers had chickenpox at the time of delivery, individuals with leukemia or immune deficiencies, and children receiving drugs that suppress the immune system.
Chickenpox rarely causes complications, but it is not always harmless. Five out of every 1,000 children who have the infection require hospitalization, and, in rare cases, chickenpox can be fatal. Chickenpox has caused about 11,000 hospitalizations each year and 100 deaths per year in the United States. Widespread vaccination, however, has produced a dramatic decline in these numbers.
The most common complications of chickenpox include itching, infections (usually from Staphylococcus aureus or Streptococcus pyogenes), scarring (complicated by scratching), ear infections, pneumonia, and encephalitis (inflammation of the brain). Other extremely rare complications of chickenpox include problems in blood clotting and inflammation of the nerves in the hands and feet. Inflammation in other parts of the body, including the heart, testicles, liver, joints, or kidney, may also occur. Such cases of inflammation are almost always temporary in otherwise healthy patients.
Complications of shingles (herpes zoster) include post-herpatic neuropathy (PHN) pain, which can either be continuous burning or aching pain, periodic piercing pain, or spasm similar to electric shock. The pain tends to be more severe at night. Temperature changes can also affect pain. The pain may extend beyond the areas of the initial zoster attack and some areas have no feeling at all. In most cases, it does not affect daily life. Rarely, however, the pain of herpes zoster affects sleep, mood, work, and overall quality of life. This can lead to fatigue, loss of appetite, depression, social withdrawal, and impaired daily functioning. Itching is also common in individuals with shingles. Infections may occur in the blisters associated with shingles.
Shingles may lead to meningitis (inflammation of the membrane around the brain) or encephalitis (inflammation of the brain). The encephalitis is generally mild and resolves in a short period. In rare cases, particularly in patients with impaired immune systems, these inflammations can be severe and even life-threatening. Also, in rare situations herpes zoster can infect the urinary tract and cause difficult urination. The condition is temporary but may require a catheter to eliminate urine in some patients who have prolonged difficulty urinating. If shingles occurs in the face, the eyes are at risk, particularly if the path of the infection follows the side of the nose. Severe infections can occur if the eyes become involved that are difficult to treat and can threaten vision, called herpes zoster ophthalmicus. AIDS patients may be at particular risk for a chronic infection in the cornea of the eye. Herpes zoster can also cause a devastating infection in the retina called imminent acute retinal necrosis syndrome. In such cases, visual changes develop within weeks or months after herpes zoster outbreak has resolved. It should be noted that this complication does not always follow a herpes outbreak in the face but can occur after an outbreak in any part of the body. Prompt treatment with a drug called acyclovir (Zovirax®) can often halt the progress of vision loss, at least in people with healthy immune systems.
In very rare cases, herpes zoster has been associated with Stevens-Johnson syndrome, an extensive and serious condition in which blisters cover most mucous membranes along with large areas of the body.
Ramsay Hunt syndrome: Ramsay Hunt syndrome is a condition of facial paralysis and rash on the ear or mouth that occurs during a herpes zoster viral infection. Symptoms include severe ear pain and hearing loss, ringing in the ear(s), loss of taste, nausea, vomiting, and dizziness. Ramsay Hunt syndrome may also cause a mild inflammation in the brain. The dizziness may last for a few days or even for weeks, but usually resolves. Severity of hearing loss varies from partial to total. However, this hearing loss almost always goes away. Facial paralysis, on the other hand, may be permanent.
Bell’s palsy: Bell’s palsy is partial paralysis of the face. In some cases, it is difficult to distinguish between Bell’s palsy and Ramsay Hunt syndrome, particularly in the early stages. Ramsay Hunt syndrome tends to be more severe than Bell’s palsy. Some healthcare providers recommend oral prednisone (a corticosteroid) along with an antiviral drug (such as acyclovir or Zovirax®) within seven days after symptoms appear.

