Herpes Simplex

Clinical Cases

Case 1

  • 7-year-old previously healthy girl with 2 days’ history of erythema on the right oral commissure and right lower cutaneous lip
  • No fevers, chills, malaise
  • No preceding illnesses or trauma

Initial visit

  • Obtain viral DFA and culture for herpes simplex virus from cells or fluid of a fresh sore
  • Empiric treatment with acyclovir 400 mg p.o. t.i.d. x 7 days

1-week follow-up evaluation

  • Viral DFA and culture confirms type I herpes simplex
  • Lesion resolved
  • Acyclovir is discontinued
  • Patient is counseled to use sunscreen-containing lip balm, as sun exposure may trigger recurrences

Case 2

  • 4-year-old boy with prior history of atopic dermatitis with a 5-day history of yellow-colored crusting on face, trunk, arms (in areas of prior skin disease)
  • Low-grade fevers, also chills, malaise
  • Mother with recent history of “cold sore” on lips

Initial visit

  • Obtain skin culture for bacteria
  • Also obtain viral DFA and culture for herpes simplex virus
  • Empiric treatment with acyclovir 400 mg p.o. t.i.d. x 10 days and cephalexin 25 mg/kg/day divided b.i.d. x 10 days
  • Follow-up in 1 week

1-week follow-up evaluation

  • Viral DFA and culture confirm presence of type I herpes simples virus
  • Bacterial culture reveals Staphylococcus aureus, methicillin-sensitive
  • Lesions are much improved
  • Reinforce atopic dermatitis skin care; also counsel for avoiding contact with family members with herpetic lesions when skin is inflamed

Case 3

  • 33-year-old man with a 7-year history of painful, recurrent clustered blisters in the same location on his lower lip, occurring 1-2X year; current outbreak was preceded by a backpacking trip to Yosemite National Park; patient recalls a “burning sensation” in the affected area 6 hours prior to outbreak of blisters
  • Denies blisters elsewhere on the body
  • Previously in excellent health

Initial visit

  • Grouped pustular vesicles on an erythematous base with necrotic skin changes and ulceration on the left lateral, external aspect of his lower lip; no other lesions
  • Tzanck smear of blister fluid reveals presence of multinucleated giant cells
  • Viral DFA and culture for HSV obtained
  • Acyclovir 400 mg p.o. t.i.d. x 5 days
  • Follow-up in 1 week

Follow-up visit

  • Lesions resolving
  • HSV DFA is positive and viral culture reveals Type 1 HSV
  • Prescription for valacyclovir or acyclovir given as abortive therapy for future recurrences (dose valacyclovir 2 g p.o. b.i.d. x 1 day or acyclovir 200 mg 5x a day x 5-10 days)
  • Counseling on photoprotection with sunscreen lip ointment SPF30