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| Medical Education Section |
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Diagnosis: Herpes simplex
Discussion:
The herpes virus family comprises a group of viruses that produce cutaneous eruptions in humans; usually the distribution of the lesions is characteristic of the infection. For example, herpes simplex occurs as an isolated cluster of vesicles on a red base. The lesions usually resolve within one to two weeks. Herpes simplex characteristically has what is known as a prodrome sequence where there is a cutaneous dysesthesia such as burning, itching, or pain that precedes the vesicular eruption by a few days. Herpes zoster is distributed in a dermatomal fashion as a reactivation of chickenpox virus. Varicella, the initial chickenpox outbreak, is usually generalized with the lesions in all different phases of resolution, with new blisters to crust. This eruption usually lasts approximately one week. Diagnosis by Tzanck’s preparation can be obtained; however, all three look the same under the microscope. The value of the Tzanck preparation is to confirm it is, indeed, a herpes viral infection. The diagnosis is usually determined by clinical presentation and distribution. Although cases of disseminated herpes simplex have been seen in immunocompromised patients, this is the exception rather than the rule.
Treatment
I prefer to treat all patients with herpes simplex. It is one of the few viral infections for which we have an excellent antiviral antibiotic available. Because the lesions can be unsightly and painful, and can lead to scarring and secondary Staph infection, medical treatment is indicated. If patients have fewer than six outbreaks per year, I treat them with a one-day course of Valtrex in the following manner: I have them take two 1000 mg tablets immediately or as close to the prodrome as possible, and then additional two 1000 mg tablets 12 hours later. This four-tablet regimen works exceptionally well and will cause resolution of the lesions in short order or prevent the development of a lesion if taken close to the prodrome. If patients have more than six outbreaks per year, then I put them on a prophylactic therapy of Valtrex 500 mg daily for one year. At the end of 1 year I have them resort to the single outbreak regimen and increase again for 1 year if they have more than 6 outbreaks. Herpes simplex is exacerbated by illness, ultraviolet radiation, and stress - hence the name cold sores or fever blisters. They tend to occur when patients are ill with a cold or fever, or commonly I see them returning when patients are exposed to high doses of ultraviolet radiation such as when spending a prolonged period of time in the sunlight, sunny vacation or skiing in the sun at high altitudes. Generally speaking, the frequency of outbreaks of herpes simplex decreases over time. In addition to Valtrex, Famvir tablets can also be used in a manner similar to the one described above with good results. For additional discussions and treatments on chickenpox and herpes zoster, please follow the links below.
In summary, patients that have recurrent cold sores that are treated with an oral antibiotic/antiviral are some of the most thankful patients that I have encountered in my practice. I see no reason why all patients should not be treated immediately and aggressively with oral Valtrex or Famvir medications.
In certain circumstances in patients with eczema or skin conditions that have epithelial disruption such as atopic eczema, Darier’s disease, or pemphigus, simplex can spread and present as a widespread vesicular eruption. This is known as eczema herpeticum. Although rare, our clinic encounters it several times per year, most commonly in patients with atopic eczema. Keep your eyes open, eczema herpeticum may show up in one of the future Crutchfield Dermatology ‘cases of the month’.
To read CME article on Herpes Simplex click here
Read comprehensive article on human herpes viruses
To view other "Crutchield Dermatology Clinical Cases of the Month" in our archives please click here
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