Treatment

Herpes simplex virus :
Genital herpes: There are three antiviral medications that the U.S. Food and Drug Administration (FDA) has approved for the treatment of genital herpes. Approved antiviral drugs include acyclovir (Zovirax®), valacyclovir (Valtrex®), and famciclovir (Famvir®). Antiviral medication is commonly prescribed for patients having a first episode of genital herpes, but they can be used for recurrent episodes as well. There are two kinds of treatment regimens: episodic therapy and suppressive therapy. With episodic therapy, the patient begins taking the medication at the first sign of recurrence. The medication is then taken for several days to hasten the recovery or healing or to prevent a full outbreak from fully occurring. All three of the antiviral treatments mentioned above have been proven to help shorten the amount of time that a person may experience symptoms of herpes. However, results may vary from person to person. Side effects of antiviral medicines include stomach upset, loss of appetite, nausea, vomiting, diarrhea, headache, dizziness, and/or weakness.
Suppressive therapy is used in individuals with genital herpes who want to eliminate (suppress) outbreaks altogether. Suppressive therapy is usually given to patients who have six or more recurrences per year. For these individuals, studies have reported that suppressive therapy may reduce the number of outbreaks by at least 75% while the medication is being taken. Also, for some, taking an antiviral on a daily basis can prevent outbreaks altogether. Suppressive therapy may completely prevent outbreaks in some patients. Side effects include nausea and vomiting. Suppressive therapy may need to be taken life-long.
Oral herpes: Medications that are swallowed to treat oral herpes include the antiviral medications acyclovir (Zovirax®), valacyclovir (Valtrex®), and famciclovir (Famvir®). There are two topical antiviral medications prescribed for the treatment of oral herpes-simplex virus (HSV)- topical acyclovir ointment (Zovirax®) and topical penciclovir cream (Denavir®). Both of these drugs work to speed up the healing process and reduce the viral activity. These drugs are put directly on the lesions themselves, but can also be used at the onset of prodrome (early symptoms of itching and burning lasting up to one to two days).
Other topical treatments for oral herpes are available over-the-counter (OTC), but are not antiviral compounds like acyclovir and penciclovir. Some also contain anesthetic ingredients (such as lidocaine or benzocaine) that numb the area and induce temporary relief from the discomfort of an outbreak. Unfortunately, some OTC treatments may actually delay the healing time of symptoms because they can further irritate the area with repeated applications. There is only one U.S. Food and Drug Administration (FDA)-approved cream, docosanol (Abreva®), the only OTC drug that has been clinically proven to help speed the healing process.
Infected individuals can also prevent recurring outbreaks by avoiding some of the known causes. During an outbreak, symptomatic relief may be obtained by keeping the area clean and dry, or by taking pain relievers (such as aspirin, acetaminophen, or ibuprofen). Some patients with genital herpes find relief by taking a bath where a person simply sits in a tub with warm water up to the hips).
Varicella-zoster virus (chickenpox) :
Pain medications: Treatment for chickenpox includes pain medicines such as acetaminophen (Tylenol®) or ibuprofen (Motrin®, Advil®). Do not give children less than 18 years of age aspirin, as a dangerous condition called Reye’s syndrome can develop.
Soothing baths: Frequent baths are particularly helpful in relieving itching, especially when used with preparations of finely ground (colloidal) oatmeal. Commercial preparations of oatmeal, such as Aveeno®, are available in drugstores, or one can be made at home by grinding or blending dry oatmeal into a fine powder. Use about two cups per bath. The oatmeal will not dissolve, and the water will have a scum. One-half to one cup of baking soda in a bath may also be helpful.
Lotions : Calamine® lotion and similar over-the-counter preparations can be applied to soothe the skin and help dry out blisters and soothe the skin.
Antihistamines: For severe itching, a type of over the counter medication called antihistamine diphenhydramine (Benadryl®) is useful; it also helps children sleep.
Antiviral drugs: Acyclovir is an antiviral drug that may be used in adult varicella-zoster patients or those of any age with a high risk for complications and severe forms of chickenpox. The drug may also benefit smokers with chickenpox, who are at higher than normal risk for pneumonia. Some experts recommend its use for children who catch chickenpox from other family members because such patients are at risk for more serious cases. To be effective, oral acyclovir must be taken within 24 hours of the first signs of the rash. Early intravenous (IV) administration of acyclovir is also treatment for chickenpox pneumonia. Foscavir (Foscarnet®) is an injectable antiviral agent commonly used in treating cytomegalovirus (an infection caused by herpesvirus type 5). It is used in cases of varicella-zoster strains that have become resistant to acyclovir (Zovirax®) and similar drugs. Administered intravenously (into the veins), the drug can have toxic effects, such as kidney damage (which is reversible) and seizures. Fever, nausea, and vomiting are common side effects. It can also cause ulcers on the genitals organs. As with other drugs, it does not cure shingles. Antiviral drugs require a prescription.
Varicella-zoster virus (shingles) :
The treatment goals for an acute (immediate) attack of shingles (herpes zoster) include reduce pain, reduce discomfort, hasten healing of blisters, and prevent the disease from spreading. Over-the-counter remedies are often effective in reducing the pain of an attack.
Antiviral drugs: Antiviral agents (acyclovir or Zovirax®), corticosteroids (prednisone or Delatasone®) are sometimes given to patients with severe symptoms, particularly if they are older and at risk for postherpes neuralgia.
