Herpes Simplex Infection of the Skin
See also articles Genital herpes Genital Herpes and Viral infections of the oral mucosa Viral Infections of the Oral Mucosa.
Essentials
- In addition to oral and genital mucosa, a Herpes simplex infection may also occur on the skin.
- The diagnosis is usually based on the clinical picture and recurrence of symptoms in the same place.
- A periocular herpes infection requires emergency consultation of an ophthalmologist.
- Antiviral medication can be used to alleviate the symptoms and shorten the duration of the disease but it will not eradicate the virus.
- Prophylactic medication can be used for frequently recurring herpes infections.
Aetiology
- Both Herpes simplex viruses (HSV-1 and HSV-2) cause skin infections. HSV-1 is more commonly involved in skin infections, HSV-2 in infections in the genital area.
- The primary HSV-1 infection is often asymptomatic or causes only few symptoms, and/or is not recognized as a herpes infection. HSV-2 infection usually occurs in adulthood.
- In some people, the primary infection may cause severe symptoms (e.g. gingivostomatitis, pharyngitis, genital herpes).
- Primary skin infections are also possible but rare.
- The virus remains latent in the nervous system and may be activated from time to time, often triggered by environmental factors.
Prevalence
- Herpes virus carriership is very common in the adult population: 40-50% and 15-20% for HSV-1 and HSV-2, respectively. Most carriers never have symptoms.
Symptoms
- The symptoms and the clinical picture are often typical, and the diagnosis is usually based on the clinical picture.
- Before the occurrence of skin lesions, there is usually pain, burning and tingling in the area involved.
- Patchy, clearly defined erythema can be seen at first and, later, groups of vesicles containing clear fluid.
- Individual vesicles may merge and become pustular or haemorrhagic.
- Groups of vesicles may occur on nearby skin areas. After their eruption, small polycyclic erosions usually remain on the surface of the skin.
- The disease usually continues for 1 to 2 weeks but it may last longer in some patients.
- The typical skin areas are the perioral area Viral Infections of the Oral Mucosa (pictures 1 2), face (picture 3), genital area Genital Herpes (pictures 4 5), buttocks, perianal area, hands and fingers (pictures 6 7) Ehttp://www.dynamed.com/condition/herpetic-whitlow#SKIN.
- Herpes on the skin usually represents reactivation of latent infection.
- Factors that may trigger reactivation include common cold, or flu, mechanical trauma, medical or dental procedures, injury, stress, UV exposure, sunburn, periods, secondary infection through fingers from, for instance, the lips or genital area (autoinoculation).
- Widespread infection (disseminated disease) can be seen in people with immune deficiency (e.g. HIV infection) and/or immunosuppressive medication (e.g. antirheumatic medication, cytotoxic drugs) Infections in Immunosuppressed and Cancer Patients.
- In patients with atopic eczema, the infection may be widespread particularly on the face (eczema herpeticum; picture 8). This does not represent immunodeficiency.
Differential diagnosis
- Differential diagnostic alternatives are presented in table T1.
Differential diagnosis
| Differential diagnosis | Clinical clues |
|---|
| Shingles (herpes zoster) Shingles (Herpes Zoster) | More severe symptoms, usually more severe pain, restricted to the area of a single dermatome, like a belt on one side of the midline (picture 9) |
| Impetigo (impetigo contagiosa) Impetigo and other Pyoderma | Usually no pain or smarting; patchy, clearly defined erythema covered with a honey-coloured crust, sometimes with thin, larger blisters on top of the erythema; tends to spread to other areas; some of the patient's contacts have the disease (picture 10). |
| Patchy eczemas, particularly nummular eczema Nummular Dermatitis (picture 11) and acute allergic contact dermatitis Allergic Contact Dermatitis (picture 12) | Itchy vesicles, scratch marks, tendency to spread; usually eczema in other areas, as well. |
| Ringworm (tinea) Dermatomycoses (picture 13) | There may be blisters on a single ringworm patch, particularly on the legs. Scaling usually occurs predominantly at the margins, and there is no pain involved. |
| Erythema fixum (fixed drug eruption) Hypersensitivity to Drugs | A reaction triggered by a drug and recurring in the same place on exposure; the erythema is usually darker or purplish; a single larger vesicle (picture 14). |
| Dyshidrotic eczema of the hands and soles of the feet, pompholyx | Very itchy vesicles containing clear fluid, usually on both hands or feet, between the fingers (picture 15) |
Workup
- In a typical case, no examinations are needed, the clinical picture providing sufficient information.
- The virus can be shown by nucleic acid detection or by culture Ehttp://www.dynamed.com/lab-monograph/herpes-simplex-virus-culture#SUSPECTED_GENITAL_HERPES_SIMPLEX.
