DISEASE
VIRUS · MECHANISM
CLINICAL PICTURE
CLUE · TREATMENT
Primary HSV-1 in children
Fever, painful oral vesicles and ulcers, drooling, poor feeding
Supportive ± acyclovir
HSV-1 reactivation (stress, UV, fever)
Tingling then grouped vesicles on the lip border
Valacyclovir early
HSV-1 in ophthalmic nerve
Painful red eye, photophobia, dendritic corneal ulcer on fluorescein
Avoid steroids · topical/oral antivirals
HSV-1 spreads to temporal lobes
Fever, confusion, personality change, aphasia, seizures; hemorrhagic necrosis
CSF lymphocytes + RBCs, PCR · MRI temporal lesions · IV acyclovir immediately
HSV-2 (increasingly HSV-1)
Painful grouped vesicles → ulcers, tender nodes, dysuria; recurrent milder
PCR of lesion · valacyclovir; suppressive therapy
Passage through canal with active lesions
Skin-eye-mouth, CNS or disseminated disease in first weeks
C-section if active lesions · IV acyclovir
HSV inoculated into finger
Painful vesicles on fingertip (healthcare workers, thumb-sucking children)
Don't incise
HSV on atopic skin
Punched-out erosions over eczema patches
Acyclovir
Primary VZV via respiratory droplets
Fever, itchy "dewdrop on a rose petal" vesicles starting on trunk, crops in different stages
Contagious until all crusted · adults: pneumonia · avoid aspirin (Reye)
VZV reactivation in sensory ganglion (age, immunosuppression)
Burning pain then vesicles in one dermatome, not crossing midline
Valacyclovir within 72 h · recombinant zoster vaccine ≥ 50
Zoster ophthalmicus · Ramsay Hunt
V1 dermatome · geniculate ganglion (CN VII)
Hutchinson sign (vesicles on nose tip) → eye involvement · facial palsy + ear vesicles
Urgent ophthalmology
Nerve damage after zoster
Pain persisting > 3 months
Gabapentin, TCAs, lidocaine patch
Maternal infection in early pregnancy
Limb hypoplasia, cicatricial skin scars, eye defects, CNS damage
VZIG for exposed non-immune pregnant women