For the vast majority of people genital herpes recurrences are far less severe than a primary outbreak. They are also quite different in character. First, since herpes is in the nerves of the patient, as the virus becomes more active and begins to travel down the nerve to the skin, a person may get symptoms that tell them an outbreak on the skin is about to appear. They may get leg pain, back pain, a tingling sensation, burning, or itching. They might notice less specific symptoms like increased urination, but symptoms like fever or muscle aches are much less common than with an initial outbreak. These symptoms collectively are known as a prodrome. It is very variable but patients begin to recognize their pattern, their unique prodrome.
The outbreaks themselves are much milder. They tend to occur on one side of the body, to cover a smaller area, and are less painful. Swelling of the lymph nodes is uncommon and all the symptoms resolve much more quickly, lasting just 3–5 days.
Because herpes lives in the sacral plexus, and nerves from that accumulation of nerves can reach out not just to the skin where the infection first started but to any area the nerves can go, recurrent outbreaks are not limited to the initial region it entered the body. They can occur on the buttocks, the thigh, or anywhere in the anal and genital regions. Recurrences in areas other than the genitals (e.g., thigh) have a similar pattern to those that occur on the genitals.
Also, while herpes tends to improve over time, people can get outbreaks at any point that their immune system is challenged. This can happen when another illness occurs, with cancer or cancer treatments, or with such simple changes as life stress due to divorce, moving, changing jobs, or death of a family member as examples. Excessive friction, sunburns, exhaustion, and poor sleep patterns can also deplete a person’s immune system. In fact, anything that makes you less healthy or is a challenge to the system can make an outbreak more likely to occur. Over time patients not only recognize their prodromes, but they also recognize the circumstances associated with an outbreak.
In terms of the frequency of recurrences, genital HSV-2 recurs far more often than genital HSV-1. In the first year after primary infection with genital HSV-2, patients average about 5 recurrences. That drops by approximately 2 outbreaks per year in the following year. In the first year after a genital HSV-1 infection, the recurrence rate is just 1.3 outbreaks/year. That drops to a mere .7 outbreaks/year in the second year.
Those statistics can be misleading, however. Some patients have no outbreaks and others can experience 9 or more outbreaks per year. It is incredibly variable.