Sacral Herpes: Genital Herpes (HSV-2) Presenting on the Buttock: By David Robles, MD, PhD

A young woman reported a history of an itchy, sometimes burning rash on her right buttock. The patient stated that the rash would start with some small blisters that would pop when she scratched them and clear fluid would leak out. The rash would crust over and resolve spontaneously in a couple of weeks. This would happen in the same location a few times a year. 

On physical examination, she had grouped, vesicles on an erythematous base. A viral culture revealed human herpesvirus infection (HSV) type 2. The patient was treated with Acyclovir 400mg three times daily for 7 days and noted complete resolution of her symptoms and physical findings. 

The patient underwent STI counseling and was offered STI screening. Herpes infection is contagious and patients with active lesions should avoid contact with immuno-compromised hosts or neonates. Condom use does offer some protection against HSV-1 infection.

HSV-1 is associated primarily with oral infections, whereas HSV-2 causes mainly genital infections; however, each type can infect any site. Following the primary infection, the virus enters the nerve endings in the skin below the lesions and travels to the dorsal root ganglia, where it remains in a latent stage until it is reactivated.

A Tzanck smear of  freshly unroofed vesicle reveals multinucleated epithelial giant cells.  Tzanck smears cannot differentiate HSV-1 from HSV-2.


Genital herpes (first episode)

Acyclovir: 200 mg po 5 ×/ d × 10 days or 400 mg po tid × 10 days Famciclovir: 250 mg po tid × 10 days Valacyclovir: 1 g po bid × 10 days.

Genital herpes (recurrence)

Acyclovir: 400 mg po tid × 5 days or 800 mg po bid × 5 days or 800 mg po tid × 2 days Famciclovir: 1 g po bid × 1 day or 500 mg po × 1 dose then 250 mg po bid × 2 days or 125 mg po bid × 5 days Valacyclovir: 500 mg po bid × 3 days or 1 g po qd x 5 days.

Chronic Suppression of Herpes Simplex

Patients with six recurrences of genital herpes a year can be treated with valacyclovir 1 g QD, acyclovir 400 mg BID, or famciclovir 250 mg BID for chronic suppression.

Daily suppressive therapy (together with consistent condom use and avoidance of sexual activity during recurrences) is recommended for individuals with genital herpes who have a seronegative partner.

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