This image displays grouped lesions typical of sacral herpes simplex. Though the lesions of herpes are typically described as fluid-filled, grouped, red elevations of the skin, this is not always the case. As displayed in this image, there may subtle or no fluid in herpes infections. This image displays the red slightly elevated lesions typical of sacral herpes simplex. Herpes virus-induced skin blisters tend to occur in crops. This image displays grouped herpes lesions on the thigh. This image displays a grouping of pus-filled blisters located at the lower back and the buttocks, a common location for recurring attacks of herpes.
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Sacral Herpes  Information for adults

Picture of Sacral Herpes: This image displays grouped lesions typical of sacral herpes simplex. Divider line
This image displays grouped lesions typical of sacral herpes simplex.
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Overview
Herpes simplex infection of the lower back and buttocks—also called sacral herpes simplex or genital herpes—is a common recurrent skin condition associated with infection by the herpes simplex virus (HSV). HSV infection usually appears as small blisters or sores around the mouth, nose, genitals, buttocks, and lower back, though infections can develop almost anywhere on the skin. Furthermore, these tender sores may come back periodically in the same sites.

Infections with the herpes simplex virus are very contagious and are spread by direct contact with the skin lesions. There are 2 types of HSV: Type 1 and Type 2. HSV Type 1 (HSV-1) infections usually occur around the mouth, lips, nose, or face, while HSV Type 2 (HSV-2) infections usually involve the genitals, lower back, or buttocks. However, HSV-1 can sometimes cause infections in the genitals or buttocks, while HSV-2 can occasionally cause infections around the mouth, lips, nose, or face.

Both types of herpes simplex virus produce 2 kinds of infections: primary and recurrent. Because it so contagious, HSV causes a primary infection in most people who are exposed to the virus. However, only about 20% of people who are infected with HSV actually develop visible blisters or sores. Appearing 2–12 days after a person's first exposure to HSV, the sores of a primary infection last about 1–3 weeks. These sores heal completely, rarely leaving a scar. Nevertheless, the virus remains in the body, hibernating in nerve cells.

Certain triggers can cause the hibernating (latent) virus to wake up, become active, and travel back to the skin. These recurrent herpes simplex virus infections may develop frequently (every few weeks), or they may never develop. Recurrent infections tend to be milder than primary infections and generally occur in the same location as the primary infection.

HSV-2 infections are transmitted sexually or from a mother's genital tract to her newborn baby. HSV-2 is often spread through direct skin-to-skin contact with active lesions on another person. However, people who have herpes simplex virus infections may be contagious even when they do not have any skin lesions, which is called asymptomatic shedding.

Because sacral HSV is not located in the groin area, people may not realize that they have a form of genital herpes. In fact, they may think that they have a recurrent skin condition such as shingles, a yeast infection, or an allergic reaction. However, sacral herpes is considered to be a form of genital herpes.
Who's At Risk
Herpes simplex virus infections occur in people of all races, of all ages, and of both sexes. However, the 2 groups most commonly infected with HSV-2 include newborns, who contract it from their infected mothers during birth, and sexually active teenagers and adults, who contract it from their sexual partners. Up to 1 in 5 Americans over the age of 12 may be infected with HSV-2.

Remember that only 20% of people who are infected with the herpes simplex virus actually develop visible blisters or sores. That means that approximately 80% of people with HSV infections have not been diagnosed and are unaware of their condition. Nevertheless, they can still transmit the infection to others.
Signs and Symptoms
The most common locations for sacral herpes simplex include:
  • Lower back
  • Right or left buttock
  • Both buttocks
In women, other locations for HSV-2 infections include:
  • External genitalia
  • Labia majora and minora
  • Vagina
  • Cervix
  • Around the anus
In men, other locations for HSV-2 infections include:
  • Head and shaft of penis
  • Scrotum
  • Thighs
  • Buttocks
  • Around the anus
Shortly after exposure to the virus, a newly infected person may develop fluid-filled blisters (vesicles) or pus-filled bumps (pustules), occurring singly or in a group. These vesicles and pustules are usually quite fragile, so many people never notice them but instead see tiny open sores (ulcers). These painful ulcers subsequently become scabbed over. The scabs eventually fall off, leaving a red area that fades. The primary outbreak typically lasts 1–3 weeks.