- A culture specimen can best be taken by piercing a vesicle and rubbing the erosive surface with a cotton swab.
- Antibody tests may show carriership but not the time or site of infection. Antibody levels are generally not elevated in disease restricted to the skin (reactivation) but in primary infection they become slowly elevated. Determining antibody levels in herpes infections of the skin is of no use.
- Nucleic acid detection (in cerebrospinal fluid) Ehttp://www.dynamed.com/lab-monograph/herpes-simplex-virus-dna-assay#SUSPECTED_HERPES_SIMPLEX_ENCEPHALITIS and antibody detection, as necessary, are used to diagnose central nervous HSV infections and neonatal herpes.
- In unclear cases, or if no response can be obtained by empirical treatment, bacterial and/or fungal samples can be taken from the area of the lesions.
- Allergic contact dermatitis is diagnosed by epicutaneous tests.
- If the clinical picture is severe and response to treatment poor, the possibility of immunodeficiency should be kept in mind (e.g. HIV, haematological malignancies, other malignant diseases) Infections in Immunosuppressed and Cancer Patients.
Treatment
| Drug | Standard dose | Alternative dose | Comment |
|---|
| Aciclovir | 200 mg 5 times daily | | Affordable |
| Valaciclovir | 500 mg twice daily | Mild cases: two single 2 000-mg doses (4 × 500 mg) every 12 hours within 24 hours | More expensive, taken less frequently |
| Famciclovir | 2 ×125 mg 3 times daily | | Less commonly used, most expensive |
- Topical treatment
- There is no strong evidence of efficacy in herpes infections of the skin but in mild cases it may be sufficient.
- Antiviral drugs: aciclovir or penciclovir cream every 2 to 4 hours during the daytime in courses of 5 to 10 days
- In the blister phase, moist compresses drying the skin, for instance, for 15 minutes 2 to 3 times daily, followed by zinc paste or lotion
- In some patients, analgesics may be necessary.
Recurrent herpes infection
- Rarely recurring infections are treated with courses of antiviral medicines mentioned above. A prescription should be made out for the patient in advance so that the course can be started quickly when symptoms occur.
- Prophylactic medication for a period of, for instance, 6 to 12 months can be used for frequently recurring herpes infections (to reduce the frequency). The doses used for prophylactic treatment are given in table T3.
- Treatment should be considered individually depending on the degree of the patient's distress. As far as possible, each period of treatment should be followed by a pause, and the need for further prophylactic treatment considered.
- If the clinical picture is severe to begin with or the infection recurs during prophylactic treatment, higher initial doses are recommended, such as 500 mg valaciclovir twice daily.
- During prophylactic treatment, patients with immune deficiency, in particular, may develop resistance to antiviral drugs. Higher daily doses are therefore commonly recommended for such patients (e.g. 500 mg valaciclovir twice daily).
- Targeted short-term prophylactic treatment can be used in courses of 1 to 2 weeks, for example, during holiday trips, periods, etc.
Doses of prophylactic antiviral medication
| Drug | Standard dose | Lower dose, or an alternative dose during a quiescent phase |
|---|
| Aciclovir | 400 mg twice daily | 200 mg 3 times daily; 200 mg twice daily |
| Valaciclovir | 500 mg once daily | 250 mg twice daily (some patients have fewer recurrences if the dose is divided) |
| Famciclovir | 125 mg × 2 twice daily | |
References
- Ayoub HH, Chemaitelly H, Abu-Raddad LJ. Characterizing the transitioning epidemiology of herpes simplex virus type 1 in the USA: model-based predictions. BMC Med. 2019 Mar 11;17(1):57.[PubMed]
- Woestenberg PJ, Tjhie JH, de Melker HE et al. Herpes simplex virus type 1 and type 2 in the Netherlands: seroprevalence, risk factors and changes during a 12-year period. BMC Infect Dis 2016;(16):364. [PubMed]
- Bradley H, Markowitz LE, Gibson T et al. Seroprevalence of herpes simplex virus types 1 and 2--United States, 1999-2010. J Infect Dis 2014;209(3):325-33. [PubMed]
- Wollenberg A. Eczema herpeticum. Chem Immunol Allergy 2012;96():89-95. [PubMed]
- Chayavichitsilp P, Buckwalter JV, Krakowski AC et al. Herpes simplex. Pediatr Rev 2009;30(4):119-29; quiz 130. [PubMed]
- Cernik C, Gallina K, Brodell RT. The treatment of herpes simplex infections: an evidence-based review. Arch Intern Med 2008;168(11):1137-44. [PubMed]
- Gilbert SC. Management and prevention of recurrent herpes labialis in immunocompetent patients. Herpes 2007;14(3):56-61. [PubMed]