Case #17 Discussion

Summary: This is a vesicular-ulcerated-erythematous lesion. Key points:   ~Acute onset of ulcers   ~History of previous ulcers in same location involving keratinized mucosa   ~Ulcers resolve in same amount of time each episode   ~Ulcers are multiple and grouped in a cluster. Based on the above key points, a diagnosis of recurrent herpes can be made. More discussion is given below. Lesions to Exclude from the Differential Diagnosis: Hereditary   ~Epidermolysis Bullosa       *Ulcers of the skin would be present       *Onset is typically at birth or in early childhood  *Ulcers are continuously forming and do not recur with complete healing in a consistent amount of time Mycotic and Bacterial Lesions   ~Mycotic (candidosis)       *Lesions are not primarily ulcers.       *Lesions do not heal in a predictable amount of time Autoimmune Disorders   ~Onset of ulcers is slower and not as abrupt   ~Ulcers are more persistent and progressive   ~Do not recur in the same location with complete healing in a consistent amount of time.   ~Usually occur bilaterally Idiopathic Lesions   ~Aphthous Ulcers       *Occur on non-keratinized mucosa   ~The remaining Idiopathic lesions can be excluded because they do not heal in a consistent period of time.  In addition:       *Erythema multiforme Ulcers are bilateral and generalized throughout oral cavity       *Erosive lichen planus             Ulcers have more gradual  onset             Lesions are bilateral       *Erythroplakia             Lesions do not occur as discrete ulcers which heal and recur Viral Lesions   ~Primary herpetic gingivostomatitis       *Ulcers bilateral and generalized throughout oral mucosa       *Tender cervical lymphadenopathy and sometimes systemic manifestations       *Does not recur as primary herpes   ~Varicella       *Skin papules, pustules, and itching rash are most prominent       *If oral ulcers are present, they are more generalized       *Varicella does not recur as varicella   ~Herpes Zoster (shingles)       *Lesions follow the distribution of a sensory nerve and extend to midline       *Typically do not recur multiple times   ~Herpangina       *Vesicles and ulcers are confined to posterior oral cavity Hand, foot, and mouth disease       *Skin lesions present         Lesions to Include in the Differential Diagnosis: Recurrent Herpes   ~Definitive diagnosis can be made on basis of history, location, and clinical appearance. Management: Educate the patient about the recurrent nature of herpes simplex virus. Antiviral drugs such as acyclovir are probably not helpful because lesions have been present for 5 days.  Since patient has had 5 recurrences it might be useful to write a prescription for systemic acyclovir and have patient begin medication during prodrome phase, if present. Final Diagnosis: Recurrent Herpes