If its not herpes then what is it

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We summarize in this article how to recognize genital herpes and why it’s important to talk to your doctor if you’re worried you may have it.

The most common symptom of herpes is skin lesions. These lesions can be confused with similar-looking lesions caused by a number of other conditions.

Using photographs to help you see what we’re saying, we describe herpes lesions and compare and contrast them with the lesions caused by these diseases:

• Syphilis
• Chancroid
• Lymphogranuloma venereum
• Human papilloma virus (HPV)
• Molluscum contagiosum
• Ingrown hair and pseudofolliculitis
• Folliculitis
• Jock itch
• Genital eczema
• Epstein–Barr virus
• Other rarer conditions

Youtube video on how to differentiate herpes from other skin conditions
Practical tips by expert STD doctor - Dr.Fuzayloff

Oops … Is that Herpes?

How to recognize genital herpes

Overview

Genital herpes is a very common sexually transmitted disease (STD). It is so common that many people, when they find any skin lesion around the genital areas, are likely to think that it is herpes. They are not entirely wrong to think that way. Genital herpes is the main cause of genital ulcers worldwide.1 And the condition is usually associated with a stigma that can itself cause anxiety and even depression2 and might influence the affected person’s decision to disclose the infection to others or seek care.3

A genital sore is not great news regardless of what is causing it. However, many other conditions causing genital sores have a prognosis different from that of herpes. Some can be worse, but others, unlike herpes,4 can be completely cured. That’s why we’re beginning this article with an explanation of how to recognize genital herpes and differentiate it from other genital skin lesions.

A sleeping virus

The herpes virus is known for staying “asleep” in the body for a long time without showing symptoms. This feature is called latency: once the virus infects a person, after an initial phase that does not necessarily manifest with symptoms, it remains hidden in the body for many years, reactivating every now and then.4 Its reactivation is usually triggered by weakness of the immune system, such as in times of sustained stress, accumulated fatigue, heavy physical activity, or fever, but may not have any apparent cause.5, 6

“….genital herpes skin lesion suddenly appears as multiple vesicles”

The reactivation of the virus rarely manifests with symptoms, so most people who have herpes don’t know it and most genital herpes transmission occurs in the absence of a visible skin lesion.

Herpes skin lesions

The most characteristic and most common symptom of genital herpes is skin lesions. They typically appear during periods when the virus is active, which corresponds to when the virus becomes highly infective through sex. When a person acquires herpes for the first time through sexual contact, after about two to four days of incubation, a genital herpes skin lesion suddenly appears as multiple vesicles (small sacs with a thin membrane and liquid inside) piled together and sitting on an inflamed base. These vesicles are commonly called herpes sores. They are a bit whiter or browner than the rest of the skin and are often delimited by a reddish ring from the inflammation. They resemble blisters and can progress into an ulcer, which is usually more painful. An ulcer is a break in the skin that usually takes time to heal. Lesions start to heal around 12 days after the sexual contact.8 The sites most frequently involved are, for women, the vagina, vulva, buttocks, anus, and thighs, and for men, the penis, scrotum, anus, buttocks, and thighs. Herpes skin lesions are expected to be fully healed after about 19 days.9

Image 1. Genital herpes in the vesicles phase on the upper image,10 and in the ulcer phase on the bottom image.11

General symptoms

The initial herpes infection is sometimes associated with general symptoms of fever, headache, malaise, and muscular aches. In addition, there is often a tender local lymphadenopathy (enlargement of lymph nodes) that manifests as a painful lump in the groin area. When the virus reactivates in an already infected person, these symptoms are milder or absent and the skin lesion, if it manifests, heals more quickly. However, the reactivation is often accompanied by prodromal symptoms (feelings that are experienced before the main symptoms), such as pain, tingling, and burning preceding the appearance of the skin lesion.5

It is not always Herpes

Youtube video that helps distinguishing the herpes infection
from other similar-looking skin conditions:

Practical tips by expert doctor (Dr.Fuzayloff) on our YouTube channel.

