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Genital herpes comparison to folliculitis, balanitis, vaginal yeast infection, syphilis, chancroid, and LGV
In this article we will compare genital herpes to common skin conditions that affect the genital area: folliculitis, balanitis, vaginal yeast infection, syphilis, chancroid, and lymphogranuloma venerum (LGV).
In our comparisons, the most significant differentiating sign and symptoms will be noted.
Each comparison will have two parts:
1. History
- What caused the rash?
- How soon did the rash appear after exposure (the rash incubation period)?
- How are the rash and other symptoms changing over time?
2. Visual exam
- General rash appearance
- Location of the rash
- Presence of any discharge and its quality (color, amount, and consistency)
- Skin depth affected by the lesion
In medical practice, the diagnosis is 90% based on a visual exam and 10% based on the history of the rash. The history of the rash, including how it is evolving over time, plays a confirmatory role.
By Slava Fuzayloff | Published on June 22, 2023
PART 1
Folliculitis vs. herpes
History
What caused the rash?
Folliculitis is caused by irritation of the hair follicles and subsequent infection of them.
If there is a history of shaving or rubbing, folliculitis is possible.
Unlike folliculitis, a herpes lesion [1] Genital Herpes – CDC Detailed Fact Sheet https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm occurs after sexual activity when skin comes into contact with infected skin(even without a visible herpes sore) and transmission occurs. [4] Folliculitis https://www.mayoclinic.org/diseases-conditions/folliculitis/symptoms-causes/syc-20361634
How soon did the rash appear?
The incubation period is an important factor differentiating herpes [3] Genital herpes: Overview https://www.ncbi.nlm.nih.gov/books/NBK525769/ from folliculitis [4] Folliculitis https://www.mayoclinic.org/diseases-conditions/folliculitis/symptoms-causes/syc-20361634 . It is shorter for folliculitis.
Unlike with herpes, in which it generally takes 2–4 days [3] Genital herpes: Overview https://www.ncbi.nlm.nih.gov/books/NBK525769/ for skin symptoms to appear, folliculitis skin symptoms appear in a few hours or at most by the next day.
How are symptoms evolving over time?
What precedes the appearance of a herpes rash and how herpes lesions evolve over time differentiate herpes from folliculitis
[3, 4]
Genital herpes: Overview
https://www.ncbi.nlm.nih.gov/books/NBK525769/
Folliculitis
https://www.mayoclinic.org/diseases-conditions/folliculitis/symptoms-causes/syc-20361634
.
✓
A herpes rash is usually preceded by systemic symptoms that are flu-like, such as fever, chills, and fatigue, as well as “nerve pain.”
A folliculitis rash, on the other hand, does not have a prodrome period—that is, nothing precedes the rash’s appearance.
✓ A herpes rash goes through multiple stages (skin redness, blister, sore, crusted sore).
A folliculitis rash, however, appears suddenly and stays in one stage: bumps filled with pus called pustules.
✓ Herpes skin lesions are very painful all the time, and the pain worsens with irritation.
Folliculitis bumps are painful only if they’re touched.
✓ Herpes presents with localized groin lymph node enlargement on the side of the rash. Folliculitis does not present with enlarged lymph nodes unless a very large skin area is involved, and it is a very severe case.
✓ Herpes lesions last for 7 to 10 days, whereas a folliculitis rash usually heals within a few days.
A herpes rash heals without scarring since it affects only a superficial layer of skin. Folliculitis bumps might cause discoloration or even scarring after they heal.
These pictures show the differences between herpes and folliculitis sores.
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Contains sensitive content
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Herpes
Folliculitis
Visual exam
Where on the body do lesions appear?
Herpes lesions mostly appear on skin bordering the mucosa [2] Genital Herpes Symptoms, Pictures, and Treatment https://www.webmd.com/genital-herpes/ss/slideshow-genital-herpes (that is, thinner, moist skin).
Folliculitis lesions appear around hair follicles. (You may even notice hair coming out the lesions). They occur in the thicker skin of the thighs, pubic area, and buttocks.
How much skin is affected?
Folliculitis affects a larger skin area and usually is widespread, affecting both sides of the body (left and right) [5] Folliculitis https://my.clevelandclinic.org/health/diseases/17692-folliculitis .
A herpes rash is usually one-sided and affects a very limited skin area—one dermatome.
What do the lesions look like?
Folliculitis skin lesions are individual bumps on a red base separated by normal skin.
Herpes lesions are clustered and share a red base.
How are the lesions shaped?
Lesions caused by folliculitis have an almost perfectly round dome shape and are filled with pus (whiteheads).
