Shedding Question

[anonymous1900]

1.) About three years ago I had an initial outbreak, the outbreak started in the pubic hair region above the shaft; curious, if wearing a condom, am I likely to shed from this region in a sufficient amount to transmit the virus (possible, of course, likely??).  I ask this because that area of the body has relatively thick skin and I’m not sure how much that would change shedding rate (thick skin Vs thin skin).  When I do have some visible sign of an outbreak (which is not often), its usually in the pubic hair region and not on the penis.

2.) Quiet frequently (way more than 20% of days) I have you know periodic itching on the inside of my thighs, my scrotum, and in the pubic hair area just above the shaft of my penis.  I generally don’t find any redness or bumps but of course any nuance in this region can be stressful.  This happens regardless of whether I’m taking antivirals or not.  May be I just have dry skin, maybe it is psychological, but hard to know.  Can anything be said about higher risk of shedding while this is occurring?
3.) Recently I did have a red bump within the pubic hair region, itched slightly periodically, finally I popped it.  White puss came out (like a zit), not clear if that means not HSV related?   Thoughts? Was on antiviral at the time.

Thanks  

[H. Hunter Handsfield, M.D.]

Welcome to the forum.

My first response is a question:  How was your initial herpes infection confirmed?  First outbreaks are uncommon in the pubic area.  In order for an HSV infection to take, in general the virus has to be massaged into the exposed area, perhaps with overt or microscopic skin breaks.  Therefore, initial herpes symptoms typically occur at the sites of maximum friction during sex:  the penis in men, the vaginal opening and labia in women, the anus in people who have had receptive anal sex.

So let me know how the diagnosis was made; if lab tests were done, whether the cause was HSV-1 or HSV-2; and also describe exactly what symptoms you mean in reference to your occasional "visible sign of an [recurrent] outbreak".

Pending that information, the following brief replies assume the diagnosis is correct.

1) Once somone has a genital area HSV infection, viral shedding can occur anywhere in the "boxer shorts" area.  It would not necessarily be limited to the site of initial inoculation of the virus.

2) Herpes does not cause itching in the absence of an obvious outbreak, and recurrent outbreaks usually are in more or less the same spot every time, give or take an inch or so.  It is very unlikely these symptoms are due to herpes.

3) Herpes lesions usually are not like pimples.  The superficial appearance can be similar, but pimples are deeper (think of them as being "in" the skin), with herpes lesions more superficial ("on" the skin) and pus cannot be expressed from deep in the lesion.  It sounds like you just had a pimple or folliculitis.

I'll comment further when you provide the information about diagnosis etc.  But for now, I'm not sure you have herpes at all; and if you do, I believe it is currently asymptomatic and unrelated to the itching, pubic area bumps/pimples, etc.

Regards--  HHH, MD

[H. Hunter Handsfield, M.D.]

Thanks for the clarification.  Your genital herpes is obviously well documented, despite my initial skepticism.

Most recurrent genital herpes outbreaks occur in more or less the same spot each time (+/- an inch or so); and usually they start as a cluster of red bumps that quickly (1-2 days) develop superficial blister-like lesions with clear fluid.  They are not associated with hairs, whereas in folliculitis -- which likely explains at least some of your recurrent lesions -- it is often possible to see a pubic hair emanating from lesions.  Herpes outbreaks never occur more often than once a month, and usually are 6 weeks to 4 months apart.  If you are uncertain about which of your "outbreaks" are herpetic, you should see a health professional within 1-2 days of onset (perhaps a few times) so the lesions can be tested for HSV.  

However, recognizing outbreaks is not the main way to avoid transmitting the virus to your partner.  Even without outbreaks, you should assume the virus is present in the genital area, including the penis, and can be up to 5% or even 10% of the time.  While it is true that viral shedding may be less frequent in the pubic area, it probably will not be limited to your pubic area.  Most people with asymptomatic shedding have virus detected from the penis and elsewhere, regardless of the location of the initial infection.

While you should not have sex when having an outbreak, you also should plan to use condoms consistently; and should consider anti-herpetic therapy to reduce asymptomatic shedding and transmission.  It would also be a good idea for your partner to be tested for HSV-2.  If by chance she has been infected previously, i.e. has a positive blood test, you'll have no worries; she won't catch it again.

My final advice is that you discuss all this with your partner, if you have not yet done so.  Some couples in your situation just don't let the possibility of herpes transmission be a big deal.  After all, if she gets infected, there's a good chance she'll never know, since many (most?) HSV-2 infections are asymptomatic; if she has symptoms, effective treatment is available; and if your relationship is committed for the long term, there should be no concerns about transmission to future partners.

I hope this helps.  Best wishes--  HHH, MD

[anonymous1900]

Thanks for your follow up:

The first outbreak started in the pubic hair area just above shaft then spread to the shaft within a few days.  I had a culture done and it was positive for HSV type II.    There were visible vesicles which eventually burst leaving lesions that resembled small craters…of sorts.  I have not had lesions per say since the initial outbreak but have had reoccurring spots that appear like small craters in the same area above the shaft, and maybe once or twice actually appeared on the shaft.

Of course every event since the first has been less severe and also less obvious.  So the problem is that most of the time it is very difficult to tell if these instances, which I refer to as recurrent outbreaks, are in fact that or an inflamed hair follicle, pimple, or a lesion; I tend to assume the ladder to be conservative.  At the root of it I am concerned with probability of transmission to my HSV negative girlfriend.    I am aware of the cited rates of transmission; 8-10% annually (reduced by 50% with antivirals), however these are statics on a population and don’t tell me anything specifically about me the individual.  So my follow up to you is the following:  is there a place/resource where I could go and get additional testing to better measure how often I shed?  Understanding that a culture test is out barring a lesion, is there not technology somewhere (even if in the academic realm) to measure asymptomatic shedding at low levels?  Is it technically possible?

I of course want to avoid sex during an outbreak but its hard to determine when I’m having an outbreak or any other minor skin issue.

Back to #1 above, I guess I was hoping to think that if I tend to shed from that original location above the the shaft (say 1 inch above), then rates of shedding might be lessened due to skin thinkness and since that area of the body is not incerted during sex transmission might be less likely....but this is probably just wishful thinking.

I know these are tough questions without good answers at the current time.  Thanks again.