Consultant: Volume 45 - Issue 3 - March 2005

Herpes Simplex


Sonia Arunabh, MD, Naveen Verma, MD, and Robert P. Blereau, MD


These painful eczematous lesions at the angle of the mouth and the base of the nostrils had been present in a 52-year-old woman for 3 days (A).
Some of the vesicles had ulcerated and left a crust over the region. The patient said she had had similar attacks in the past. The diagnosis of recurrent herpes simplex virus 1 (HSV-1) infection was made. The patient was treated with acyclovir for 1 week, and all the lesions disappeared.

The painful vesicles of HSV-1 infection appear most commonly on the lip and rarely on other regions of the face, as in this patient. It is frequently difficult to distinguish primary HSV infection from a recurrent attack, because the presentation can be similar. Unless the history suggests otherwise, assume that an HSV infection is primary and treat the patient accordingly. In a second atypical case, numerous small pustules with surrounding erythema 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. The thumb lesions had developed 2 days earlier as clear vesicles and became pustular 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 times daily, 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.)