Herpes lesions may have different shapes and are filled with clear or yellowish fluid.
How deeply does the rash penetrate the skin?
A herpes rash involves a very superficial area of the skin.
Folliculitis bumps affect deeper skin areas, as can be felt with a pinch test or seen visually as swelling or thicker skin.
What is discharge from the lesions like?
Herpes has minimal watery discharge for a short time (when a blister turns into a sore).
Folliculitis lesions have a thicker discharge for a longer time.
Herpes or Folliculitis-learn how to tell the difference. Expert STD doctor (SlavaFuzayloff) explains.
PART 2
Balanitis vs. herpes
History
What caused the rash?
Unlike herpes, which is infectious and transmitted by skin-to-skin contact, balanitis is caused by fungal overgrowth due to a combination of increased moisture production, the area being wet for a prolonged period, and poor hygiene. [6] Balanitis https://www.nhs.uk/conditions/balanitis/ It is very common in overweight, physically active, and uncircumcised people.
How soon did the rash appear?
The incubation period for both conditions is about the same, 1–3 days, so this is not a differentiating factor.
How are symptoms evolving over time?
This is a primary differentiating factor between herpes and balanitis.
✓ Herpes rash is preceded by prodrome symptoms (flu-like symptoms and skin tingling), unlike balanitis.
[1]
Genital Herpes – CDC Detailed Fact Sheet
https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm
The herpes rash is painful and goes through stages, from a red bump to a blister to a sore to a crusted sore, over a one-week period. Balanitis skin lesions begin with red skin that itches, and the red area becomes swollen and develops a white discharge as the itch intensifies.
✓ Unlike herpes, balanitis does not usually present with enlarged, painful groin lymph nodes.
The healing time for both conditions is about the same: 5 days for mild balanitis vs. 7 to 10 days for herpes.
These pictures show the differences between herpes and balanitis sores.
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Contains sensitive content
View Photos
Herpes
Balanitis
Visual exam
What do the lesions look like?
Herpes can present in different stages—as a blister, sore, or crusted sore. [2] Genital Herpes Symptoms, Pictures, and Treatment https://www.webmd.com/genital-herpes/ss/slideshow-genital-herpes
Balanitis rash presents as skin redness that might become swollen over time. Dark red pinpoint spots may be seen as the disease progresses. [8] Balanitis https://www.ncbi.nlm.nih.gov/books/NBK537143/
How much skin is affected?
Herpes lesions are usually clustered together and confined to one small area.
Balanitis rash is widespread, affecting the entire penile head area.
What is discharge from the lesions like?
Herpes has very minimal, watery discharge for a short time (when the roof of a blister comes off, forming a sore).
Balanitis discharge is significant and can be described as having the appearance of thick, white cottage cheese; it is present all the time, especially as the disease progresses. [7] Balanitis https://my.clevelandclinic.org/health/diseases/21186-balanitis
Herpes or Balanitis-learn how to tell the difference. Expert STD doctor (Slava Fuzayloff) explains
PART 3
Yeast infection vs. herpes
History
What caused the rash?
A vaginal yeast infection, unlike herpes, is not a sexually transmitted disease. It is caused [1] Genital Herpes – CDC Detailed Fact Sheet https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm by fungal (yeast) overgrowth due to a change in the normal vaginal pH. The most common causes are recent antibiotic intake, oral contraceptive or other hormonal medication use, pregnancy, diabetes, or even sexual activity or a high-carbohydrate diet.
How soon does the rash appear?
The incubation period is the same for yeast infection and genital herpes:1–3 days.
[1, 9]
Genital Herpes – CDC Detailed Fact Sheet
https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm
Yeast infection (vaginal)
https://www.mayoclinic.org/diseases-conditions/yeast-infection/symptoms-causes/syc-20378999
Therefore, this is not a differentiating factor.
How are symptoms evolving over time?
There is a significant difference in how these two conditions progress over time.
✓ Both conditions begin with a mild itch, but then symptoms progress differently.
With a yeast infection, the entire vulva and vaginal area become even itchier and red and swollen. Abundant white thick discharge (also known as “cottage cheese” discharge) is present most of the time.
[10]
Vaginal yeast infection
https://my.clevelandclinic.org/health/diseases/5019-vaginal-yeast-infection
With herpes, the initial itch progresses to painful skin lesions that go through multiple stages over a few days’ times: bumps, blisters, sores, and crusted sores. Herpes lesions, unlike yeast infections, are mostly one-sided clustered lesions with minimal swelling of the underlying skin.