Antihistamines: In general, to prevent or reduce itching, home treatments are similar to those used for chickenpox. Patients can try antihistamines, particularly diphenhydramine (Benadryl®, either orally or topically), oatmeal baths, and calamine lotion.
Oral corticosteroids: Drugs called oral corticosteroids, including methylprednisolone (Medrol®) or prednisone (Deltasone®), are used for inflammation associated with shingles. They have some benefit for reducing pain and accelerating healing in acute attacks of shingles when used with acyclovir (Zovirax®). However, they are not recommended without acyclovir. They also may be helpful for improving symptoms of Bell’s palsy and Ramsay Hunt syndrome. Corticosteroids do not appear to prevent a further attack or reduce the risk for post herpetic neuralgia (PHN). Side effects of corticosteroids, including weight gain and lowered immunity, can be severe and oral steroids should be taken at as low a dose and for as short a time as possible.
Epidural blocks: Epidural blocks are injections of local anesthetics, pain medications, or steroids outside the tough membrane surrounding the spinal cord (the dura matter). The injected substances block the nerves and offer relief from acute herpes zoster pain for some people. Some studies, but not all, have indicated that if they are given early enough (within two months), they may prevent nerve damage that leads to postherpetic neuralgia. Combinations of anesthetics with steroids in the epidural blockade may be particularly beneficial. This procedure is invasive, however, and is not widely used.
Over-the-counter (OTC) pain relievers: For an acute (immediate) shingles attack, individuals may take over-the-counter (OTC) pain relievers, including acetaminophen (Tylenol®) or ibuprofen (Motrin®, Advil®). Children should take acetaminophen, not aspirin. Adults may take aspirin. Such remedies, however, are not very effective for postherpetic neuralgia.
Post herpetic neuralgia (PHN) :
Postherpetic neuralgia (PHN) is difficult to treat. Once PHN develops, a multidisciplinary approach that involves a pain specialist, psychiatrist, primary care physician, and other healthcare professionals may provide the best means to relieve the pain and distress associated with this condition.
Anesthetic patches: Topical (on the skin) preparations, including a skin patch containing the anesthetic drug lidocaine (Lidoderm®), are generally used. They are effective in many people without producing any known severe side effects. The patch appears to reduce pain and improve quality of life for many patients. One to four patches can be applied over the course of 24 hours. Another patch (EMLA®) contains both the anesthetic drugs lidocaine and prilocaine. These patches are expensive and require a prescription. The most common side effects are skin redness or rash.
Topical creams: Capsaicin (Zostrix®) is prepared from the active ingredient in hot chili peppers. An ointment form has been approved for postherpetic neuralgia and is available over-the-counter (OTC). Its benefits are limited, however, and it is uncertain whether they are meaningful for most patients. A new patch form that uses a higher than standard dose may be more effective than current options. In one study, it reduced pain by 33% in nearly half of patients. Capsaicin should not be used until the blisters have completely dried out and are falling off the skin. Capsaicin ointment should be handled using a glove, and applied to affected areas three or four times daily. The patient will usually experience a burning sensation when the drug is first applied, but this sensation diminishes with use. It may take up to six weeks for the patient to experience its full effect, however, and about a third cannot tolerate the burning sensation. Many find no benefit.
Topical aspirin, known chemically as triethanolamine salicylate (Aspercreme®), may bring relief. Also, menthol-containing creams such as Ben Gay® and Flexall 454® may be helpful.
Oral medicines: Low-dose tricyclic antidepressant (TCAs), preferably nortriptyline (Pamelor®, Aventyl®), is also used. Side effects include drowsiness, fatigue (tiredness), dry mouth, and constipation. If that does not work, gabapentin (Neurontin®), an anti-seizure drug, can be used. Doctors usually start with a low dose and slowly increase the amount given until relief or severe side effects occur. Side effects include drowsiness and nausea or vomiting. Also, a type of painkilling drugs known as opiates, including oxycodone (Oxycontin®) or hydrocodone (Vicodin®, Lortab®), may be used. These drugs cause drowsiness and may cause physical dependence, even in short term use (two weeks or less).
Investigative agents: Cannabinoids are compounds in marijuana (cannabis) that may have properties that protect nerve cells. They are being studied for a number of nerve-disorders, including chronic nerve-related pain. In one study, they were effective in reducing pain and had no major side effects.
Mexiletine (Mexitil®) is a calcium channel blocking agent that alters nerve impulse transmission. It is normally used for heart rhythm disorders but is being used in some cases for PHN in patients who do not respond to standard agents. The agent can have adverse effects, including serious allergic reactions, nausea, vomiting, flushing, and arrhythmias (irregular heart beat).
Psychological approaches: A number of relaxation and stress-reduction techniques are helpful in managing chronic pain. They include meditation, deep breathing exercises, biofeedback, and muscle relaxation. Such techniques may apply to those with severe pain from acute infection and from persistent long-term postherpetic neuralgia. Cognitive behavioral therapy is showing benefit in enhancing patients’ beliefs in their own abilities for dealing with pain. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that it is only one negative and, to a degree, a manageable experience among many positive ones.