It is a sore but not a herpes

While genital ulceration is often associated with herpes, it can be the result of several other conditions, including but not limited to, other sexually transmitted diseases, inflammatory conditions, skin irritation, and allergic skin lesions. In addition to herpes, the main sexually transmitted diseases that present with a genital ulcer are primary syphilis and chancroid. In the United States, syphilis infection is more common than chancroid.

Syphilis

The skin lesion of primary syphilis usually develops about three weeks (up to 90 days) after contracting the disease through sexual contact. Initially, it appears as a dark red mark or spot, and it rapidly becomes ulcerated.

Unlike the genital herpes skin lesion, which presents with multiple vesicles, primary syphilis’s skin lesion is usually solitary. However, when grouped herpes vesicles progress, they might take look like a solitary ulcer and can resemble an ulcerated primary syphilis. However, a herpes ulcer is usually painful, while a primary syphilis skin lesion is typically painless. The lymphadenopathy of syphilis is also painless, unlike the lymphadenopathy associated with genital herpes, which is often painful.12

SimilarityDifferenceHerpes vs SyphilisBoth very prevalent in the United States. Both can present with multiple vesicles and get ulceratedHerpes usually presents with multiple fluid-filled vesicles that turn into ulcers over time. Herpes ulcers are shallow, small, and on a red base (that is, they are surrounded by red skin). They are painful and may occur with painful lymphadenopathy. Syphilis usually has a solitary sore. A syphilis ulcer is usually deeper and larger and is painless in itself with painless lymphadenopathy.

Image 2. Primary syphilis skin lesions that could be mistaken for genital herpes Joseph Engelman, MD; San Francisco Department of Health.13

Chancroid

Chancroid is less common in the United States. It is prevalent in Africa and Asia. Its skin lesion appears about five days after sexual contact as a painful and inflamed spot that turns into an ulceration in several days.

Sometimes the skin lesion is solitary, but often more ulcers are present. A chancroid ulcer is usually deeper and bleeds easily when touched. It sometimes releases a purulent (infected) liquid. After some days, a painful local lymphadenopathy presents.14

Chancroid particularly resembles genital herpes when the latter is in its ulcerated form.

SimilarityDifferenceHerpes vs. chancroidBoth very prevalent in the United States. Both can present with multiple vesicles and become ulcerated.Herpes starts as vesicles before it ulcerates. Its ulceration is superficial and sometimes appears as an elevation with a hole in the middle. Chancroid starts as an inflamed patch before it ulcerates. Its ulceration is deep and bleeds easily, and it can release a purulent liquid.

Image 3. Chancroid of the penis accompanied with its lymphadenopathy. Source: CDC/Dr. Pirozzi.15

Lymphogranuloma Venereum

Another sexually transmitted disease that presents with a genital ulcer resembling herpes is lymphogranuloma venereum, which is caused by the bacterium Chlamydia trachomatis. This disease is more common in tropical countries, but in the United States it tends to be particularly prevalent in men who have sex with men.

A genital skin lesion usually develops three days to three weeks after the sexual contact as a small vesicle that can ulcerate on its top and that heals after a few weeks. It is usually soft and painless.

The most characteristic sign of this disease is perhaps the painful lymphadenopathy that can progress to fistulas (a fistula is an abnormal canal that usually gets created by pus making its way out of where it formed).

SimilarityDifferenceHerpes vs. Lymphogranuloma VenereumBoth can present with an ulceration. In the United States, both are most prevalent in men who have sex with men.Herpes starts as vesicles that can be painful. It is possible to have a painful lymphadenopathy in herpes, but it is unlikely to progress to fistulas, and the main symptom is the skin lesion. Lymphogranuloma venereum starts as a button that may go unnoticed. The skin lesion is painless. Painful lymphadenopathy is the main symptom and can progress to fistulas.