✓ The prodrome period—the time before the symptoms described above appear—also differentiates these two conditions. With a yeast infection, nothing happens before the main symptoms. But with herpes, the lesions can be preceded by flu-like symptoms such as fever, chills, and fatigue and by tingling of the skin (“nerve pain”) on the side of the evolving skin lesion.
✓ Herpes, unlike yeast infection, presents with painful groin lymph nodes enlargement, usually on the side of the rash.
✓ Most yeast infections heal within 1–3 days. A herpes outbreak takes at least a week to heal.
These pictures show the differences between herpes and yeast infection.
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Contains sensitive content
View Photos
Herpes
Yeast Infection
Visual exam
What do the lesions look like?
Herpes-infected skin changes over time and can present as bumps, blisters, sores, or crusted sores. [3] Genital herpes: Overview https://www.ncbi.nlm.nih.gov/books/NBK525769/ Any of these will be clustered together on the same red base. Yeast infection, on the other hand, presents with redness and swelling of the vulva and vagina. If it is left untreated, sores might appear.
How much skin is affected?
Herpes lesions are usually confined to a smaller skin area and usually one sided.
Unlike it, yeast infection affects the entire area of the vulva and vagina.
What is discharge from the lesions like?
Discharge is an important differentiating factor between two conditions.
✓ Yeast infection discharge is very abundant, white, and thick. It presents most of the time and gets worse as the disease progress.
✓ Herpes discharge is very short lived, minimal, and watery consistency.
How to differentiate between herpes and vaginal yeast infection
PART 4
Herpes vs. syphilis
Syphilis has multiple stages. Here, we are comparing a primary syphilis sore to herpes.
History
What caused the rash?
The cause of the skin lesion is not a differentiating factor because both conditions are caused by infection that is transmitted by skin-to-skin contact.
How soon do symptoms appear?
Unlike herpes’s incubation period, which is very short (2–4 days on average), syphilis’s incubation period is much longer and can be from 10 to 90 days (the average is 3 weeks). [11] Syphilis – CDC Detailed Fact Sheet https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm
How are symptoms evolving over time?
A prodrome period, significant skin pain, and the fact that lesions change over time differentiate herpes from syphilis.
✓ Both conditions can present with sores. But the primary syphilis sore (chancre) is not preceded by any signs or symptoms, unlike a herpes skin flare-up, which is preceded by prodrome symptoms and “nerve pain.”
✓ Unlike herpes skin lesions, which change from one stage to another (bumps, blisters, and sores), syphilis lesions stay in one stage (ulcer) for a prolonged time (4–6 weeks).
✓ Herpes lesions, unlike syphilis, are very painful during all stages (bumps, blisters, and sores). The syphilis sore is painless and for that reason is often missed.
✓ Both conditions cause localized groin lymph nodes enlargement (lymphadenopathy). But with herpes, lymphadenopathy is painful; with syphilis, it is not.
✓ Syphilis sores take a long time to heal (6 weeks), unlike a herpes flare-up, which on average resolves in 7–10 days.
✓ Unlike herpes sores, which heal without scarring, syphilis sores commonly leave a scar. The scar formation depends on how deeply the lesion penetrated the skin.
These pictures show the differences between herpes and primary syphilis lesions.
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Contains sensitive content
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Herpes
Syphilis Infection
Visual exam
What do the lesions look like?
Usually, there are multiple herpes lesions clustered on the same red base. However, with syphilis, a patient will typically have only one syphilis sore. [12] Syphilis Images https://www.cdc.gov/std/syphilis/images.htm
How deeply do the lesions penetrate the skin?
Unlike herpes lesions, which don’t penetrate the entire skin thickness, a syphilis sore is deep and does penetrate the entire skin thickness. Due to this deeper skin involvement, a syphilis sore has firm, well-defined borders.
What is the discharge like?
A syphilis sore is dry, unlike a herpes lesion, which can have a discharge for a very short time.
PART 5
Herpes vs. chancroid
Chancroid is more common in Africa than in the United States.
History
What caused the rash?
People contract chancroid and herpes in the same way: infection is transmitted via skin-to-skin contact. Therefore, this is not a differentiating factor.
How soon do the symptoms appear?
It takes slightly longer for chancroid to appear.
The herpes incubation period is very short (2–4 days on average), while the chancroid incubation period is a bit longer, 5–7 days.
How are symptoms evolving over time?
There is a significant difference in how these conditions progress over time.
✓ Unlike a herpes skin flare-up, which is preceded by prodrome symptoms (flu-like symptoms such as fever and chills) and “nerve pain,” chancroid has no preceding signs and symptoms.