Integrative Therapies

B Good scientific evidence

Lemon balm : Several clinical studies have reported that a topical preparation of lemon balm (Melissa officinalis) heals sores associated with oral herpes simplex virus infections (herpes simplex type 1). More studies are needed in this area.
Based on available research, lemon balm taken by mouth has been reported to be relatively well tolerated when taken for up to eight weeks. Evidence for topical administration of cream suggested minimal side effects for up to 10 days of application. Avoid if allergic or hypersensitive to lemon balm. Avoid with Grave’s disease or thyroid hormone replacement therapy. Use cautiously in glaucoma because lemon balm may increase eye pressure. Use caution when operating heavy machinery. Lemon balm preparations may contain trace amounts of lead. Avoid if pregnant or breastfeeding.
Para-aminobenzoic acid : Evidence of para-aminobenzoic acid’s (PABA) possible antiviral activity have led to its study as a therapeutic agent for herpetic keratitis. Actipol® is a 0.007% PABA solution for ophthalmic use that has been studied for this purpose and found to be effective in most patients. Further randomized trials may help to confirm its effectiveness for this indication.
Sunlight exposure, particularly ultraviolet B (UVB) radiation (290-320nm), has been shown to stimulate recurrence of the herpes simplex virus infection on the mouth. Sunscreens are known to prevent erythema and sunburn following exposure to UVB rays. For this reason, it is hypothesized that sunscreens may be capable of preventing UVB-induced reactivation of recurrent herpes labialis infection (prevention) in predisposed patients.
Avoid with known hypersensitivity to PABA or its derivatives. Avoid oral use in children and pregnant or nursing women. Use cautiously in patients with renal disease, bleeding disorders or those taking anticoagulants, diabetics or patients at risk for hypoglycemia. Discontinue use if rash, nausea, or anorexia occurs. Pharmaceutical doses of PABA and its derivatives should only be taken under appropriate medical supervision. PABA should not be given concurrently with sulfonamides.
Sage : Early laboratory and clinical evidence suggests that sage extracts may be useful in the treatment of herpes skin manifestations. Additional research is needed in this area.
Avoid if allergic or hypersensitive to sage, its constituents, or to members of the Lamiaceae family. Use cautiously with hypertension (high blood pressure). Use the essential oil or tinctures cautiously in patients with epilepsy. Avoid if pregnant or breastfeeding.
Zinc : Proper nutrition, including vitamins and minerals, has been reported to help in decreasing recurrent herpes simplex virus infections. Lesser quality studies have been conducted to assess the effects of zinc (topical or taken by mouth) in herpes type 1 or type 2. A small study found that oral zinc sulphate appeared to reduce both the number of episodes and the time to recovery of herpes labialis. Several of these studies used combination treatments or permitted the continued use of other medications, so the exact role of zinc in those studies is unclear. However, the positive results obtained in most trials suggest that zinc may represent a safe and effective alternative or adjunct treatment for herpes type 1 and 2, and should encourage further research into the topic using well-designed studies.
Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.

