Non sexual transmission of herpes

[Esthetician]

Let me give you a scenario.  An esthetician is performing a brazilian bikini wax (complete hair removal from genital/anal area).  Esthetician is not wearing gloves and has a papercut on her finger.  The esthetician is not in a sexual relationship with anyone and has not been for about 5 months.  That relationship was the only intimate sexual relationship for the past three years. Five days after performing the brazilian, the esthetician noticed a tiny red spot that appeared to be an insect bite.  She found it first thing that morning (5th day).  No itching but hot to the touch.  Next day it had grown to the size of a quarter and had a small patch of blisters in the center.  The following morning she was awakened by vomiting.  That afternoon she went to the doctor.  The site had enlarged to the size of a silver dollar and the blisters starting to scab and also quite painful.  Doctor looked at it and commented that it looks like shingles.  He cultured the blisters to rule out herpes. He prescribed her Zovirax and stated that antiviral would work for either diagnosis (shingles or herpes).  The culture tested positive for herpes.  In your opinion, is it possible that the brazilian client transmitted the herpes virus to the esthetician?  

[Edward W Hook, MD]

The scenario you describe is conceivable.  The lesion you describe is called a herpetic whitlow and used to be common (pre-glove days) in dentists and oral hygienists who would be caring for people with cold sores. The infection is tranmitted by direct contact and something like a paper cut could make it more likely to occur.  The situation you describe is sufficiently similar to be this.  Alternatively, the esthetician could have gotten their infection from touching someone else's mouth.   EWH

[Esthetician]

I forgot to mention the lesion was located between inner and frontal thigh mid region  (about where hem of boxer shorts would hit) . This client periodically has cold sores and tends to fidget by keeping her fingers in her mouth and biting her nails during service until sometimes they bleed.  The esthetician has never done any facial waxing or facial services on this client. Strictly a brazilian client.  Does this change your opinion?  I am sorry for leaving out the location of the infection site!

[Esthetician]

Just viewed your credentials and found you are a professor of microbiology.  Now I ask a different question,,,can wax be contaminated during a brazilian waxing service if the client is undergoing viral shedding?    Are there any other ways wax can be contaminated if the esthetician is not double dipping the spatula?

[Edward W Hook, MD]

The location of the lesions does not change my opinion.

As for the possibility of contaminating the wax, there are no studies of this that I am aware of.  On the other hand, to avoid this sort of contamination, in medical facilities and other situations in which one might worry about contamination, it is generally recommended that nothing that has touched a patient (client) then be placed back into a container from which supplies to be used on others will come from .  this is done to minimize contamination and the theoretical transfer of infectious organisms from person to person through contaminated materials.  While this is the theoretical perspective and good practice, I would also guess it is a rare occurrence.  EWH

[Esthetician]

I am confused.  I do not have any lesion of any kind on my hands.  The only lesion I have is the one on my thigh.  I thought that herpetic whitlow pertains to the hand/finger area.  Since you said your opinion did not change, where you under the impression the lesion was on my hands, too?  I realized that I was not clear in my first post.  Since this lesion is in the boxer shorts area, does this mean I have genital herpes?  Thank you!

[Edward W Hook, MD]

Sorry, your presentation in the 3rd person was confusing. My thought was that the estethician was you and that you had acquired herpes on your hand from a client's thigh.  As I understand it now, you are the client and the lesion is on your thigh.  If this is the case, the question becomes, in the absence of sexual contact, could the brazilian waxing have been involved with your acquisition of herpes and if so, where could it have come from? (Answer- it is most likely from her hand, the wax is less likely but as I said above, possible)

As far as is this genital herpes - this is an issue of semantics.  You have herpes and it is on your thigh rather than your genitals.  You could theoretcially transmit your infection to others through direct contact.  The likelyhood of contact varies with they type of herpes (if your lesion was HSV-1, transmission is rather unlikely) and whether or not you have a lesion present (lesions are associated with increased risk of transmission).  EWH

[Esthetician]

