Definition
A.Herpes simplex virus (HSV)-1 viral infection of the cutaneous tissue manifests itself by vesicular lesions on the mucous membranes and skin. HSV-1 is most often associated with oral lesions (mouth, lips), and HSV-2 is associated with genital lesions. The virus appears in three stages:
1.Primary.
2.Latency.
3.Recurrent infections.
Incidence
A.HSV-1 is seen in patients of all ages and in equal numbers of males and females.
B.There are approximately 500,000 new cases of herpes diagnosed annually in the United States.
Pathogenesis
A.Viral infection can be transmitted from a vesicular lesion or fluid (saliva) containing the virus to the skin or mucosa of another person by direct contact, with an incubation period of 2 to 14 days. Trigeminal ganglia are the host of the oral virus. The virus can be reactivated, whereupon it travels along the affected nerve route and produces recurrent lesions. Common sites of infection are the lips, face, buccal mucosa, and throat.
Predisposing Factors
A.Immunocompromised patients.
B.Prior HSV infections.
C.Exposure to virus.
Common Complaints
A.Painful lips, gums, and oral mucosa.
Other Signs and Symptoms
A.Primary lesion: Fever, blisters on lips, malaise, and tender gums.
B.Recurrent episodes: Fever blisters with prodrome of itching, burning, and tingling sensation at site before vesicles appear.
Subjective Data
A.Ask questions regarding location, onset, and duration of lesions.
B.Elicit description of prodromal symptoms.
C.Ask the patient if systemic symptoms occur with vesicular outbreak.
D.Determine when the initial outbreak of lesions occurred (commonly seen in childhood).
E.Inquire whether the patient has been exposed to anyone with similar lesions.
F.If the lesion(s) is recurrent, ask the patient if stress, skin trauma, or sun exposure stimulates outbreak of fever blisters.
Physical Examination
A.Inspect: Inspect skin, note location, appearance, and stage of vesicles.
B.Palpate: Palpate lymph nodes for lymphadenopathy.
Diagnostic Tests
A.Viral cultures.
Differential Diagnoses
A.HSV-1.
B.Impetigo (appears as amber-colored vesicular lesions with crusting).
C.Stomatitis (appears as erythemic or erosion lesions in the mouth and lips).
D.Herpes zoster (causes vesicles that run along a single dermatome).
E.Stevens–Johnson syndrome (SJS).
F.Herpangina: Vesicles can be noted on the soft palate, tonsillar area, and uvula area, usually caused by the coxsackievirus.
Plan
A.General interventions:
1.Comfort measures. Ice may be used to reduce swelling as needed.
2.Vaseline or other lip ointments may be applied as needed and lip ointment with sun protection factor (SPF) 30 or greater when exposed to sunlight.
B.Patient teaching:
1.Educate the patient regarding the disease process of HSV-1.
2.Instruct patient to wash hands frequently.
3.Suggest proper care of lips to prevent drying and to reduce pain.
4.Educate regarding transmission of virus to others.
5.Teach patient to expect recurrences at variable times.
C.Pharmaceutical therapy: Precautions should be used when administering medication to patients who are immunocompromised and who have a history of renal insufficiency:
1.Lidocaine 2% as needed for comfort.
2.Diphenhydramine (Benadryl) elixir may be used to rinse mouth as needed.
3.Acetaminophen (Tylenol) as needed for pain.
4.Campho-Phenique application as needed.
5.Initial episode: Acyclovir 200 mg by mouth five times per day for 7 to 10 days or until resolved.
6.Recurrent episodes: Begin one of the following when prodrome begins or within 2 days of onset of lesions to get maximum effect:
a.Acyclovir 200 mg by mouth five times per day for 5 days.
b.Acyclovir 800 mg by mouth twice daily for 5 days.
7.Other alternative antivirals: Dosage depends on renal function:
a.Famciclovir (Famvir).
b.Valacyclovir (Valtrex).
8.Suppressive therapy is recommended for patients with frequent lesions that affect everyday life:
a.Acyclovir 200 mg by mouth two to five times per day.
b.Acyclovir 400 mg by mouth twice daily.
Follow-Up
A.None needed if resolved without complications.
Consultation/Referral
A.Refer the patient to a physician if treatment is unsuccessful or further complications arise.
Individual Considerations
A.Pregnancy: Educate regarding the diagnosis of HSV-1 and precautions to take to avoid transmission to the genital area. Limit the number of sexual contacts, use a latex condom during sexual activity, use water-based lubricants (avoid oil-based lubricants), and avoid spermicides to prevent transmission. Advise the patient that if a lesion in the genital area presents at any time, she is to notify her healthcare provider for testing.
B.Geriatrics:
1.Avoid first-generation anticholinergics because of risk of confusion, dry mouth, constipation, and other anti-cholinergic effects or toxicity.
2.HSV-1 has been implicated as a major component in Alzheimer’s disease for those that carry type 4 allele of the apolipoprotein E gene (APOE). Studies indicate that the virus remains latent in elderly brains and can be triggered by stress, immunosuppression, and infection. The cumulative damaging effects could further progress the disease and cognitive decline. Practitioners must look for any signs of HSV-1 outbreaks for those patients suffering with Alzheimer’s disease and quickly treat.