C Unclear or conflicting scientific evidence

Acupuncture : Several clinical studies have reported that acupuncture therapy is effective in reducing the pain associated with post-herpetic neuralgia (PHN). More studies need to be performed before a firm conclusion can be drawn.
Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers because therapy may interfere with the device.
Alizarin : Limited available evidence suggests that alizarin may be of benefit in the treatment of viral infections. Additional research is needed in this area.
Avoid if allergic or hypersensitive to alizarin or any plants in the Rubiaceae family. Alizarin may be toxic and should not be handled for long periods of time, rubbed in the eyes, or eaten. Avoid if pregnant or breastfeeding.
Astragalus : Some studies suggest that astragalus may inhibit herpes viruses. Additional research is needed in this area.
Avoid if allergic to astragalus, peas, or any related plants or with a history of Quillaja bark-induced asthma. Avoid with aspirin or aspirin products or herbs or supplements with similar effects. Avoid with inflammation (swelling) or fever, stroke, or transplant or autoimmune diseases (like HIV/AIDS). Stop use two weeks before surgery/dental/diagnostic procedures with a risk of bleeding and avoid use immediately after these procedures. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders, or kidney disorders. Use cautiously with blood-thinners, blood sugar drugs, or diuretics or herbs and supplements with similar effects. Avoid if pregnant or breastfeeding.
Blessed thistle : Laboratory studies report no activity of blessed thistle against herpes viruses, influenza, or poliovirus. Effects of blessed thistle (or chemicals in blessed thistle called lignans) against HIV are not clear. Human research of blessed thistle as a treatment for viral infections is lacking.
Blessed thistle is generally considered to be safe when taken by mouth in recommended doses for short periods of time, with few reported side effects such as birth defects, bleeding, breathing problems, bruising, cancer of the nose or throat, increased production of stomach acid, itching, kidney disease, liver toxicity, skin rash, stomach discomfort, stomach ulcers, and vomiting. Allergic reactions to blessed thistle including rash may occur, as well as cross-sensitivity to mugwort and Echinacea. Cross-reactivity may also occur with bitter weed, blanket flower, Chrysanthemum, coltsfoot, daisy, dandelion, dwarf sunflower, goldenrod, marigold, prairie sage, ragweed or other plants in the Asteraceae/Compositae family. Avoid if pregnant or breastfeeding.
Chlorophyll : Oral consumption of chlorophyll liquid was reported in clinical study to be effective in both herpes simplex and varicella-zoster infections. More clinical research is needed.
Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressant agents or antidiabetes agents. Avoid if pregnant or breastfeeding.
Cranberry : Limited laboratory research has examined the antiviral activity of cranberry. Further research is warranted in this area.
Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Pregnant and breastfeeding women should avoid cranberry in higher amounts than what is typically found in foods.
Dimethylsulfoxide (DMSO) : Topical use of dimethylsulfoxide (DMSO) has been reported effective in the treatment of herpes zoster (shingles). Limited available study reported that benefits may be more effective when DMSO is combined with the drug idoxuridine. Further research is necessary.
Avoid if allergic or hypersensitive to DMSO. Use caution with urinary tract cancer or liver and kidney dysfunction. Avoid if pregnant or breastfeeding.
Honey : Honey is a sweet, viscid fluid produced by honeybees (Apis melliflera) from the nectar of flowers. It has been used for thousands of years as a healing agent. Limited available clinical study found that topical honey may be effective in treating labial but not genital herpes. More research is needed in this area to draw a conclusion.
Avoid if allergic or hypersensitive to honey, pollen, celery, or bees. Honey is generally considered safe in the recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously if taking antibiotics. Avoid in patients with diabetes. Potentially harmful contaminants (e.g. C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously if pregnant or breastfeeding.
Hypnosis : Hypnosis is associated with a deep state of relaxation. A small study showed potential benefit of a hypnotherapeutic treatment program for patients suffering from recurrent orofacial herpes infections. Further research is needed to confirm these results.
Use cautiously with mental illnesses (e.g. psychosis, schizophrenia, manic depression, multiple personality disorder, or dissociative disorders) or seizure disorders.
Licorice : Licorice (Glycyrrhiza glabra) has been found in laboratory studies to hinder the spread and infection of the herpes simplex virus. Clinical studies need to be performed.
Avoid with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, hormonal abnormalities or if taking diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.
Peppermint oil : The essential oil from peppermint (Mentha piperita) has been reported effective in decreasing recurrent herpes infection. Case study found that topical peppermint oil was effecting in reducing the pain of post-herpetic neuralgia. More clinical studies are needed.
Avoid if allergic or hypersensitive to peppermint or menthol. Peppermint is generally considered safe in non-allergic adults when taken in small doses. Use cautiously with G6PD deficiency or gallbladder disease. Menthol, which makes up part of peppermint oil, is generally considered safe in non-allergic adults. However, doses of menthol greater than 1 gram per kilogram of body weight may be deadly in humans. Peppermint oil may burn the skin if undiluted. Avoid if pregnant or breastfeeding.