✓
Both conditions can present as a sore, but unlike herpes skin lesions, which transform to sores eventually (they start as a red skin patch that turns into bumps, blisters, and then sores), chancroid starts as a sore that over time gets bigger and deeper with significant discharge.
[1, 14]
Genital Herpes – CDC Detailed Fact Sheet
https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm
Chancroid
https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/sexually-transmitted-diseases/chancroid.html
✓ The skin lesions in both conditions are painful, but chancroid presents with significantly more painful and enlarged lymph nodes. The lymph nodes eventually become purulent (meaning they produce a lot of pus).
✓ The healing time for herpes is much shorter (1 week on average) compared to chancroid, which takes 8 weeks to heal.
✓ Unlike herpes, which heals without scarring, chancroid can form a scar if it is left untreated.
These pictures show the differences between herpes and chancroid.
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Contains sensitive content
View Photos
Herpes
Chancroid
Visual exam
What do the lesions look like?
Herpes present with multiple small sores (2–3 mm across) clustered on the same red base. [3] Genital herpes: Overview https://www.ncbi.nlm.nih.gov/books/NBK525769/ A chancroid sore is much larger (10–20 mm); it is formed from multiple sores. [15] Chancroid https://dermnetnz.org/topics/chancroid
How much skin penetration is involved?
Herpes, unlike chancroid, affects only very superficial skin layers. A chancroid sore is deep; it penetrates the entire thickness of the skin.
What is the discharge like?
Discharge is a very important differentiating factor between herpes and chancroid lesions. Herpes can have minimal discharge for a short time. On the other hand, a chancroid sore is very purulent—that is, it produces a lot of pus. It can bleed easily as well.
PART 6
Herpes vs. lymphogranuloma venerum
LGV is more common in tropical countries than in the United States. In the U.S., LGV mostly affects homosexuals, with the rectum being the most commonly affected area.
LGV is a disease of lymph nodes that begins with a sore. LGV has two stages: primary and secondary. [16] Lymphogranuloma venereum (LGV) https://www.nhsinform.scot/illnesses-and-conditions/sexual-and-reproductive/lymphogranuloma-venereum-lgv A few asymptomatic weeks pass between the first and second stages.
Primary LGV can present as a sore, so this is going to be the focus of our attention here.
History
What caused the rash?
Both conditions are infectious and transmitted via skin-to-skin contact. Therefore, this is not a differentiating factor.
How soon do the symptoms appear?
Unlike herpes, which has an incubation period that lasts 2–4 days on average, the primary LGV incubation period can be as long as 7–12 days. [17] Lymphogranuloma venereum (LGV) https://www.cdc.gov/std/treatment-guidelines/lgv.htm
How are symptoms evolving over time?
There is a significant difference in how these two conditions progress over time.
Both conditions can start with elevated bumps that turn into ulcers. After that, they evolve differently:
✓ Unlike a herpes skin flare-up, which is preceded by prodrome symptoms and “nerve pain,” LGV has no preceding signs and symptoms.
✓ Unlike herpes skin lesions, which go from one stage to another (bumps, blisters, sores, crusted sores), LGV sores stay in one stage (ulcer) for a prolonged period (a few months).
✓ Unlike with herpes, LGV symptoms (swollen, painful lymph nodes and discharge) appear only after the initial sore heals.
✓ Unlike herpes skin lesions, which are constantly painful, the initial skin sore with LGV does not hurt.
✓ Unlike herpes, which presents with painful groin lymph nodes enlargement, with the initial LGV sores there is no lymph nodes enlargement. The lymph nodes become enlarged and painful with LGV during the second stage, after the initial skin sore has healed. A few asymptomatic weeks pass between the first and second stages.
✓ Unlike herpes lesions, which take one week to heal, the healing time for the primary LGV lesion is a few days.
These pictures show the differences between herpes and lymphogranuloma venerum.
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Contains sensitive content
View Photos
Herpes
Lymphogranuloma Venerum
Visual exam
What do the lesions look like?
Unlike herpes sores, which are multiple and clustered [3] Genital herpes: Overview https://www.ncbi.nlm.nih.gov/books/NBK525769/ ,an LGV sore is usually singular.
What are the stages?
Herpes skin lesions go from one stage to several others, but an LGV lesion starts as a blister that rapidly turns into a small, soft, painless ulcer.
What is the discharge like?
Both herpes and primary LGV sores do not have any significant discharge. LGV will have significant discharge in the second stage, which occurs 2–6 weeks after the sore has healed.