I'm so sorry for the confusion.  Let me see if I can clear this up.  I am the Esthetician.  I had a paper cut on my finger while performing a brazilian bikini wax and I was not wearing gloves. The infection site showed up on my thigh.  Could I have contracted the herpes virus in this scenario?  If so, is it HSV1 or HSV2?  This client always has cold sores and is anorexic.  I feel sorry for her and that's the reason I service her.  I had always worn gloves while servicing her until this time.  She is the only client I have ever worn gloves with.  I had an intuition that she may not aways practice good hygiene and even suspected drug use.  At the time of this last service with her, I was running behind with a packed schedule, and just did it without gloves.  And, I remember her touching my thigh to get my attention as I was turned to get my wax.  As I said before, she tends to keep her fingers in her mouth.  Is it possible that she could have transmitted the virus to me when she touched my thigh, even though I had on cotton scrub pants?  I'm just trying to figure out how this could have happened since I have had no other direct skin-on-skin contact outside of work.  I'm single, don't have children, and live alone with my dog.  I'm 30 years old.  Also, I work in an extremely humid environment.  My service room is very hot and stays humid since I use a steamer in many services.  My towel cabby stays at 180 degrees inside.  There is no ventilation in my room since it is in the center of the second floor of a building that is over 100 years old. I begin to sweat during my first service of the day.  By afternoon, the temperature in my room reaches 90 degrees. I am usually drenched with sweat by that point. I have had to excuse myself on more than one occasion during a service to go and throw up. Should I get a dehumidifier or portable air conditioner so that my service room is not a perfect environment for viruses, bacteria, etc.?  As of now, the only relief that my employer has provided to me is a big fan.

Believe me, this has been a lesson to me.  I've been wearing gloves with every client since this happened.  It would just ease my mind if I knew how I contracted this.  I'm worried now that I may have spread it to my clients before my symptoms presented.

I think I've covered it all now.  I trust you because of your education and because of the fact that you are in my home state of Alabama.
ROLL TIDE!!

[Edward W Hook, MD]

thanks for the clarification,  I now have a clearer picture of what has happened.  That said, I have no idea how you became infected. HSV does not pass through clothing , even wet scrubs and no part of your client touched your thigh.  In the same way, you have nothing to worry about as far as spreading your infection to your clients unless they are touching your bare thigh (seems unlikely from your description)

I would ask the doctor who did your culture if it was HSV-1 or HSV-2.

I doubt that your environment, while uncomfortable, will contribute to your risk of outbreaks or recurrences.

Again, thanks for the clarification.  I hope this helps.  EWH

[Esthetician]

I plan to call the doctor who performed the culture in the morning.  In the meantime, please let me ask you one more question.  Is it possible that I had the virus on my hand or under my fingernails after the service, went to the restroom and while pulling my scrubs down touched my thigh (had not washed hands at this point), then washed my hands thoroughly after using the restroom.  Could washing my hands have saved them from infection?

[Edward W Hook, MD]

Washing one's hands regularly is always a good idea.  On the other hand, there are no data to suggest that transmission of infection from a lesion to another site through the mediation of the hands occurs.  In fact, what we know about the virus suggests that this would not happen.  I am at a loss to explain how you got your infection unless perhaps it is an infection that has been there in the past and was overlooked and this is a recurrence.  If your culture was positive for HSV-2, this is a possibility.EWH

[Esthetician]

I just called and spoke to a nurse at the doctor's office and she informed me it is HSV-1. The only time I'm working around the mouth of a client is in facials (up til now never wore gloves for facials) or upper lip wax (again, no gloves until now).  I also do microdermabrasion, chemical peels but with these services I always wear gloves!  Just wanted to follow up and let you know what the culture said.  Thank you for all of your help and for taking the time to help me make some sense of it all.  It's just a mystery,,,if I'd been physical with someone intimate I don't think I'd have any questions.  But the only direct skin on skin I have is with my clients (sad but true).  Again, thank you for everything.

[Edward W Hook, MD]

It is a mystery.  That it is HSV-1 is, all things considered, good news.  HSV-1 is less likely to recur than HSV-2 and as far as transmission to others, which is unlikely to occur at all, it is less likely with HSV-1, both becasue recurrences are less common and becasue over 60% of adults already have antibodies to HSV-1 and thus are protected from infection.  Good luck.  EWH

[Esthetician]

It's me again, I have another question,,,it has been brought to my attention that shingles is sometimes misdiagnosed as herpes.  The doctor did comment that it did look like shingles, but he was perplexed since I only had one lesion (that had tripled in size in 3 days).  He said it was either Herpes or Shingles, and cultured it for herpes.  He never suggested any bloodwork.  I've been in touch with the nurse at my ob/gyn for viral bloodwork.  In your opinion, what is the most accurate way to determine if this is shingles or herpes.  It would be nice to know what it is, how I got it, and I can protect others from contracting it.  If it's shingles, I'll know it wasn't an occupational hazard!

