4.1 Introduction
The viruses in the herpesvirus group include herpes simplex, varicella-zoster, Epstein Barr, and cytomegalovirus. This chapter addresses both herpes simplex and varicella-zoster viruses. Herpes simplex cutaneous lesions are caused by the herpes simplex virus. Herpes zoster and varicella are caused by the virus varicella-zoster.
4.2 Epidemiology
The lesions of cutaneous herpes simplex virus can occur at any age. Herpetic gingivostomatitis is more common in younger children. Reactivation of the lesions can occur following the initial simplex infection. Genital herpes lesions are generally more common in adolescents and adults than in young children. Herpes zoster is seen at any age, however, is more common in adolescents than young children and most common in adults. An association has been noted between herpes zoster and a diagnosis of asthma [1, 2].
4.3 Clinical Findings
Herpes simplex – Cutaneous lesions consist of grouped vesicular lesions with an erythematous surround. Lesions may be located anywhere, including mucous membranes. When the vesicles rupture, the ulcers are deep seated (occurring at the subepidermal level). Crusting can be noted (Fig. 4.1). Some vesicles may become pustular. There may be regional lymphadenopathy noted.
Reactivation of the lesions may be accompanied by a prodrome of burning, itching, or stinging.
Herpes zoster is characterized by lesions similar to those in Herpes Simplex; however, these lesions are arranged in a dermatomal pattern involving usually 1–3 dermatomes (Fig. 4.2). Pain, burning, or itching may occur prior to the onset of visible lesions. Occasionally, systemic viremia may be present.
Herpes simplex of the lips. Ulcers and crusting are noted
Herpes zoster of the right chest
4.4 Laboratory
Herpes simplex and herpes zoster lesions can be diagnosed by the clinical appearance. If confirmation is needed, the virus can be identified from a specimen retrieved from the base of an intact vesicle. The specimen can be submitted for PCR, fluorescent antibody, or culture (Herpes simplex virus grows more reliably than varicella-zoster virus). Both viruses are present in the respective lesions and can be contagious to susceptible individuals.
4.5 Treatment
Herpes simplex virus– Cutaneous lesions are acutely treated with analgesics and prevention of secondary bacterial infection. Recurrent lesions can be treated with topical docosonal or topical penciclovir (both used at home as soon as prodrome begins). If recurrent lesions are occurring more often than 4–6 weeks or are occurring in an immunosuppressed patient, consider systemic ant-viral treatment either episodically or on a suppressive basis.
Varicella-zoster lesions can be treated with analgesics and prevention of secondary bacterial infections. If the lesions continue to enlarge and spread even after several days or are occurring in an immunosuppressed patient, systemic anti-virals may be necessary. Post-herpetic neuralgia is less common in children than older adults; thus, systemic steroids are not prescribed as often as with older adults.
4.6 Prognosis
In immunocompetent individuals, recurrent herpes simplex lesions tend to be confined to a specific area. Recognizing triggers (e.g., fever, illness, menses, sun exposure) can be useful – triggers can sometimes be avoided to decrease frequency of recurrences. In immunocompromised individuals, the lesions can be widespread and cause systemic issues. In addition, any active lesions can be contagious to susceptible individuals.
In adolescents, herpes zoster can sometimes be a signal of an immune issue. Considering this, further work-up should be initiated as indicated. As mentioned above, post-herpetic neuralgia is less common in children and adolescents versus adults. Scarring may be noted (Fig. 4.3). Most typically herpes zoster occurs only once. In addition, any active lesions can be contagious to susceptible individuals.
Scarring following herpes zoster