Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Herpes Simplex Type 1
HERPES SIMPLEX TYPE 1
A recurrent viral infection characterized by multiple small, grouped vesicles on an erythematous base on the skin or mucous membranes. A mild, self-limiting infection commonly known as cold sores, or fever blisters.
I. Etiology
A. Herpes simplex virus type 1 (HSV-1) in its recurrent form
B. The primary herpes simplex infection is often seen in children as acute herpetic gingivostomatitis (see Herpetic Gingivostomatitis, p. 317).
C. The virus remains latent in the sensory ganglia and can be activated by a number of triggering factors or excitants throughout life. Emotional stress, exposure to sun, drugs, menses, trauma, febrile illness, and systemic infections have been identified as factors responsible for activating the virus.
D. HSV-1 also causes 5% to 15% of initial episodes of genital herpes.
E. Herpes simplex virus 2 (HSV-2) can be etiologic agent if orogenitally contracted.
II. Incidence
A. Seen in all age groups; affects approximately 7% of the population
B. Incidence of herpes simplex lesions is related to susceptibility and exposure to triggering factors.
C. Approximately 50% of population have antibodies to HSV by age 4 years.
D. After primary infection, 20% to 45% of individuals will have recurrent episodes, but some develop effective immunity.
III. Incubation period: 2 to 12 days
IV. Communicability
A. At least as long as lesion is present
B. Recurrent herpes lesions shed virus for approximately 5 days after appearance of lesion. Asymptomatic shedding can occur as well.
C. Spread by close personal contact, usually to an area with a breech in skin barrier.
V. Subjective data
A. Burning or tingling sensation several hours prior to appearance of lesion
B. “Cold sore” on lip or sore anywhere on body
C. Generally, no systemic symptoms unless fever or infection is the triggering factor
D. Frequently a history of herpetic gingivostomatitis—the primary infection of HSV-1.
E. Frequently a history of a similar lesion following exposure to same triggering factor
F. Pertinent subjective data to obtain: Any symptoms of ocular involvement, such as photophobia, pain (herpetic keratitis), or inflammation of the eyelid (herpes simplex blepharitis)
VI. Objective data
A. Lesion progresses through the following stages; may be seen at any stage.
1. Collection of small transparent vesicles on an erythematous base
2. Vesicles become cloudy and purulent.
3. Vesicles are dry and become crusted: may crack and bleed. Base is edematous and erythematous.
B. Lesion generally found at the mucocutaneous junction of the lips or nose but may be found anywhere on the body; consistently at the same site with recurrent infections
C. Herpetic whitlow (inoculation in paronychial area) may be found on finger or thumb of child, particularly one who sucks a finger or thumb; characterized by sudden appearance of vesicles and intense local pain.
D. Regional, tender lymphadenopathy often present
E. Inspect entire body.
VII. Assessment
A. Diagnosis is usually made by characteristic appearance of lesion (grouped vesicles) and history of similar lesion or herpetic gingivostomatitis.
B. Differential diagnosis.
1. Impetigo: Lesions often similar. Presence of yellow or honeycolored crust on lesion is indicative of bacterial superinfection.
2. Traumatic lesion
VIII. Plan
A. Topical medications. Apply using finger cot.
1. Penciclovir (Denavir) 1% cream: Apply every 2 hours for 4 days.
a. Relieves pain and discomfort
b. Reduces healing time by 2 days
2. Tetracaine cream 1.8%, prn: Reduces healing time by 2 days
3. Idoxuridine ointment (Herplex): Apply to lesion hourly for 1 day, then qid until lesion is healed.
4. Blistex or petroleum jelly: Apply to lesion as often as desired to soothe and protect from cracking.
5. Bacitracin or Neosporin ointment: Apply to lesion qid for prevention or treatment of bacterial superinfection.
B. Zovirax ointment is not generally indicated for the treatment of simple, uncomplicated HSV infection in a non-immunocompromised host. It may help select out resistant strains. It can, however, be prescribed for particularly large or unsightly lesions or to speed the healing process in certain circumstances (e.g., for a bride, for a health care worker, or other such cases). If ordered:
1. Use as soon as lesion appears.
2. Apply, using finger cot or rubber glove, 3 to 6 times a day for 7 days.
C. Domeboro soaks to vesicular lesions:
1. One packet per pint of cool water
2. Apply as wet compress 20 minutes, tid
D. Do not perform incision and drainage (I&D) on a herpetic whitlow. Virus will be implanted in excised tissue.
E. Systemic treatment is not generally indicated. However, it will speed up recovery and decrease contagion.
1. Acyclovir 400 mg bid or
2. Valacyclovir 500 mg/d
IX. Education
A. Latent virus in sensory ganglia can be activated by stress, sun exposure, drugs, menses, trauma, fever, or infection.
B. Incubation period is 2 to 12 days.
C. Recurrences are common, and are usually at the same site.
1. Recurrent lesions are less painful than the original herpetic gingivostomatitis.
2. Recurrent lesions are preceded by a burning or tingling sensation, which may last for several hours.
D. Lesions may be spread by autoinoculation. In a young child, concurrent lesions may be found on fingers or thumb (particularly if child is a finger or thumb sucker). Lesions may also be spread to labia via autoinoculation.
E. Lesion does not leave a scar but may cause temporary depigmentation.
F. Lesion is self-limited, lasting 8 to 14 days.
G. Transmitted through direct contact with saliva
H. Communicable at least as long as lesion is present
I. Do not allow child near newborns, children with eczema or burns, or people on immunosuppressive therapy.
J. Prevention: There is no cure for recurrent herpes simplex, but many methods have been attempted to prevent or abort lesions. The most effective method is to avoid known triggering factors, if possible.
1. For lesions activated by sun exposure, liberal use of sunscreen (e.g., Sundown) has been effective for some people.
2. Application of ice to lesion may be of benefit in aborting the lesion if used as soon as tingling or burning sensation is felt.
3. Fluorinated corticosteroid creams used at the onset of tingling have been felt to be useful in diminishing the severity of the lesion by decreasing the inflammatory response. Such creams are contraindicated for use on the face, because they may cause telangiectasia.
4. Zovirax ointment is not indicated for the prevention of recurrent HSV.
K. Reschedule dental procedures because of risk of herpetic whitlow to dental personnel.
L. Healing is usually complete in 7–10 days without scarring.
M. Disqualify from sports, particularly wrestling, until lesions have crusted.
X. Complications
A. Secondary bacterial infection.
B. Eczema herpeticum in a child with atopic dermatitis: Characterized by irritability, high temperature (104F), and generalized lesions (crops of vesicles at site of eczematous skin lesions).
C. Erythema multiforme may occur in 3 to 4 days after a recurrence.
D. Herpetic paronychia: From auto-inoculation or in caretaker
XI. Consultation/referral
A. Neonates or infants
B. Suspicion of herpetic keratitis or herpes simplex blepharitis (photophobia, pain)
C. Children with atopic dermatitis
D. Newborns or children with atopic dermatitis, with burns, or those who are immunocompromised and exposed to herpes simplex