Herpes Simplex Virus Infections

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Herpes simplex virus (HSV) type I most commonly occurs on the face. Initial infection occurs during childhood or adolescence and varies in its presentation. Many individuals experience mild symptoms while a few experience a debilitating eruption. Recurrences tend to be mild and occur primarily on the lips, in the nose, and in the oral cavity.

The typical lesions of HSV are painful, grouped vesicles with an erythematous base. The primary eruption may be preceded by constitutional symptoms. The characteristic primary eruption is a gingivostomatitis with herpetic lesions on the lips and in the oral cavity. It may persist for weeks. The differential diagnosis includes erythema multiforme, Coxsackie virus, varicella zoster virus, idiopathic aphthae, and, rarely, Behcget's disease and pemphigus vulgaris.

Recurrent HSV is typically seen as herpes labialis ("fever blisters" or "cold sores"). The individual often experiences a prodrome of localized tingling or burning several hours before the onset of the eruption. The herpetic lesion usually occurs along the lip margin and completely heals within 10 days. Ultraviolet light, fever, or local trauma can induce these eruptions.

The diagnosis is established in the same manner as that for herpes zoster with a positive Tzanck preparation and viral culture.

Treatment for primary HSV gingivostomatitis includes symptomatic treatment, as mentioned previously for herpes zoster infections, including compresses and topical antibiotics. If mild, oral antiviral medications are not necessary; in more severe cases, use acyclovir (200 mg po five times per day for 5 days). Immunocompromised patients with severe involvement require hospitalization for intravenous acyclovir. Treatment can continue for up to 10 days if lesions have not crusted. Recurrent HSV does not require oral antiviral therapy. Patients with recurrent disease should be instructed to avoid triggers, especially the sun, by using sunscreen and a lip balm with ultraviolet light protection.

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