6-year-old with painful vesicle and prodromal discomfort (watch video)
Patient will present as → a 17-year-old female 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 itching and a tingling discomfort before a break out of the lesions. On physical exam, you observe clusters of small, tense vesicles on an erythematous base.
Herpes simplex virus (HSV) is an enveloped double-stranded DNA virus. It exists as two distinct subtypes, HSV-1 and HSV-2, and is responsible for a wide spectrum of illness ranging from fever blisters to genital ulcers and fatal encephalitis. It establishes lifelong latency and can lead to interval episodes of asymptomatic shedding and disease recurrence.
- HSV-1 infects 40–80% of the U.S population by young adulthood, and 60–85% by age 60.
- Infections “above the waist” are classically due to HSV-1, whereas HSV-2 most commonly causes genital infection. However, both serotypes can cause genital and/or mucocutaneous infection.
- Primary infection is characterized by fever, irritability, and severe pain/burning of the oral mucosa, with vesicular and ulcerative lesions on the lips, gingiva, and tongue.
- Pharyngitis is also common in older children and adolescents.
- Illness lasts for 2–3 weeks, with viral shedding continuing for several weeks.
Symptomatic treatment with antipyretics and analgesia is recommended. IV hydration is sometimes needed in cases of decreased oral intake
- First episode:
- Oral acyclovir 400 mg TID x 7-10 days (peds: 15 mg/kg/dose five times per day for 7–10 days; max 200 mg per dose) may decrease the duration of illness if started within 72 hours at the onset of symptoms.
- Valcyclovir 1 g BID or Famciclovir 250 mg TID x 7-10 days
- Recurrent episodes:
- Acyclovir 400 mg TID x 5 days
- Valacyclovir 1 g PO BID x 1 day x r days or Famciclovir 1 g PO BID x 1 day
- Suppressive therapy
- Acyclovir 400 TID
- Famciclovir 500 mg BID
- Valacyclovir 1 g BID
Highest rate of infection occurs in adolescent children.
Overall, the highest rate of infection occurs during the preschool years.
Lesions are usually painless vesicles that form on the tongue, palate, and gingival area.
It typically takes the form of painful vesicles and ulcerative erosions on the tongue, palate, gingiva, buccal mucosa, and lips. Edema, halitosis, and drooling may be present, and tender submandibular or cervical lymphadenopathy is not uncommon.
Topical acyclovir is the drug of choice.
Recurrent infections are less severe and shorter in duration.
Pain associated with lesions typically lasts 2 to 3 weeks.