Case #18 Discussion

Summary: These lesions are vesicular-ulcerated-erythematous lesions. Key Points   ~Acute onset of vesicles   ~History of previous lesions in same location involving keratinized mucosa   ~Lesions resolve in same amount of time each episode   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 and clinical appearance.    ~This case illustrates that recurrent herpes labialis can involve the skin around the lips.   ~The lesions on the fingers represent autoinoculation from the labial and paraoral lesions. Management: This is a severe case of recurrent herpes.  Treatment includes systemic acyclovir or similar medications and palliative care with an emphasis on maintaining hydration. Prophylactic acyclovir should be prescribed for use when the patient first experiences prodromal symptoms or events that usually lead to recurrences in the patient. Prophylactic acyclovir may also be prescribed for daily low-dosage intake if the patient continues to experience recurrences that are frequent and severe. Final Diagnosis: Recurrent herpes