[Question #7712] STI or DERMATOLOGICAL or PSYCHOSOMATIC?

54 months ago

Like many visitors at askexpertsnow - I had a visit with a high-risk individual - an asian massage worker. We had brief genital contact. A condom was used thereafter. I performed oral sex on her + some vaginal intercourse. She performed some manual stimulation on me. One week after this encounter (mid Nov 2020) I experienced a burning in the corner of my lips and what I perceive as an explosion of fordyce like spots. No herpes lesions formed but my upper lip did swell and pus. I have been tested for all stis. some both orally and genitally(gon/chlam/hiv). That also includes a hsv swab and hsv igg tests at 4 weeks 8 weeks and 14 weeks. Negative. So I feel that I am hsv free. (let it be so!)

My question becomes:

1. Why might my face - around my mouth - still feel inflamed 4 months later? - particularly when my beard gets longer. the hairs get dry/brittle and feel like stabbing the skin. might the skin and/or follicles be infected?

2. Same with my scrotum?. it has been red and increasingly more distracting/aggravated ever since.

3. Thoughts on the following I have tried with little effect: 2weeks:hydrocortisone 2% and nystatin for yeast. 5days : ketoconazole fungal dermatitis. 2days:metronidazole topical antibiotic. Lotrimin regular use on scrotum.

4. Might it just be a bacteria thing? Perioral dermatitis has been presented to me. I have had regular yellow spit each morning, yellowing teeth, imo beard yellowing as well.

5. Is an oral antibiotic a good next step?

6 Are there any stis besides herpes that might present with these symptoms?

7. I took a few 1g valtrex tabs around week 5. I can’t imagine that would throw off the igg test at week 14?

8. If this is all in my head – or to help alleviate the anxiety - what antidepressants might you recommend?

9. Or might some form of hypnotherapy be useful? (regular psychotherapy is ongoing!)

H. Hunter Handsfield, MD

54 months ago

Welcome to the forum. Thanks for reading ahead to see other discussions about questions similar to your own.

The first thing is to clarify that initial episode. From all you say, initial herpes seems possible or even likely, despite the negative tests. Was the swab test for HSV culture or PCR done during the first few days, when you had "fordyce like spots" that later developed into "swelling and pus"? A negative test after healing had started doesn't mean very much. And the timing certainly is right for an initial HSV infection. Did you kiss the massage worker? If it was herpes, it likely was HSV1, and about one third of people with HSV1 do not develop positive HSV1 IgG antibody tests. (That said, you can be sure it wasn't HSV2, which almost always gives a positive blood test by the times you were tested.) More comments about herpes after I address your numbered questions.

1. Any time there is an injury of any kind, discomfort may persist long after healing is complete. Just think about the sprained ankle that may still ache several months after the sprain has healed. No different for skin inflammation, etc. The continuing discomfort doesn't say anything about the initial cause of the problem.

2. No STI (including herpes) causes the sort of scrotum discomfort or redness you imply. These are extremely common symptoms in all men. Jock itch always is a possibility, but other kinds of dermatitis are possible. This often can be anxiety related. (I'm not a believer in anxiety creating symptoms out of the blue. But it certainly can make trivial symptoms or even normal body sensations more apparent and bothersome.)

3. Lack of improvement with these treatments tends to support the anxiety relationship I just mentioned.

4,5. Neither your mouth nor scrotal symptoms suggest a bacterial infection at the present time. I can't exclude the possibility that your initial oral symptoms were due to bacteria like streptococcus or staphylococcus, although I think these are unlikely. Certainly not for your current symptoms. Therefore, no antibiotic is likely to help.

6. No other STIs would cause such symptoms.

7. Just "a few" doses of valacyclovir probably would not alter the reliability of the HSV IgG tests, although prolonged treatment can have that effect. More below when I return to the herpes issue.

8,9. I'm not a mental health expert, and on this forum we don't practice medical care and therefore do not recommend any specific treatments, even for STIs. I hadn't focused on this question when I commented above about anxiety, but your question reinforces my suspicion that's the main problem. Whenever someone suggests his or her own symptoms have a psychological or emotional basis, usually s/he is right. I have zero experience with hypnosis therapy and can't say anything about it. But if the problem continues and/or you remain concerned about it, professional counseling might be something to consider. (Although I would suggest you start with a primary care provider, then follow his or her advice if s/he agrees there is a psychological component.)

Back to herpes: Given my suspicion about the original event, and your valacyclovir treatment, it would make sense to have another HSV IgG antibody test, to reconfirm the negative results, in particular for HSV1. (Be sure the lab does not do an IgM test. The HSV IgM antibody tests are notoriously unreliable and should not be done in this situation.) Also, if you ever develop another episode of blisters or sores on or near your mouth (or anywhere on your face), get seen within a couple of days for an HSV swab test for culture or, preferably, PCR testing. Finally, if another IgG test remains negative for HSV1, you could consider an HSV western blot test -- the conclusive tie-breaker blood test for HSV antibody.

On the other hand, all this may be optional. As discussed above, a continuing active HSV infection does not explain your symptoms. The large majority of people with oral herpes have few if any problems with it and infrequently transmit to others. You would need to be alert to fresh outbreaks and avoid kissing or performing oral sex on anyone at those times, but that's about all.

I hope these comments are helpful. I look forward to hearing more about the initial event, or if any of this isn't clear.

HHH, MD

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53 months ago

Hello Dr. Handsfield,

I appreciate your reply.

To answer your questions about the initial episode. No I did not kiss the woman. A PCR swab was used on my lips and base of penis.

H. Hunter Handsfield, MD

53 months ago

Thanks for the clarifications. They make herpes quite a bit less likely. Having exposed your mouth only to your partner's genitals, if you had herpes, HSV2 is far more likely than HSV1 (which would have been likely with mouth-mouth exposure, i.e. kissing). HSV2 would have produced a positive antibody test, usually by 8 weeks and always by 14 weeks. (For HSV1, 30% of infected people remain antibody negative.) The neagative PCR tests also make herpes unlikely.

So it's clear you don't have HSV2. There's still a slight possibility of HSV1 -- the risk of that virus from cunnilingus is very low, but not zero. And conceivably you could have acuqired HSV1 from another, nonsexual exposure of some sort at about the same time as the sexual event described. In the event of a new outbreak (overt blisters, open sores), a repat PCR swab test coudl be done. But based on all you have said so far, it is unlikely you have herpes, either oral or genital. And no other STD causes the sorts of symptoms you have had.

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