[Esthetician]

I just wanted to keep you up to date on this, being there have not been any studies!  I went back today to the medical facility who cultured the site.  They performed a viral culture, so no need to do bloodwork!  It is HSV-1.  She's referring me to a dermatologist because of the fact she's never seen hsv-1 located on someone's thigh before.  So I had to contract this occupationally!  

[Edward W Hook, MD]

Thank you for the follow-up.  We all learned something from your unusual experience.  I hope all goes well from here on out.  EWH

[Esthetician]

Thank you for taking the time to help me make sense of this nightmare.  I'm just curious...what is the protocol for more studies being done on this subject?  Our world has changed.  Eight years ago in esthetics school we were trained to double-dip and were not told to wear gloves except during extractions and lancing.  That hasn't changed.
It needs to.

Thanks again,
Esthetician (who is now wearing gloves during all services!!)

[Esthetician]

I woke up this morning to a phone call from a friend/client who's a pharmacist in my local area.  He had phoned a dermatologist and told him about my experience.  The dermatologist wanted to see me right away.  I got there within an hour.  It turns out that I have shingles!  He stated it is difficult to differentiate the two viruses under the microscope during first three days.  He's seen this before many times where there's only one lesion.  He said that was probable due to my age (again I'm 30).  This has been an ordeal!  I have learned a lot through this experience.  I will continue to be assertive with my health.  Since I'm a medical esthetician and deal with the skin, I had a gut feeling it was shingles given the symptoms.  I'm grateful in a way, because I'm changing the way I perform my services.  I will continue to wear gloves!  Thanks again for all your help!  Hopefully this will be the last post I make!  :)

[gracefromHHP]

did they repeat your lesion culture and it came back as herpes zoster at the dermatologist appointment or did he just do a looksee and say it was shingles and not simplex?

grace

[Esthetician]

He just did a looksee at the lesion.  He also took the end of a woodstick and ran it across above and below the lesion to see if there was a different sensation and there was.  The blisters on the lesion have now crusted and scabed.  He stated over and over that hands down this was a case of shingles and not herpes simplex.

[Edward W Hook, MD]

I am worried about this. A culture or PCR is needed.  The fact of the matter is that HSV looks like varicella zoster virus (the shingles virus) clincially when it is on non-genital skin.  I do not make it a habit of arguing against clinicians who have had the opportunity to examine patients who I only communicate with over the net but in this case I MUST differ.  Remember, you had a positive culture already from the lesion that grew HSV-1.  Unless you have another test of the virus from the lesion, I think you should consider this HSV.  EWH

[Esthetician]

This all started on May 12, 2008.  Looking back, I remember pain on the left side of my abdomen about 1-2 weeks before the rash appeared.  I had called my mother and told her I think I have appendecitis, but she told me that would be on the right side.  And for the past 3 days, I've had tingling sensations and pain in my left hip, everything's happening on the left side of my body.  And the lesion is on my left thigh.  
The dermatologist stated it probably was a false positive culture.  He said that does happen. Everyone in the medical field I have seen has told me that there is no "test" for shingles.  I still have an appointment with my ob/gyn regarding possible bloodwork next Wednesday.  It was suggested to me by a client (who's a BSN, RN), to check for other risks, such as HIV and Hepatitis.  Since the lesion is in the healing process, and I've been taking 800mg Zovirax 5x daily (today is 10th day since rash appeared), is it too late for me to have the PCR?  This makes me want to run to the ER right now. I TRUST YOUR OPINION.  I wish I could jump in my car and drive to Birmingham right now so you could see it for yourself!  

[Edward W Hook, MD]

A PCR test would be higher yield that a culture (and, unfortunately, more expensive) and after 10 days of therapy the culture or PCR would likely be negative.  Again, with all due respects to your dermatologist, false positive cultures are very, very uncommon.  they happen but rarely.  I think the key question is, will the sore recur.  If it does, get a culture or PCR test ASAP.  I know you are anguished over this and wish I had a clearer answer.  Sorry.  EWH

[Esthetician]

I read some exam test sometimes performed when differentiating HSV and VZV. It mentioned a skin biopsy that could be done, even when there's no lesion.  Or is it too late for this test also?  If I have HSV-1 on my thigh, does that mean that I will start having cold sores on my mouth at some point?

[Edward W Hook, MD]

1.  At this time a biopsy will be of little value other than to make your care expensive and perhaps leave a small scar.  

2.  If this is HSV-1 as it seems to be, it may or may not recur at about the same place it first appeared although with milder recurrences.  It will not appear otherwise.  In all likelyhood, you body has developed an immune response which will keep it localized to the area where it first appeared.  EWH