Herpes Simplex

These painful eczematous lesionsat the angle of the mouth and thebase of the nostrils had been presentin a 52-year-old woman for 3days (A). Some of the vesicles hadulcerated and left a crust over theregion. The patient said she had hadsimilar attacks in the past. The diagnosisof recurrent herpes simplexvirus 1 (HSV-1) infection was made.The patient was treated with acyclovirfor 1 week, and all the lesionsdisappeared.The painful vesicles of HSV-1infection appear most commonly onthe lip and rarely on other regionsof the face, as in this patient. It isfrequently difficult to distinguishprimary HSV infection from a recurrent attack, because the presentationcan be similar. Unless the history suggests otherwise, assume that an HSVinfection is primary and treat the patient accordingly.In a second atypical case, numerous small pustules with surroundingerythema were seen on the thumb of a 5-year-old girl, a thumb-sucker(B). She also had recurrent tiny ulcerations on one side of her tongue. Thethumb lesions had developed 2 days earlier as clear vesicles and becamepustular overnight. She now had a low-grade fever and decreased appetite.One lesion was deroofed with a fine scalpel and the fluid was cultured.The culture grew HSV-1. After treatment with mupirocin ointment, 3 timesdaily, the thumb lesions resolved rapidly.

(Case and photograph A courtesy of Sonia Arunabh, MD, and Naveen Verma, MD;case and photograph B courtesy of Robert P. Blereau, MD.)