Snap Shot A 20-year-old college student presents to the student health clinic complaining of a painful rash on her cheek. She says that it has come and gone a few times before, and that she usually can feel it before a break out of the lesions. Introduction Herpes simplex is highly-transmissible viral infection of the skin Characterized by painful, recurrent vesicular eruptions of the mucocutaneous surfaces Caused by two major strains of the Herpes simplex virus (HSV) HSV-1 oral-labial form HSV-2 genital form Contraction/transmission occurs via direct contact with active lesions after which the virus resides in the dorsal root ganglia of local nerves intrahost viral spread occurs via epidermal cells causing them to fuse into "giant cells" Epidemiology usually occurs in sexually active adults if child has disease, must rule out sexual abuse Mechanism for recurrence is not totally understood, though immunosuppression has a role Symptomatic HSV for >1 month can be considered an AIDS-defining illness Presentation Symptoms primary eruptions are more severe and longer-lasting may be accompanied by painful lymphadenopathy fever malaise recurrent infections usually localized to tissues innervated by the involved nerve(s) Physical exam all infections present with grouped vesicles on an erythematous base HSV-1 typically presents in infancy, but affects adults as well with severe, widespread gingivostomatitis and oral erosions recurrence consists of the common "cold sore" can be triggered by sun and fever HSV-2 typically affects adults with bilateral, erosive vesicles on the genitals accompanied by edema and painful lymphadenopathy recurrence is usually unilateral characterized by cluster of blisters less painful than the initial infection Herpetic Whitlow cutaneous lesion on the hand that can be caused by HSV-1 or HSV-2 most commonly seen in health care workers who come in contact with oral secretions (respiratory therapists, dentists) Evaluation Diagnosis is based primarily on clinical observations and patient history Tzanck smear useful for presumptive diagnosis multinucleated giant cells acantholytic cells Culture or direct fluorecent anti-body staining required for definitive diagnosis necessary to distinguish betwen Varicella zoster and Herpes due to similar findings on Tzanck smear Differential Herpes or Varicella zoster virus (HZV, VZV), contact dermatitis (poison ivy), molluscum contagiosum, genital warts, pemphigoid disorders Treatment Medical Management acyclovir (oral or IV) indicated as mainstay of treatment both decreases frequency and severity of recurrences side effects may be nephrotoxic acyclovir ointment may be indicated as adjunct to first line therapy effective in reducing duration of viral shedding does not prevent recurrence acyclovir suppresive therapy indicated only in patients with >6 breakouts per year or with erythema multiforme acyclovir taken daily Prognosis, Prevention, and Complications Prognosis there is no cure for HSV, however, current treatments can reduce or prevent recurrence and transmission Prevention avoid direct contact with active "shedding" lesions on infected patients use barrier protection during sexual contact or intercourse Complications HSV can persist in AIDS patients, with antiviral resistance