In mild cases of primary herpes simplex virus infection, an individual may develop 1 or 2 lesions or may notice no symptoms at all. The lymph nodes in the groin may or may not be swollen. In severe cases of primary HSV-2 infection, people may develop fever, headache, neck stiffness, sensitivity to bright lights, muscle pain, painful urination, and discharge from the vagina or urethra.

Repeat (recurrent) herpes simplex virus infections are often milder than the primary infection, though they look alike. However, some people never develop the symptoms of a primary HSV infection and may mistake a recurrent infection for a primary infection. A recurrent infection typically lasts 7–10 days. People who are prone to recurrent outbreaks tend to get them 3–4 times per year, though some may have 10 or more outbreaks per year.

Many people with recurrent sacral herpes infections report that the skin lesions are preceded by sensations of burning, itching, or tingling (prodrome). About 24 hours after the prodrome symptoms begin, the actual lesions appear as one or more small blisters or open sores, which eventually become scabbed over.

Triggers of recurrent HSV infections include:
  • Fever or illness
  • Sun exposure
  • Hormonal changes, such as those due to menstruation or pregnancy
  • Stress
  • Trauma, such as that caused by dental work or cuts from shaving
  • Surgery
  • Friction to the area, such as that caused by sexual intercourse or tight-fitting clothes
Self-Care Guidelines
Acetaminophen or ibuprofen may help reduce fever, muscle aches, and pain caused by the herpes virus sores. Applying cool compresses or ice packs may relieve some of the swelling and discomfort. Wear loose-fitting clothes that won't irritate your skin.

Because herpes simplex infections are very contagious, it is important to take the following steps to prevent spread (transmission) of the virus during the prodrome phase (burning, tingling, or itching) and active phase (presence of blisters or sores) of HSV-2 infections:
  • Avoid sharing towels and other personal care items.
  • Wash your hands with soap and water if you touch an active lesion.
  • Avoid sexual contact (including oral, vaginal, and anal sex) during both the prodrome phase and the active phase.
Unfortunately, the virus can still be transmitted even when someone does not have active lesions. Therefore, safe sex practices such as using a condom should be used between outbreaks, even if no sores are present on the lower back or buttocks.
When to Seek Medical Care
If you develop tender, painful sores on the lower back or buttocks, see a physician as soon as possible, since treatment is much more effective if started early.

Recurrent outbreaks rarely require immediate medical attention. However, because some people have milder forms of genital herpes, you should also see a doctor for any recurring rash on the lower back or buttocks, even if you think it is from bug bites, ingrown hairs, or any other condition.

If you have an underlying medical condition such as cancer or HIV, if you have undergone organ transplantation, or if you are pregnant, you are at higher risk for more serious complications. Seek medical advice as soon as possible, especially if you are at high risk for complications.
Treatments Your Physician May Prescribe
Most herpes simplex virus infections are easy for physicians to diagnose. On occasion, however, a swab from the infected skin may be sent to the laboratory for viral culture, which takes a few days to grow. Blood tests may also be performed.

Untreated herpes simplex virus infections will go away on their own, but medications can reduce the symptoms and shorten the duration of outbreaks. There is no cure for herpes simplex virus infection.

Treatment for primary herpes simplex virus infection includes the following oral antiviral medications:
  • Acyclovir pills
  • Valacyclovir pills
  • Famciclovir pills
These medications are usually taken for 7–14 days.

More severe primary herpes simplex virus infection may require additional medications:
  • Oral antibiotic pills if the areas are also infected with bacteria
  • Oral antifungal pills if the areas are also infected with yeast
  • Topical anesthetic cream, such as lidocaine ointment, to reduce pain
Treatment for recurrent herpes simplex virus infection includes the same oral antiviral medications:
  • Acyclovir pills
  • Valacyclovir pills
  • Famciclovir pills
People who experience early signs (prodromes) before recurrent infections may benefit from episodic treatment by starting to take medication after the onset of tingling and burning but before the appearance of blisters and sores.

Other people have recurrent infections that are frequent enough or severe enough to justify suppressive therapy, where medications are taken every day in order to decrease the frequency and severity of attacks.



References

Bolognia, Jean L., ed. Dermatology, pp.1235-1241. New York: Mosby, 2003.

Freedberg, Irwin M., ed. Fitzpatrick's Dermatology in General Medicine. 6th ed, pp.2059. New York: McGraw-Hill, 2003.
Last Updated: 22 Dec 2008