[Question #6494] HSV scar versus active lesion

13 months ago
I am a 53 year old female with type 2 genital HSV, My male partner does not have herpes. We met 9 months ago and I went on suppressive valacyclovir at 1 mg daily. Two months ago I got very stressed when I inadvertantly exposed my partner to an outbreak. He did not contract herpes, but in the meantime when I was stressed I picked at the lesions. Now they are either slow to heal or scarred and we are trying to decide when to resume sexual activity.

There are 4 lesions, each of which started as a single raised red bump with no prodrome, blister, itching, pain, etc.   The 1st lesion arose on my right buttock 3 months ago and it is now a red spot flush with the adjacent skin.  The next 3 lesions developed two months ago. The smallest was on my left low back. I did not touch it, and it healed completely within a couple weeks. There are two lesions at the top of my gluteal cleft. The smaller of these which I picked at has resolved over the last couple weeks. The larger of these is still an asymmetrically raised red bump, which has gotten only slightly less red in the last month. I am still taking 1 g valacyclovir.

Questions:
When is a lesion a scar vs just slow to heal? If not based on the appearance of the lesion, is there a time frame I can use?

How long should we wait to resume protected vaginal intercourse? Unprotected oral sex? My partner touching my vulvar/vaginal area with his hand?

For a variety of reasons we have decided to assume the risk of unprotected vaginal intercourse as long as I am on suppressive valcyclovir and we abstain during outbreaks. At what point would the lesions/scars not be an issue in deciding to return to that practice?

Does transmission only occur between a lesion or area of asymptomatic shedding and a mucous membrane and non intact skin?  That ma

Can suppressive therapy change the nature of an outbreak, making lesions more difficult to detect?

I would prefer to wait to have sexual activity for as long as necessary to be as safe as possible.

Thank you!




Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
13 months ago
When is a lesion a scar vs just slow to heal? If not based on the appearance of the lesion, is there a time frame I can use?

Lesions that come up on the buttocks do tend to scar and take longer to heal.  I think after two months this should not still be a concern for transmission from an active sore.

How long should we wait to resume protected vaginal intercourse? Unprotected oral sex? My partner touching my vulvar/vaginal area with his hand?

Touching with his hand with intact skin is NOT a risk.  I think you can resume protected intercourse at this point.  I am assuming that he knows about your herpes and both of you know about asymptomatic viral shedding, right?  Unprotected oral sex involves some but minimal risk

For a variety of reasons we have decided to assume the risk of unprotected vaginal intercourse as long as I am on suppressive valcyclovir and we abstain during outbreaks. At what point would the lesions/scars not be an issue in deciding to return to that practice?

Well, that's impossible to say, honestly, but probably now would be as good as any time, given the duration since the beginning of the outbreak


Does transmission only occur between a lesion or area of asymptomatic shedding and a mucous membrane and non intact skin? 

Yes

Can suppressive therapy change the nature of an outbreak, making lesions more difficult to detect?

Yes, but the point is not as much outbreak as shedding of the virus

I would prefer to wait to have sexual activity for as long as necessary to be as safe as possible.

But I think you've waited long enough, at least, given your description.  No outbreak lasts two months

Terri


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13 months ago
Hi Terri,  

Thank you!!!

Could you clarify one thing. I did not get your answer, "Yes, but the point is not as much outbreak as shedding of the virus,".  Everything else I understood. 

Regarding asymptomatic shedding, is it more likely to occur in areas where one typically has an outbreak or are the areas of shedding more random? Also, when one is having an outbreak, is one more likely to be shedding virus elsewhere?  In otherwords if I have an outbreak on my buttocks, am I more likely to be shedding elsewhere such as vaginally?  (I am sometimes tempted to put a bandaid on my typical out break area on my buttocks like a reverse condom.)

Do nonlatex condoms prevent transmission as well as latex?  I'm allergic to latex.

Finally, what is the rate of female to male unprotected vaginal transmission of HSV2 on suppressive valacyclovir (while abstaining during outbreaks)?  Or if not known is there some range?

FYI, Yes, my boyfriend does know I have herpes.  I have had it for almost 30 years and typically have had very mild infrequent outbreaks in a couple of locations when stressed and just treated them at the first hint if one. That is why this outbreak was odd especially since I wasn't stressed, it was in a new location for me, had no prodrome, and I was taking suppressive therapy...perhaps it was something other than an outbreak, but the location at the top of the gluteal cleft seemed good for it to be an outbreak. 

Anyway, yes, my boyfriend knows.  Despite my questions I am usually very careful. I have never transmitted the virus to anyone.
Knock on wood.

You may find it interesting that when I first contracted herpes in the early 90s, I  wrote in to ASHA's publication, the Helper, and my story was "published".  I wrote about how after initially being quite distressed about contracting herpes, that I hoped herpes might actually make my sexual relationships better in the long run because I would be forced to be comfortable enough with my potential partner to tell them about herpes, and any partner would have to care about me enough to assume the risk if contracting it.  Also I would have to care enough about my partner and the relationship to make the risk of spreading herpes worthwhile... I would have to be ready, not just my partner.  Fast forward to today... while my sexual relationships may not have been as spontaneous as they otherwise might have been, I think having herpes has helped me get into very fulfilling long term relationships with partners who really care about me.  I can't say I like having herpes, but there have probably been some advantages. My current boyfriend is certainly a keeper!!!  

Thanks for all you do for us!
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
13 months ago
Could you clarify one thing. I did not get your answer, "Yes, but the point is not as much outbreak as shedding of the virus,".  Everything else I understood.

We used to prescribe herpes medicine based on the number of outbreaks per year, for example - some clinicians required (and some still do) a certain number of outbreaks in a year to place patients on suppression.  But now we know it's not really about the frequency of outbreaks because people give off virus at times when there are no outbreaks or symptoms at all.  That's what I meant.

Regarding asymptomatic shedding, is it more likely to occur in areas where one typically has an outbreak or are the areas of shedding more random? Also, when one is having an outbreak, is one more likely to be shedding virus elsewhere?  In otherwords if I have an outbreak on my buttocks, am I more likely to be shedding elsewhere such as vaginally?  (I am sometimes tempted to put a bandaid on my typical out break area on my buttocks like a reverse condom.)

When one is having a buttocks outbreak, they are frequently shedding from the genital tract as well, yes.  The BandAid solution is not really viable to prevent transmission (at least not alone, without meds or condoms)

Do nonlatex condoms prevent transmission as well as latex?  I'm allergic to latex.

There are condoms made of other materials - animal skin condoms are not quite as great as latex but polypropolene condoms are very effective.  They do make a little noise and generate some heat but that might not be all bad!

Finally, what is the rate of female to male unprotected vaginal transmission of HSV2 on suppressive valacyclovir (while abstaining during outbreaks)?  Or if not known is there some range?

Having sex twice a week, while on suppression, the transmission rate is about 2% per year.

Terri


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13 months ago
And the transmission rate with condoms and valacyclovir suppression?

And again, thank you.
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
13 months ago
from females to males, the transmission rate of HSV 2 with condom use and suppression is about 1-2% per year having sex twice per week.   These are averages.  I hope this is helpful for you.

Terri
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