Propolis : Propolis is a natural flavonoid-rich resin created by bees, used in the construction of hives. Propolis is produced from the buds of conifer and poplar tress, in combination with beeswax and other bee secretions. A limited number of laboratory studies have demonstrated effectiveness of propolis and its constituents against herpes simplex virus types 1 and 2. Preliminary results from human trials suggest some degree of efficacy of topical propolis for resolving the lesions associated with genital herpes virus infections. There is also limited research of propolis for the treatment of post-herpetic corneal complications. Some evidence suggests that propolis may speed up healing and improve sight. More clinical research is needed.
Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, or Balsam of Peru. Severe allergic reactions have been reported. Use cautiously with asthma or gastrointestinal disorders. Avoid if pregnant or breastfeeding because of the high alcohol content in some products.
Reishi : Reishi mushroom (Ganoderma lucidum) has been reported to improve immune system function in humans. Reishi extract was shown to be effective in decreasing post-herpetic neuralgia in case study. However, there is insufficient data to make any conclusion at this time.
Avoid if allergic or hypersensitive to any constituents of Ganoderma lucidum or any member of its family. Use cautiously with diabetes, blood disorders (including hemophilia), low blood pressure or ulcers. Avoid if pregnant or breastfeeding.
Rhubarb : Clinical study indicates that topically applied rhubarb-sage extract cream may reduce the symptoms of herpes. It was compared to acyclovir (Zovirax®) cream and was equally effective in relieving the symptoms. More high quality studies using rhubarb as a monotherapy are needed to discern rhubarb’s effect on herpes symptoms.
Avoid if allergic/hypersensitive to rhubarb, its constituents, or related plants from the Polygonaceae family. Avoid using rhubarb for more than two weeks because it may induce tolerance in the colon, melanosis coli, laxative dependence, pathological alterations to the colonic smooth muscles, and substantial loss of electrolytes. Avoid with atony, colitis, Crohn’s disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, pre-eclampsia, renal disorders, ulcerative colitis and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12 due to potential water depletion. Use cautiously with bleeding disorders, cardiac conditions, coagulation therapy, constipation, history of kidney stones, or thin or brittle bones. Use cautiously if taking anti-psychotic drugs or oral drugs, herbs or supplements (including calcium, iron, and zinc). Avoid if pregnant or breastfeeding.
Sorrel : There is currently not enough evidence on the proposed antiviral effects of sorrel. More research is needed.
Avoid large doses of sorrel because there have been reports of toxicity and death. This may be because of the oxalate found in sorrel. Many sorrel tinctures contain high levels of alcohol and should be avoided when driving or operating heavy machinery. These sorrel formulations may cause nausea or vomiting when taken with the prescription drugs metronidazole (Flagyl®) or disulfiram (Antabuse®). Avoid if pregnant or breastfeeding.
Tai chi : Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system, and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility, and strength. Limited available study showed that treatment with tai chi may increase immunity to the virus that causes shingles. This may suggest the use of tai chi in the prevention of chickenpox (varicella zoster) and shingles, but further well-designed large studies should be performed. Tai chi may also help with physical fitness, which is important with individuals with weakened immune systems.
Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.
Tea tree oil : Tea tree oil, from the Melaleuca alternifolia tree, has been proposed as a potential topical therapy for genital herpes simplex virus infections based on in vitro findings of antiviral activity. However, at this time there is insufficient human evidence to recommend either for or against this use of tea tree oil for recurrent herpes labialis infection.
Tea tree oil should not be taken internally, although vaginal and rectal use is recommended by some healthcare providers. Apply tea tree oil with a cotton ball. If sensitivity develops, such as rash or irritation, diluting the oil with water may help. If the rash or irritation continues, discontinue use. Avoid if allergic or hypersensitive to tea tree oil (Melaleuca alternifolia), any of its constituents, balsam of Peru, benzoin, colophony (rosin) tinctures, eucalyptol, or other members of the Myrtle (Myrtaceae) family. Avoid if taking antineoplastic agents. Avoid if pregnant or breastfeeding.
TENS : Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin or using acupuncture-like needles. TENS is believed to help stimulate the chi or energy of the body. TENS has been effectively used in treating pain associated with post-herpetic neuralgia in several clinical studies. However, more studies are needed.
Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.
Turmeric : Turmeric is a perennial plant native to India and Indonesia, and it is often used as a spice in cooking. Based on early research, turmeric may help treat various viral infections. However, reliable human studies are lacking in this area. Well-designed trials are needed.
Avoid if allergic or hypersensitive to turmeric (curcumin), yellow food colorings, or plants belonging to the Curcuma or Zingiberaceae (ginger) families. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, or gallstones. Use cautiously with blood thinners (e.g. warfarin). Use cautiously if pregnant or breastfeeding.

