A 36-year-old woman comes to the physician complaining of recurrent vesicular lesions on her lips. The lesions always occur at the lip borders. Her pharynx and oral mucosa are not involved. The appearance of the lesions is preceded by tingling, burning, and discomfort in the area as well as mild malaise. She has approximately 1 to 2 episodes a year. The patient relates that these lesions are uncomfortable and result in an unprofessional appearance at work. She has no genital lesions and is in otherwise good health. There is no history of tobacco, alcohol, or illicit drug use. She is monogamous with her husband.
Physical examination is unremarkable.
Which of the following is the best next step in management of this patient?

Question

A 36-year-old woman comes to the physician complaining of recurrent vesicular lesions on her lips.  The lesions always occur at the lip borders.  Her pharynx and oral mucosa are not involved.  The appearance of the lesions is preceded by tingling, burning, and discomfort in the area as well as mild malaise.  She has approximately 1 to 2 episodes a year.  The patient relates that these lesions are uncomfortable and result in an unprofessional appearance at work.  She has no genital lesions and is in otherwise good health.  There is no history of tobacco, alcohol, or illicit drug use.  She is monogamous with her husband.
Physical examination is unremarkable.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient most likely has secondary herpes simplex type 1 (HSV-1), commonly referred to as herpes simplex labialis. The virus reactivates within the trigeminal sensory ganglion, resulting in recurrent painful vesicles that appear at the vermillion border of the lips. Secondary infection may present with prodromal symptoms (eg, pain, burning, tingling, or pruritus) near the reactivation site lasting about 5 days from onset to resolution of the lesion. In contrast, primary HSV-1 seen in children and young adults can cause significant pharyngitis and intraoral lesions. The treatment of HSV-1 infection depends on whether the infection is primary (which tends to be more severe and symptomatic) or secondary, the extent and severity of symptoms, and the frequency of recurrences. Treatment options for recurrent HSV-1 infections include symptomatic, episodic, or chronic suppressive treatment. Recurrent HSV-1 with minimal clinical symptoms can be treated with symptomatic therapy (eg, anesthetics or antiseptics) without the need for antiviral therapy. Recurrent HSV-1 with pain or discomfort usually requires oral antiviral therapy at prodromal symptom onset, as in this patient (Choice D). These agents prevent viral replication and are therefore most effective when administered early in the course. Treatment speeds up healing of lesions and shortens symptom duration and severity. (Choice A) Chronic suppressive therapy (daily acyclovir or valacyclovir) is recommended for patients with > 4 episodes a year, painful or disfiguring lesions without a prodrome, or HSV recurrences accompanied by complications such as recurrent aseptic meningitis. (Choice B) This patient does not have a history of genital ulcers and is in a monogamous relationship. Recurrent herpes simplex labialis is common in the immunocompetent general population and per se does not warrant testing for sexually transmitted diseases. (Choice E) Topical antiviral therapy (eg, acyclovir) may also improve recurrent lesions. However, it is not preferred over oral therapy due to modest clinical improvement and the need for frequent applications (5 times a day). Educational objective: Patients with symptomatic recurrent herpes labialis should be treated with oral antiviral therapy (acyclovir, famciclovir, or valacyclovir) at symptom onset (eg, pain, burning, tingling, or pruritus). Chronic suppressive therapy (daily acyclovir or valacyclovir) is recommended for patients with > 4 episodes a year, painful or disfiguring lesions without a prodrome, or herpes simplex virus recurrences with complications (eg, aseptic meningitis). __________ References: Treatment of common cutaneous herpes simplex virus infections. (http://www.ncbi.nlm.nih.gov/pubmed/10750877) Treatment and prevention of herpes labialis. (http://www.ncbi.nlm.nih.gov/pubmed/19074705) Nongenital herpes simplex virus. (http://www.ncbi.nlm.nih.gov/pubmed/21121552)

A 36-Year-Old Woman Comes to the Physician Complaining of Recurrent