Genital Herpes

Dr. Penny Lane
Jun 29
8 min read

Most are familiar with herpes, the sexually transmitted disease that is too easy to get and becomes a "friend" for life. This virus can cause lesions on the mouth or in the genitals, either herpes simplex virus type 1 or type 2. We typically think of the first virus as oral and the second as genital, but either can be found in either location. HSV1 is usually acquired during childhood, and HSV2 is primarily a sexually transmitted disease.

Often we say, "everyone has herpes," and while it is probably safe to think such, the reality is that just over one of every ten people has herpes, about 13% of the population (Plunkett et al., 2024). After the initial infection, the virus becomes latent in the nerve root and can be reactivated by minor infections, trauma, sunlight and stress.

Women who have bacterial vaginosis shed this virus more so are more inclined to spread the virus (Plunkett et al., 2024). The same is true for those with Group B streptococcus colonization, so a balanced gut microbiome, when impacts the perineum and vaginal health is important for protecting oneself and others from this virus. Hormonal contraceptives also increases shedding of the virus, and of course, those who have herpes are more vulnerable to also getting HIV.

This isn't a virus we routinely screen for, at any point in our wellness exams or even during pregnancy (Plunkett et al., 2024). When this screening is performed, know that there are high false-positive rates and this may lead to unnecessary antiviral suppression therapy or even valse accusations and psychosocial disruption.

Condoms can be helpful in preventing the spread of the virus (although not as good as for protecting against other sexually transmitted infections), but also inspection of a new partner. No lesions should be present prior to engaging in sexual activity. Suppression therapy does reduce transmission, which can occur even without an apparent outbreak. This therapy does not work in those with HIV (Plunkett et al., 2024). During pregnancy, of course, we offer suppressive therapy at 36 weeks to minimize risk of transfer to the child. This also reduces cesarean delivery, although if a pregnant mother's first outbreak of HSV occurs in the third trimester, she is likely to be offered surgical birth as their is such significant viral shedding with this first outbreak, which can be catastrophic to the child. There are no vaccines for HSV approved by the FDA although these are in development and a priority for the World Health Organization.

As a clinician, when a client has a new lesion and share they have had a recent outbreak of herpes, an important consideration is assuring that lesion was in fact herpes, and not a cancroid associated with syphilis. Herpes more often breaks out, especially the first time, with several blistered lesions. Syphilis however, presents with a single lesion and ultimately resolves without subsequent symptoms for many years. There are other potentials as well, such as fungal or bacterial infections, psoriasis, granulomas, even cancers so with that first lesion, it is important to be evaluated so diagnosis can be confirmed. Keep in mind, it takes a little time for your blood to identify and tag the HSV virus so if hoping to confirm diagnosis with blood testing, you'll need to wait about 12 weeks after the initial outbreak. We typically also screen for HIV, gonorrhea, chlamydia and syphilis at this time as a precaution, as HIV for example is three-times more likely in those with HSV infection.

Herpes often presents with clusters of shallow, painful vesicles or ulcers on an erythematous base (pink and inflamed) either on the genitals, the rectum or the perineum. This may be associated with fever, overall feeling of exhaustion, sore muscles, burning with urination or inability to empty the bladder, and tender and swollen groins. Mild outbreaks may go unrecognized, but more often these are significant and can make one pretty miserable. The first outbreak is most always the most significant and over time these become more mild, but severe outbreaks into the future certain can occur.

How Do We Treat Herpes?

That first outbreak is most always treated, as it can be significant. Recurrent outbreaks though may be treated as their arise, or suppressive therapy may be offered. That initial outbreak is often treated with Acyclovir 400 mg three times daily for 7-10 days at about $10 or with Famciclovir 250mg 3 times a day for 7-10 days for $15, or even Valacyclovir 1gram twice daily for 7-10 days for about the same cost.

When these outbreaks are recurrent, we may treat with Acyclovir 800mg twice daily for 5 days, or three times a day for just two days. A single dose of Famciclovir 500mg followed by 250mg twice daily for two more days is also effective, or even Famciclovir 125mg twice daily for 5 days or even 1000mg twice that first day. There are a number of approaches. Valacyclovir 500mg is also used twice a day for three days, or at higher doses of a gram, just once a day for 5 days and these treatments are about $5.

When outbreaks are more common, we can offer suppressive therapy. Acyclovir is used at 400mg twice daily, every day, or Famciclovir 250mg twice daily, every day or more commonly, Valacyclovir at either 500mg or 1000mg daily. Acyclovir is the most widely available and least expensive medication for episodic treatment but generally requires more frequent dosing. Acyclovir and valacyclovir can be used for suppression therapy during pregnancy. Topical antiviral medications aren't overly effective and just aren't recommended for genital herpes.

Early studies in the late 1980s determined that based on dosage, long-term suppressive acyclovir therapy was safe and efficacious for recurrent genital herpes, with no clinical side effects observed, while another study showed no viral resistance even after 6 years of administration. However, more recently, evidence that contradicts this has emerged, yet this likely relates to a crossing population of immunocompromised individuals.