D Fair negative scientific evidence

Echinacea : Initial human studies suggest that echinacea is not helpful in the treatment of genital herpes. More research is needed to confirm these results.
Avoid if allergic to echinacea, its constituents, or any members of the Asteraceae/Compositae family (ragweed, chrysanthemums, marigolds, daisies). Use cautiously in patients prone to atopic reactions and in those with hemochromatosis and diabetes. Some natural medicine experts discourage the use of echinacea by people with conditions affecting the immune system, such as HIV/AIDS, some types of cancer, multiple sclerosis, tuberculosis, and rheumatologic diseases (such as rheumatoid arthritis or lupus). Use parenteral preparations of echinacea (no longer approved for use in Germany) cautiously. Use tinctures cautiously with alcoholic patients or in patients taking disulfiram or metronidazole. Avoid using echinacea in patients presenting for anesthesia. Use cautiously if pregnant or breastfeeding.
Historical or theoretical uses lacking sufficient evidence :
Arabinoxylan : Arabinoxylan is produced from Hyphomycetes mycelia mushroom extract. Arabinoxylan has been used traditionally for herpes zoster infection and post-herpetic neuralgia. Arabinoxylan increases immune function and may help the body fight off infection. Clinical studies are needed to support these uses.
Use cautiously if elderly or with kidney dysfunction, due to potentially high calcium and phosphorus content. Use cautiously with diabetes. Avoid if pregnant or breastfeeding.
Lysine : In preliminary study, lysine has been investigated for its effects on the herpes simplex virus. Study results are conflicting at this time. Additional high quality clinical research is needed to make a conclusion.