Image 4. Lymphogranuloma Venereum’s lymphadenopathy16

Non-sexually transmissible diseases

Some other medical conditions that are not necessarily sexually transmitted can present with a skin lesion that patients sometimes confuse with a genital herpes. Epstein–Barr virus (EBV) in rare cases manifests with a painful genital ulceration that resembles common herpes. However, other manifestations would be more prominent in EBV infection, resembling the symptomatology of infectious mononucleosis with high fever and a swollen liver or spleen.17 Other rare conditions that can present with a herpes-like genital ulceration include Behcet disease, genital tuberculosis, amebiasis, and chancriform pyoderma.18

These conditions and the previously mentioned ones are challenging to diagnose even for doctors. Inspection of the skin lesions and history alone are usually not sufficient to accurately identify a genital ulcer. Laboratory testing is often necessary to confirm a diagnosis.7

When it is clearly not genital Herpes

Youtube video that helps distinguishing the herpes infection
from other similar-looking skin conditions:

Practical tips by expert doctor (Dr.Fuzayloff) on our YouTube channel.

The following are some conditions that cause skin imperfections around the genital area. They do not necessarily look like genital herpes or pose a diagnostic problem. However, they are common conditions and many patients ask if their skin lesions are related to herpes.

Human Papillomavirus (HPV)

HPV is a common sexually transmitted infection that can manifest with warts in different parts of the genital area. HPV warts typically are cauliflower shaped. However, there are about 100 types of HPV, and flat, spiky, and dome-shaped forms are also commonly seen. HPV warts are usually firm and, unlike herpes, very unlikely to ulcerate.19

SimilarityDifferenceHerpes vs. HPVSkin lesion may present as multiple buttons organized in a flower shape.Herpes vesicles (sacs full of liquid with thin membranes) have a fragile consistency and are likely to ulcerate. HPV lesions are firm and very unlikely to ulcerate.

Image 5. Genital HPV warts. Source

Molluscum contagiosum

Molluscum contagiosum is a highly infectious condition caused by a virus and commonly seen in HIV patients. It usually presents with a growth sort of skin lesion. The skin lesions, known as mollusca, can appear anywhere on the body. They are small and raised and usually have a characteristic pit in the center. They may become itchy or painful, but they are smooth and firm and do not look like an ulcer.20

SimilarityDifferenceHerpes vs. Molluscum contagiosumSmall buttons that can be found grouped. The dimpled aspect of mollusca can look like ulcerated herpes.Herpes lesions are fragile vesicles that ulcerate. They typically around the mouth and in the genital area. Molluscum contagiosum lesions are firm and smooth and only rarely ulcerate, and they are more likely to also be present on other body parts, such as the abdomen, legs, and arms.

Image 6. Molluscum contagiosum21

Ingrown hair and pseudofolliculitis

When the hair is not properly shaved on fragile skin, it can curl inside it, forming a bump, and can progress to pseudofolliculitis or even folliculitis.

The skin in the genital area is particularly fragile, and ingrown hair can easily occur there as a result of a nonoptimal shaving technique. The bump of ingrown hair is usually small and firm, but it can look like a blister, which makes it look like a herpes lesion. It can also be painful, but its pain does not resemble the distinctive burning pain of herpes. It also does not ulcerate, and if it pops open it usually heals very quickly, unlike herpes.

When there is recurrence of ingrown hair, inflammation can occur in that area and present as redness of the surface of the skin and a chronic recurrence of itchy buttons. The condition is commonly seen in the beard area, especially on the neck and under the chin where the skin is more fragile, but it can also be seen in the pubis and other areas.

Estimated probabilities of HPV transmission from the penis to the anus were significantly higher than were those from the anus to the penis.

The skin lesions of pseudofolliculitis are, like ingrown hair and contrary to herpes, unlikely to ulcerate. They follow the pattern of hair growth, and they have particularly more pruritis or pain a day or two after shaving.22

SimilarityDifferenceHerpes vs. ingrown hair and pseudofolliculitisLike herpes, ingrown hair can look like a blister, and pseudofolliculitis tends to be more symptomatic a day or two after shaving.Herpes has vesicles that ulcerate and a characteristic burning pain. Ingrown hair and pseudofolliculitis have small, firm lesions that do not ulcerate and mild tingling pain and itching.

Image 7. Ingrown hair (left) and pseudofolliculitis (right). Source : NHS

Folliculitis

A hair follicle can become infected and form an inflamed button, most commonly because of a superficial bacterial or fungal infection or the progression of ingrown hair toward the infection.

