There’s a newly identified, atypical, but substantial subset of patients: Young children who have frequent episodes of herpes simplex virus (HSV) that may not affect mucosal tissue, often are multifocal, and may require suppressive therapy, according to a report published in Pediatric Dermatology.
“Most of our knowledge of the clinical manifestations of HSV infections in children derives from cases of common mucosal HSV that present to and are treated by primary care providers,” said Julia K. Gittler, MD, and her associates at New York University.
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These cases comprise primary herpetic gingivostomatitis or the well-known orolabial HSV. To characterize the more atypical presentations in the pediatric population, the investigators reviewed the charts of all 48 patients referred to their pediatric dermatology clinic in a 10-year period after receiving a diagnosis of HSV. Only 19% of these patients were older than 11 years of age, and more than 40% were younger than 2 years of age at presentation.
Dr. Gittler and her associates found a “substantial” subset of 19 patients (approximately 40% of the study sample) who had six or more outbreaks per year. Only four patients (8.3%) had one or fewer outbreaks per year. The mean frequency of outbreaks in their study population was seven per year. “Reported triggers for outbreaks included fever, viral infections, sun, cold, stress, vaccinations, and courses of oral corticosteroids for asthma flares,” the investigators said.
Given this high frequency of outbreaks, antiviral therapy was initiated in 16 patients (33%). The average age of this treatment initiation was only 6 years. “In the general population, only approximately 15%-40% of patients with serologic evidence of HSV-1 have recurrent HSV; most of these will have an average of 2 outbreaks per year, and only 5%-10% have more than 6 outbreaks per year,” the investigators wrote (Pediatr Dermatol. 2017. doi: 10.1111/pde.13190).
The majority of the study participants (29 patients) had no labial or mucosal involvement. Approximately 23% had cutaneous involvement of the cheek, “which may have been because the primary infection was acquired through the kiss of a caregiver,” they said. Other sites of cutaneous lesions that were frequent in this population but are considered atypical in general were the ear, forehead, chest, and knees.
Most commonly, the physical examination findings were vesicles or papulovesicles (52%), but crusting (33%), pustules (6%), and erosions (23%) also occurred.
Fully half of the study population had multifocal rather than unifocal presentations.
Atypical presentation of HSV is frequently misdiagnosed as impetigo or herpes zoster, according to reports in the literature. Fifteen (31%) patients in this study had a previous misdiagnosis of impetigo. “These less typical cutaneous presentations of HSV may evade accurate diagnosis and delay initiation of appropriate treatment,” Dr. Gittler and her associates noted.
No financial disclosures were provided for Dr. Gittler and her associates.