All children with suspected genital herpes infection should be referred for specialist assessment and management.
Genital herpes is less common in childhood than in adulthood but can occur.
When assessing a child or young person with genital ulcers the diagnosis of herpes simplex should be considered, but not presumed.
Ulcers can occur as a manifestation of aphthosis in response to acute illness.102 The appearance of aphthous genital ulcers is also usually preceded by a history of fever, malaise and headache, but PCR testing, including HSV PCR, is negative.
Epstein-Barr virus and cytomegalovirus infections have also been reported to cause genital ulceration.
Any genital ulcers should, therefore, be swabbed before decisions are made about management.
Genital herpes infection may present in pre-adolescent children. When it does it is important to explore carefully in the history the aetiology of the herpes infection. Possible sources of transmission include an orolabial lesion or a herpetic whitlow in another family member and autoinoculation. For example, genital herpes in a child under one year of age may result from kissing ‘all over’ by a pre-school aged sibling with orolabial herpes.
If an obvious source of the infection cannot be identified, then sexual transmission should be considered. The diagnosis must be confirmed by HSV PCR testing with typing of the herpes virus. The presence of HSV-1 does not rule out sexual transmission, but a non-sexual route of transmission should be carefully sought, especially if there are no other pointers to suggest sexual abuse. The presence of HSV-2 in the genital area does not automatically imply sexual contact but does mean that sexual abuse, as a cause of the infection, must be seriously considered. In a recent local review of 2,162 children who had an examination in the context of allegations of sexual abuse, eight of the 1,909 children who underwent laboratory screening for sexually transmitted infections were positive for HSV and a sexual transmission was thought likely for six of these children.103
Because of these very difficult issues in diagnosis, all children with suspected genital herpes infection should be referred to a paediatrician for assessment and treatment. The paediatrician may, in turn, seek advice from a local Sexual Abuse Assessment and Treatment Service (SAATS) with special training in the area of recognition of child sexual abuse.
For the purposes of these guidelines, sexually active adolescents should be managed as adults. Adolescents who have never been sexually active should be managed as per the pre-adolescent children section above.
The above is based upon on internationally accepted standards of practice. Grade C
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The Guidelines are a consensus opinion of the STIEF Professional Advisory Group (PAG). The PAG has representation from nationwide medical, nursing and allied disciplines involved in the management of STIs. The Guidelines are produced by considering available literature, both New Zealand wide and international, and by basing the medical recommendations on the evidence in the literature or reasonable supposition and opinions of medical experts.