“ Herpes has vesicles that ulcerate”

Folliculitis appears as a pimple, usually with a hair topping it and reddish surroundings. A white coloration—a sign of pus—can sometimes be seen under the skin of the button. If the folliculitis is due to ingrown hair, the ingrown hair can also sometimes be seen under the button.23

The pimple of folliculitis does not ulcerate and heals quickly when it opens. The condition is benign and usually self-limiting.

SimilarityDifferenceHerpes vs. folliculitisFolliculitis’s pimples might look like ulcerated herpes when they open.Herpes has vesicles that ulcerate. It has no relationship to hair. Folliculitis presents as pimples that do not ulcerate. Either a hair will top each pimple or an ingrown hair will be seen underneath it.

Image 8. Folliculitis. Source: HC-UFPR Dermatology Service

Jock itch

Jock itch, or tinea cruris, is a common dermatologic condition, especially in men. It is caused by a fungus and classically results in a well-delimited red patch of skin formed by a pattern of rings. The patch usually forms in the groin and skin folds in the genital area but can spread to other parts of the body. The infection might cause itching and even a burning sensation but does not cause the distinctive ulceration of genital herpes.24

SimilarityDifferenceHerpes vs. Jock itchThe delimited red patch of jock itch might look like the inflamed background of herpes.Herpes has vesicles that ulcerate. Jock itch has no buttons or ulcerations.

Image 9. Jock itch on the inner thigh of a man25

Genital eczema

Eczema, or dermatitis, refers to a group of skin diseases that cause skin inflammation. They have an allergic and environmental causal mechanism and are not contagious.

The genital area can be particularly prone to eczema since its skin and fragile and easily irritated and because of moisture and friction from clothing. Various types of eczema could affect the genital area, and each has its own characteristics. However, all types of eczema cause skin redness and itching. The skin lesion is poorly defined, and itching is usually the predominant symptom. Swelling is also a common feature of eczema. Bumps that can scar are frequent, blisters are rarer, and ulceration similar to that of herpes is almost exceptional unless the lesions have been extensively scratched.26, 27

One type of eczema looks especially like herpes but has nothing to do with the herpes virus. It is called dermatitis herpetiformis. It is characterized by blisters filled with a clear fluid and is intensely itchy. It is related to celiac disease and gluten intolerance and its skin lesions can appear in multiple places on the body.28

SimilarityDifferenceHerpes vs. EczemaBoth can present with blisters.With herpes, lesions that look like blisters are frequent, very prone to ulceration, and cause a burning sensation. With eczema, blisters are rare, ulceration is exceptional, and itching is the primary symptom.

Image 10. Allergic Eczema. Source

Should I talk to a doctor about it?

Now that you have a broad idea of how to differentiate a genital herpes ulcer from other commonly encountered conditions, you should consult your doctor when you suspect genital herpes for the first time. The first episode of herpes can have more noticeable symptoms than recurrences later will and it will be less difficult to ensure that the prognosis is benign and rule out more harmful conditions.

Herpes is still a condition often associated with anxiety, fear, and shame. Your healthcare provider can talk to you about your feelings in that regard and give you support and guidance.

With any genital condition, it is important to have the correct diagnosis made by your doctor, who will use laboratory tests for confirmation to establish a proper management plan.

Youtube video on how to differentiate herpes from other skin conditions
Practical tips by expert STD doctor - Dr.Fuzayloff

References

1. Gupta R, Warren T, Wald A. Genital herpes. The Lancet. 2007;370(9605):2127-2137. doi:10.1016/S0140-6736(07)61908-4

2. Mindel A, Marks C. Psychological symptoms associated with genital herpes virus infections: epidemiology and approaches to management. CNS Drugs. 2005;19(4):303-312. doi:10.2165/00023210-200519040-00003

3. Fortenberry JD. The effects of stigma on genital herpes care-seeking behaviours. Herpes J IHMF. 2004;11(1):8-11.

4. Centers for Disease Control and Prevention. STD Facts - Genital Herpes.Published October 22, 2019. Accessed November 1, 2019.

