October 2005

This 12-year-old girl presented to the office with vesicular lesions of the right corner of the mouth. The lesions had been present for two days. She initially had some itching, but later complained of some aching in addition to pain. She has some moderate right anterior cervical lymphadenopathy. What do you think is the diagnosis?

Answer

This is recurrent herpes simplex. A herpes simplex virus (HSV), a double-stranded DNA virus in the herpesvirus group, causes the rash. The initial infection in children is often herpetic gingivostomatitis, usually with HSV type 1, with an incubation of two to 20 days following exposure. Most patients with herpetic gingivostomatitis are younger than 5.

Symptoms of the initial infection include high fever, painful erosions in the mouth (especially anteriorly), tender cervical and submandibular lymphadenopathy, drooling and decreased appetite. Following the initial infection, the virus lies dormant in the sensory ganglia and can be activated by triggers. Common triggers for recurrent herpes simplex lesions are fever, illness, stress, sunlight, local trauma and menses. A prodrome of redness, itching and/or burning is noted with subsequent development of grouped vesicles with an erythematous surrounds most often at the mucocutaneous junctions (ie, around the nose and mouth). The lesions progress to become erosions and/or can be crusted; some lesions are painful.

Transmission of HSV can occur from both symptomatic and asymptomatic individuals. Direct person-to-person contact transmits HSV, usually to an area with a breech in the skin barrier (eg, wrestlers with skin abrasions or children with eczema [this is termed eczema herpeticum]).

Diagnosis can be made in one of four ways: demonstration of multinucleated giant cells in a Tzanck smear from a lesion (seen from all viruses in the herpesvirus group; this is an insensitive method that infectious disease physicians do not recommend any longer); direct immunofluorescence antibody test using monoclonal antibodies on skin/ulcer scrapings; polymerase chain reaction to detect HSV DNA from skin lesions; or a positive culture for HSV from a vesicle (better results are noted from newer lesions).

Differential diagnoses of herpetic gingivostomatitis include herpangina, aphthous ulcers and hand-foot-mouth disease. Differential diagnoses for recurrent lesions include varicella zoster, contact dermatitis and cytomegalovirus.

The treatment of recurrent lesions of herpes labialis can be topical or systemic. Patients keep topical docosanol 10% cream or topical penciclovir 1% cream at home and use the medications at the initial sign of a prodrome. These topical medications applied five times daily within hours of onset decrease the viral shedding and decrease the time to heal when used in this manner (a half day less than placebo). These products are labeled for use in children 12 and older.

Oral acyclovir, famciclovir and valacylovir can be used episodically (prescribed and kept at home to begin course at the first prodromal sign) or can be prescribed as suppressive therapy given on a daily basis. Clinical trial results with product use within 12 to 24 hours of onset showed healing and pain reduction one to two days sooner than placebo, in addition to less viral shedding. Suppressive therapy with oral antivirals has shown a decrease in recurrences when compared with placebo use. Acyclovir is approved for use from the neonatal period. Famciclovir does not have established safety and efficacy in children and are labeled for children 18 and older.

For more information:

• Buccolo LS. Severe rash after dermatitis. J Fam Pract. 2004;53:613-615.
• Burkhart CG. Herpes acquisition and transmission. J Drugs Dermatol. 2005;4:378-383.
• Efstathiou S, Preston CM. Towards an understanding of the molecular basis of herpes simplex virus latency. Virus Res. 2005;111:108-119.
• Johnson R. Herpes gladiatorum and other skin diseases. Clin Sports Med. 2004;23:473-484.
• Sacks SL, Aoki FY, Martel AY, et al. Clinic-initiated, twice daily oral famciclovir for treatement of recurrent genital herpes: a randomized, double-blind, controlled trial. Clin Infect Dis. 2005;41:1097-1104.
• Sacks SL, Thisted RA, Jones TM, et al. Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: a multicenter, randomized, placebo-controlled trial. J Am Academ Dermatol. 2001;45:222-230.