Complementary Medicine

Our goal is to support the immune system, to screen and remove any additional underlying infections, to assess and balance methylation, to avoid triggers, avoid high arginine-containing foods, to increase lysine intake, and to manage stress.

Arginine promotes HSV viral growth and acts as a medium for growth of herpes. When tissues are deficient of arginine, herpes can not flourish. Foods rich in the amino acid arginine include various nuts, seeds, and legumes, as well as some meats and dairy products. White meats such as chicken, pork, and turkey are especially arginine-rich, as are pumpkin seeds, peanuts, and soybeans. Other sources are walnuts, almonds, chickpeas, lentils, and dairy products like milk, cheese, and yogurt. These are healthy foods though, so balance is key.

Studies have shown that chocolate and other sweets reduces our ability to produce antibodies and has a significant impact on our immune response so that improving one's diet may be the necessary step for reducing HSV outbreak. Think about consuming more antioxidants and anti-inflammatory foods, such as fresh fruits and vegetables, and overall maintain a diet low in sugar and processed foods.

Supplementing vitamin B12 can support the immune system, as does vitamin D and C, even zinc. Lysine has an antiviral activity due to its antagonism of arginine metabolism. Echinacea supports the immune system, as does andographis, baptisia, cat's claw and St. John's wort is specifically anti-viral, along with licorice, lemon balm and goldenseal. Adaptogens that may be helpful are Siberian ginseng and withania. Topically, St. John's wort, lemon balm, licorice, goldenseal, myrrh, tea tree oil and lavender may be supportive.

L-Lysine

L-lysine has long been the recommended supplement for minimizing herpes outbreaks and while there is some evidence in support (Pedrazini et al., 2022) of its use as a prophylactic agent offering reduction in outbreaks and severity, as well as shorter healing time, there is also a good amount of conflicting data. Dose does play a role here, in that less than a gram a day doesn't seem to be effective, and doses greater than 3grams a day improve outcomes (Mailoo & Rampes, 2017).

Lysine is an essential amino acid, meaning the body can not produce it and it must be obtained through the diet or supplementation. It plays a vital role in protein synthesis, calcium absorption, and collagen formation, which is important for skin, bones, and connective tissues. Lysine may also have antiviral properties, particularly against herpes virus. Its effectiveness seems to come in its ability to suppress the viral growth-promoting actions of its analog, arginine.

Overall, lysine doesn't compare to the effectiveness of Acyclovir, but it is a safe, natural compound, without reported adverse side effects, and its a promising alternative option for individuals with herpes.

Bee Products

Two bee products, both honey and propolis, have shown antiviral properties and have been compared to acyclovir for treating painful herpetic lesions (Johnston et al., 2019). Propolis is a resin-like material synthesized by bees to coat small openings in their hives, and it is widely used in home remedies with many pharmacological properties. It's a combination of bee discharge, beeswax, and tree sap.

Propolis ointment has shown to be more effective than acyclovir cream for healing painful herpetic lesions (Rocha et al., 2022). In three randomized controlled trials, honey led to slightly faster healing of herpetic lesions than acyclovir and was similar to acyclovir in reducing the duration of pain. This approach is currently underutilized as it has vast potential for the symptomatic treatment of herpes. However, this approach is not recommended by the CDC. The ointment for genital herpes is Herstat and this one, a little less expensive, is an option for oral lesions.

Lemon Balm

Another herb with support in the literature for effectiveness against herpes is lemon balm. In one study, hydroalcoholic lemon balm leaf extract reduced HSV-2 by 60% (Chang et al., 2023). Similarly, a Melissa extract was found to be 80% and 96% inhibitory of HSV-1 strains. A double-blind study found recurrent genital herpies was significantly relieved after just two days of treatment with lemon balm cream. When initiated with 72 hours of onset, two to four times daily for ten days, healing is significantly increased.

Vitamin E

Well known as a fat-soluble antioxidant, vitamin E is believed by many to enhance immune function. In mice, offering vitamin E in diets, compared to diets low in vitamin E, significantly reduced symptoms of HSV and progression of the virus (Chang et al., 2023). Topically, vitamin E oil applied with a cotton ball does improve healing and pain relief within just 8 hours. Another study applied the vitamin E every four hours during a breakout, and resolution was prompt with reduced pain relief.

Zinc

One of our super antioxidants, zinc deficiency is related to numerous diseases, including childhood developmental disorders, and dysfunction of both humoral and cell-mediated immunity, increasing susceptibility to infection. Supplementing zinc twice daily at 22.5mg for four months over a year's period significantly reduces lesions (Chang et al., 2023). Even when applied topically zinc reduces duration of cold sores and severity of symptoms.

Vitamin D

This family of lipid-soluble steroid hormones significantly downregulates HSV-1 titers and represses mRNA expression of Toll-like receptors, which are our inflammatory mediators previously shown as host-detrimental in HSV infection. A large study of more than 14-thousand people, utilizing the National Health and Nutrition Survey, found that vitamin D deficiency was a risk factor for both HSV-1 and HSV-2 (Huang et a., 2023).