1. HSV often presents as dysuria, and in women, this can lead both patient and physician to wrongly attribute symptoms to cystitis. Look for lesions in apparent cases of cystitis and you may be surprised how many HSV infections turn up. One major difference — cystitis increases the frequency of urination, while HSV often reduces the urge to urinate.

2. Lesions can be easy to miss. Check under the foreskin or the labial folds. Bear in mind the possibility that a single ulcer, whether painful or not, might just be syphilis.

3. Take a good sexual history. This is especially important in adolescents and young adults. If they deny sexual activity, it might mean they’re embarrassed — but it might actually be true, in which case consider Behçet’s disease as a possible cause of genital ulceration. This will usually also cause mouth ulcers.

4. Keep an eye out for non-genital symptoms. Eye and brain infections are the most serious complications. Neuralgia in the affected dermatome can be treated with systemic acyclovir as well as analgesics. Ulcers can appear in the anogenital region or the back of the leg, often with local neuralgia.

5. Diagnosis can often be made clinically. If the patient is in pain, there’s no need to wait for test results or even identifiable ulcers. Start them on five days of oral acyclovir. Topical antivirals don’t help, but topical lidocaine 5% can ease pain and even speed healing of ulcers.

6. Condoms do protect against herpes, but oral sex is a common route of transmission.

7. It’s always a good idea to type the virus. For one thing, patients with type 1 can be assured that many future contacts will already have antibodies. Also, typing helps predict recurrences, which are far more common in type 2. Testing and typing the partner can be helpful — knowing they both have the same type antibodies reduces worry about recurrences.

8. PCR assay works better than viral culture. If you’re taking a viral culture, wet the swab first in the culture medium, then rub the ulcer’s base.

9. It’s probably wise to avoid speculating on the origin of a newly diagnosed genital herpes infection. It’s much more helpful to note that most people who carry the virus don’t know it, and many have symptoms so minor as to go unnoticed. These asymptomatic carriers can pass on the virus years after contracting it themselves. Also, new first onset of symptoms doesn’t necessarily mean new infection. HSV can lie dormant for years before a first ulcer appears.

10. Patients can get discouraged by multiple recurrences in the first year. Reassure them that these usually slow or stop, even in type 2 HSV. Prophylactic acyclovir (400 mg bid) is a safe option. So is acyclovir 200 mg qid, famcyclovir 250 mg bid, or valacyclovir 500 mg qd. Try it for a year if symptoms are recurring every few months, then stop and see if symptoms return. There’s a good chance they won’t.