Prevention

Herpes simplex virus type 1 (HSV-1, herpes labialis, oral herpes) :
Taking steps to guard against the development of cold sores, to prevent spreading them to other parts of the body, or to avoid passing them along to another person is important when dealing with oral herpes.
Contact with infected individuals: The virus can spread easily as long as there are moist secretions from blisters. In individuals with depressed immune systems, the virus can be spread even after the skin appears to be healed. Also, not kissing others on the mouth if a herpes viral infection is present is important.
Sharing common items: Utensils, towels, water glasses, and other commonly used items can spread the virus when blisters are present.
Clean hands: Washing the hands carefully before touching another person when a cold sore is present is very important. The eyes and genital area may be particularly susceptible to spread of the virus.
Triggers: Avoiding or preventing conditions that stress the body, such as poor diet, not getting enough sleep, or staying in the sun for long periods of time without applying sun-block is very important in preventing oral herpes outbreaks.
Herpes simplex virus type 2 (HSV-2, genital herpes) :
Measures for preventing genital herpes are the same as those for preventing other sexually transmitted diseases (STDs). HSV-2 is highly contagious while lesions are present. The best way to prevent infection is to abstain from sexual activity or to limit sexual contact to only one person who is infection-free. Individuals should use, or have their partner use, a latex condom during each sexual contact, limit the number of sex partners, avoid any contact with a partner who has sores until the sores are completely healed, or use a male or female condom during anal, oral, or vaginal sex (however, transmission can still occur if the condom does not cover the sores), avoid having sex just before or during an outbreak since the risk for transmission is highest at that time, and ask the sexual partner if they have ever had a herpes outbreak or been exposed to the herpes virus. Also, getting tested for herpes-simplex viruses is important if the individual is sexually active outside of a monogamous relationship.
If an individual is pregnant, it is important to tell the doctor that HSV is present. If the individual has had unprotected sex and is unsure, testing for HSV is recommended by healthcare professionals. Watch for signs and symptoms of HSV during pregnancy. A doctor may recommend that the individual start taking herpes antiviral medications when they are about 36 weeks pregnant to try to prevent an outbreak from occurring around the time of delivery. If the individual is having an outbreak when they go into labor, the doctor will probably suggest a Caesarean section to reduce the risk of passing the virus to the baby.
A vaccine in clinical trials is being tested in women who have not been infected with herpes simplex virus (HSV). The vaccine is Herpevac® and may become available for prevention of genital and oral herpes infections.
Human herpesvirus type 3 (varicella-zoster virus, chickenpox) :
Varivax®: A vaccine for varicella-zoster infections is now used to prevent chickenpox. Varivax®, a live virus vaccine, produces persistent immunity against chickenpox. Data show that the vaccine can prevent chickenpox or reduce the severity of the illness even if it is used within three days, and possibly up to five days, after exposure to the infection. The vaccine against chickenpox is now recommended in the United States for all children between the ages of 18 months and adolescence who have not yet had chickenpox. Children are given one dose of the vaccine. Two doses one to two months apart are given to people over 13 years of age. To date, more than 75% of children have been vaccinated.
Some experts suggest that every healthy adult without a known history of chickenpox be vaccinated. Adults without such a history of infection by varicella-zoster should strongly consider vaccination if they are adults who are at high risk of exposure or transmission (hospital or day care workers, parents of young children), individuals who live or work in environments in which viral transmission is likely, individuals who are in contact with people who have compromised immune systems, non-pregnant women of childbearing age, adolescents and adults living in households with children, and international travelers.
Women who are trying to become pregnant should postpone conception until three months after the vaccine.
Side effects of Varivax® include discomfort at the injection site. About 20% of vaccine recipients have pain, swelling, or redness at the injection site. Only about five percent of adverse reactions are serious. Adverse events may include seizures, pneumonia, anaphylactic reaction (a life-threatening allergic reaction), encephalitis (inflammation of the brain), Stevens-Johnsons syndrome, neuropathy (nerve damage), herpes zoster, and blood abnormalities. The vaccine may also produce a mild rash within about a month of the vaccination that has been known to transmit chickenpox to others. Individuals who have recently been vaccinated should avoid close contact with anyone who might be susceptible to severe complications from chickenpox until the risk for a rash has passed. Months or even years after the vaccination, some people develop a mild infection termed modified varicella-like syndrome (MVLS). The condition appears to be less contagious and have fewer complications than naturally acquired chickenpox.
There is currently intense debate over the long-term protection of the vaccine. Studies have reported that more than 15% of vaccinated children still develop chickenpox (called breakthrough infections). The long-term protective effect for adults is even less clear. Between 1979 and 1999, it was reported that although nine percent developed chickenpox months to years after their last vaccination, in all cases, infection was mild with none of the serious complications of adult chickenpox. A 2003 study on booster shots in older adults suggests that revaccination with the live virus is safe and effective.
Varicella-zoster immune globulin (VZIG): Varicella-zoster immune globulin (VZIG) is a substance that triggers an immune response against the varicella-zoster virus (VZV). It is used to protect high-risk patients who are exposed to chickenpox or those who cannot receive a vaccination of the live virus. Such groups include pregnant women with no history of chickenpox, newborns under four weeks who are exposed to chickenpox or shingles, premature infants, children with weakened immune systems, adults with no immunity to VZV, and recipients of bone-marrow transplants (even if they have had chickenpox). VZIG should be given within 96 hours and no later than ten days after exposure to someone with chickenpox.
Human herpesvirus type 3 (varicella-zoster virus, shingles) :
Zostavax®: Zostavax® is a live vaccine made from the herpes zoster virus that causes shingles. Zostavax® has been reported to reduce the incidence of herpes zoster by 51.3% in adults aged 60 and older who received the vaccine. The vaccine also reduced by 66.5% the number of cases of postherpetic neuralgia and reduced the severity and duration of pain and discomfort associated with shingles by 61.1%. Zostovax was approved by the U. S. Food and Drug Administration (FDA) in May 2006. The FDA recommended it only for adults aged 60 and older who meet requirements. These requirements include not having a life-threatening allergy to gelatin nor a life-threatening allergy to the antibiotic neomycin or other component of the herpes zoster vaccine. Individuals should not have a weakened immune system due to HIV/AIDS human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), or any other disease. Patients should also not be on other disease medications, such as steroids, radiation, or chemotherapy, which affect the immune system. There should be no history of cancer of the bone marrow or lymphatic system, such as leukemia or lymphoma, and also no active or untreated tuberculosis. Side effects include headache, itching, and tenderness or redness at site of injection.
Zostavax® is not a substitute for Varivax® in children.

Author Information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

References

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

American Academy of Family Physicians. . Accessed April 4, 2009.
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