5. Whitley RJ, Kimberlin DW, Roizman B. Herpes simplex viruses. Clin Infect Dis Off Publ Infect Dis Soc Am. 1998;26(3):541-553; quiz 554-555. doi:10.1086/514600

6. Freeman ML, Sheridan BS, Bonneau RH, Hendricks RL. Psychological Stress Compromises CD8+ T Cell Control of Latent Herpes Simplex Virus Type 1 Infections. Immunol Baltim Md 1950. 2007;179(1):322-328.

7. Mertz GJ, Coombs RW, Ashley R, et al. Transmission of genital herpes in couples with one symptomatic and one asymptomatic partner: a prospective study. J Infect Dis. 1988;157(6):1169-1177. doi:10.1093/infdis/157.6.1169

8. Kimberlin DW, Rouse DJ. Clinical practice. Genital herpes. N Engl J Med. 2004;350(19):1970-1977. doi:10.1056/NEJMcp023065

9. Corey L, Adams HG, Brown ZA, Holmes KK. Genital herpes simplex virus infections: clinical manifestations, course, and complications. Ann Intern Med. 1983;98(6):958-972. doi:10.7326/0003-4819-98-6-958

10. Merck Manuals. Image: Genital Herpes on the Penis. Merck Manuals Consumer Version. Published 2019. Accessed November 8, 2019.

11. Draeger E. Management of genital herpes: a guide for GPs. Prescriber. February 2014. Accessed November 8, 2019.

12. Lautenschlager S. Cutaneous manifestations of syphilis : recognition and management. Am J Clin Dermatol. 2006;7(5):291-304. doi:10.2165/00128071-200607050-00003

13. Klausner JD. The Great Imitator Revealed: Syphilis. Top Antivir Med. 2019;27(2):71-74.

14. Wolff K, Goldsmith L, Katz S, Gilchrest B, Paller AS, Leffell D. Fitzpatrick’s Dermatology in General Medicine. 7th Edition. 2008. Accessed November 4, 2019.

15. Buensalido JAL. Chancroid: Background, Pathophysiology, Epidemiology. October 2019. Accessed November 8, 2019

16. Latini A, Zaccarelli M, Paglia MG, et al. Inguinal and anorectal Lymphogranuloma Venereum: a case series from a sexually transmitted disease center in Rome, Italy. BMC Infect Dis. 2017;17. doi:10.1186/s12879-017-2484-8

17. Halvorsen JA, Brevig T, Aas T, Skar AG, Slevolden EM, Moi H. Genital ulcers as initial manifestation of Epstein-Barr virus infection: two new cases and a review of the literature. Acta Derm Venereol. 2006;86(5):439-442. doi:10.2340/00015555-0140

18. Laetsch Semadeni B, Lautenschlager S. Le diagnostic différentiel des ulcères génitaux. 1re partie. Forum Méd Suisse ‒ Swiss Med Forum. 2009;9(03). doi:10.4414/fms.2009.06724

19. Anic GM, Giuliano AR. Genital HPV infection and related lesions in men. Prev Med. 2011;53(Suppl 1):S36-S41. doi:10.1016/j.ypmed.2011.08.002

20. Centers for Disease Control and Prevention. Molluscum Contagiosum | Poxvirus | CDC. Published January 3, 2019

21. File:Molluscaklein.jpg. In: Wikipedia.

22. Ogunbiyi A. Pseudofolliculitis barbae; current treatment options. Clin Cosmet Investig Dermatol. 2019;12:241-247. doi:10.2147/CCID.S149250

23. Winters RD, Mitchell M. Folliculitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019.Accessed November 5, 2019

24. Degreef H. Clinical forms of dermatophytosis (ringworm infection). Mycopathologia. 2008;166(5-6):257-265. doi:10.1007/s11046-008-9101-8

25. Tinea cruris. In: Wikipedia. ; 2019.Accessed November 8, 2019

26. Williams HC. Atopic Dermatitis. N Engl J Med. 2005;352(22):2314-2324. doi:10.1056/NEJMcp042803

27. Nedorost ST. Generalized Dermatitis in Clinical Practice. 2012 edition. Dordrecht: Springer; 2012.

28. Katz SI, Hall III RP, Lawley TJ. Dermatitis Herpetiformis: The Skin and the Gut. Ann Intern Med. 1980;93(6):857. doi:10.7326/0003-4819-93-6-857

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