What Are Herpes Prodromal Symptoms?

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Genital and oral herpes infections are experienced very differently by different people. Some people never have an outbreak. Some people have one outbreak and then never have symptoms again. Then there are the approximately 20-40 percent of infected individuals who have herpes outbreaks on a regular or semi-regular basis. Many of those people will notice that they have tingling and other sensations that appear before each recurrence of their herpes.Those symptoms are referred to as herpes prodromal symptoms.

The prodromal period is the period between when symptoms start to appear but full symptoms haven't developed. Another way to think of it is that the prodromal period is an advanced warning sign that an outbreak is about to occur. Prodromal symptoms are symptoms of a disease that are not a full-on outbreak or attack. The term isn't solely used to refer to herpes infections. Other infections can have prodromal periods as well. For instance, a  measles outbreak is often preceded by a fever. Non-infectious conditions can also have prodromal periods. For example, migraines are sometimes preceded by prodromal symptoms. Prodromal migraine syndromes are not the well known migraine "aura", but symptoms that appear even before that. These can include irritability and sensitivity to light or sound. 

What Are Herpes Prodromal Symptoms?

The herpes prodromal period lasts anywhere from two to 24 hours. During that time, people may experience:

  • Pain
  • Tingling
  • Burning

All of these symptoms can either be local to the outbreak area, or in the broader area of the body where outbreaks occur. In addition to these more localized symptoms, some people also feel generally unwell during the prodromal period. For example, they may lose interest in eating.

They may also have a headache, a fever, or swollen lymph nodes.

After the prodromal period, people usually then undergo an outbreak. Over the next few hours or days, they'll develop the classic herpes lesions. Those lesions will then crust over and heal on their own, usually without any scarring. However, there are topical treatments that may reduce the discomfort of lesions and potentially speed healing.

The Prodromal Period and Herpes Treatment

Some people take daily medication for herpes as a form of suppressive therapy. The goal of suppressive therapy is to reduce the number of outbreaks they have as well as to reduce the risk of transmitting the virus to a partner. Other people use what is known as episodic therapy. They take their herpes medications as soon as their herpes prodromal symptoms start, or within 24 hours of the start of an outbreak. The goal is to have the brief episode of therapy either shorten the upcoming outbreak or decrease its likelihood.

Data suggests that the suppressive therapy approach may be more effective in preventing outbreaks. However, it is not always an option for people due to cost, lack of willingness to take a daily medication, concern about side effects, and other reasons.

For them, starting episodic herpes treatment during the prodromal period can sometimes help prevent outbreaks, or at least make them less severe. However, this type of therapy does not reduce the risk of transmitting herpes to a partner. Therefore, when compared to suppressive therapy, it is less likely to be recommended for people who have sexual partners who might be at risk of acquiring an infection.

How Common Are Herpes Prodromal Symptoms?

Not everyone with genital or oral herpes infections will have recurring outbreaks. In fact, most people will either never have a noticeable outbreak or only have a single noticeable outbreak.

Unfortunately, there is little to no data about how many people have herpes prodromal symptoms, either before an outbreak or instead of one. (For example, the outbreak might be interrupted by therapy and never occur.) It is, however, generally assumed that most people with outbreaks will have prodromal symptoms before then. In fact, it is the reliability of herpes prodromal symptoms preceding and predicting an outbreak that allows episodic therapy to work in the way described above.

Are People With Herpes Infectious During the Prodromal Period?

People with herpes can potentially transmit the disease to their partners whether or not they have noticeable symptoms of an outbreak. That absolutely includes during the herpes prodromal period. Several studies have looked at viral shedding during this period. In general, research has found that there isn't quite as much herpes virus present on the skin during the prodomal period as during the worst phases of an outbreak. Still, there is more virus present than when no symptoms are present. That said, up to half of individuals may shed herpes virus even once they are healed from an outbreak and showing no symptoms at all.

It's important to realize that most herpes infections are transmitted when the person with the virus does not have symptoms—neither during an outbreak nor during a prodromal period. That's why it's important for sexually active people with herpes infections to consistently practice safe sex and consider suppressive therapy. That's particularly true if someone with an infection is part of a discordant couple. Neither safe sex nor suppressive therapy is a guarantee of safety, but both can reduce a partner's risk.

A Word From Verywell

Prodromal symptoms usually appear before a herpes outbreak. However, they're not the only thing for which that's true. For many people, another thing that often shows up before a herpes outbreak is stress. Stress is well known to have negative effects on the immune system. People tend to get sicker when they're stressed. They may also be, as it turns out, somewhat more likely to have herpes outbreak.

If you're a person who gets frequent herpes outbreaks, it can sometimes to be helpful to see if they're correlated with stressful periods in your life. If so, you might want to look at reducing your stress as another way to reduce your outbreak frequency. Stress relief isn't a cure-all, by any means. However, combined with suppressive therapy, it can do some people a lot of good.

Sources:

Chi CC, Wang SH, Delamere FM, Wojnarowska F, Peters MC, Kanjirath PP. Interventions for prevention of herpes simplex labialis (cold sores on the lips). Cochrane Database Syst Rev. 2015 Aug 7;(8):CD010095. doi: 10.1002/14651858.CD010095.pub2.

Chida Y, Mao X. Does psychosocial stress predict symptomatic herpes simplex virus recurrence? A meta-analytic investigation on prospective studies. Brain Behav Immun. 2009 Oct;23(7):917-25. doi: 10.1016/j.bbi.2009.04.009.

Gilbert SC. Oral shedding of herpes simplex virus type 1 in immunocompetent persons. J Oral Pathol Med. 2006 Oct;35(9):548-53.

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