Painful perianal erosions
If a patient comes in complaining of perianal pain, look carefully for the erosions of herpes. You may mistake them for stretch fissures and you might also consider them a marker for perianal Crohn’s disease. However, sometimes genital herpes will solely present in this area. You need to perform a PCR test for herpes. Performing this test early in the presentation improves the chance of it being positive. If the patient has had several similar attacks that have completely resolved in between episodes, this helps to rule out other conditions. Recurrent attacks need prophylactic antivirals such as acyclovir. An acute attack benefits symptomatically from a lignocaine topical gel.