eMedicine Specialties > Dermatology > Viral Infections

Herpes Simplex: Differential Diagnoses & Workup

Author: Gisela Torres, MD, Staff Physician, Department of Dermatology, University Hospitals of Cleveland; Senior Instructor in Dermatology, Case Western Reserve University
Coauthor(s): Malcolm Schinstine, MD, PhD, Staff Physician, Department of Pathology and Laboratory Medicine, Dartmouth College Hitchcock Medical Center; Paul Krusinski, MD, Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont; Stephen K Tyring, MD, PhD, MBA, Founder and Medical Director, Center for Clinical Studies, Clinical Professor, Departments of Dermatology, Microbiology, and Molecular Genetics, and Internal Medicine (Infectious Diseases), University of Texas Health Science Center at Houston
Contributor Information and Disclosures

Updated: Aug 25, 2009

Differential Diagnoses

Aphthous Stomatitis
Herpes Zoster
Chancroid
Syphilis
Chickenpox
Erythema Multiforme
Hand-Foot-and-Mouth Disease

Other Problems to Be Considered

Cytomegalovirus infections
Fixed drug eruption
Herpangina

Members of the Herpesviridae family, including varicella-zoster virus; Epstein-Barr virus; cytomegalovirus; and human herpesvirus types 6, 7, and 8, can cause similar eruptions.

Workup

Laboratory Studies

  • Detection and typing of herpes simplex virus (HSV) can be completed by obtaining a viral culture from skin vesicles. Early in the course of recurrent infection, 80-90% of viral cultures of untreated lesions are positive, but the false-negative rate increases after 48 hours of lesion onset.
  • HSV DNA detection is performed in specific instances by polymerase chain reaction (PCR).
  • The virus may be isolated from cerebrospinal fluid (CSF) (in newborns), stool, urine, throat, anogenital mucosa, nasopharynx, and conjunctivae. HSV-1 DNA has also been detected in tears and saliva.8
  • In the office, a Tzanck smear can be performed as a rapid test for the presence of multinucleated giant cells, though the findings are not specific for the type of herpes virus. A Tzanck smear is prepared by scraping the floor of the herpetic vesicle; samples may be stained with either a Wright stain or a Papanicolaou stain. Approximately 50% of the results are positive.
  • Direct fluorescent antibody testing may be used on air-dried smears, and approximately 75% of the results are positive.
  • Serologic assays to detect antibodies against HSV-1 and HSV-2 may be useful in identifying organ transplant recipients or pregnant women who may be at risk for HSV reactivation. Their use is also becoming more common for confirming infection and for testing of partners or those with asymptomatic infection.
    • Enzyme-linked immunosorbent assays (ELISAs) and several other HSV-1 and HSV-2 serologic assays that can detect antibodies against these viruses are available.
    • A rapid HSV-2 POCKit test is now commercially available and has a high sensitivity. Western blot assays are highly sensitive and specific, but they are only available for research purposes.
  • Immunoperoxidase techniques may be used to distinguish HSV-1 and HSV-2 antigens in formalin-fixed tissue samples.

Histologic Findings

Cells infected with HSV demonstrate ballooning and reticular epidermal degeneration; epidermal acantholysis and intraepidermal vesicles are common. Intranuclear inclusion bodies, steel-grey nuclei, multinucleate giant keratinocytes, and multilocular vesicles may also be present.

More on Herpes Simplex

Overview: Herpes Simplex
Differential Diagnoses & Workup: Herpes Simplex
Treatment & Medication: Herpes Simplex
Follow-up: Herpes Simplex
Multimedia: Herpes Simplex
References
Further Reading
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References

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Keywords

herpes simplex virus, HSV, herpes genitalis, genital herpes, herpes labialis, orolabial herpes, HSV-1, HSV type 1, herpes simplex virus type 1, HSV-2, HSV type 2, herpes simplex virus type 2, localized eczema herpeticum, disseminated eczema herpeticum, Kaposi's varicelliform eruption, Kaposi varicelliform eruption, herpes whitlow, herpes gladiatorum, disseminated HSV infection, neonatal HSV infection, herpetic sycosis

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Contributor Information and Disclosures

Author

Gisela Torres, MD, Staff Physician, Department of Dermatology, University Hospitals of Cleveland; Senior Instructor in Dermatology, Case Western Reserve University
Gisela Torres, MD is a member of the following medical societies: American Academy of Dermatology and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Malcolm Schinstine, MD, PhD, Staff Physician, Department of Pathology and Laboratory Medicine, Dartmouth College Hitchcock Medical Center
Malcolm Schinstine, MD, PhD is a member of the following medical societies: American Society for Clinical Pathology, College of American Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Paul Krusinski, MD, Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont
Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Stephen K Tyring, MD, PhD, MBA, Founder and Medical Director, Center for Clinical Studies, Clinical Professor, Departments of Dermatology, Microbiology, and Molecular Genetics, and Internal Medicine (Infectious Diseases), University of Texas Health Science Center at Houston
Disclosure: Nothing to disclose.

Medical Editor

Sungnack Lee, MD, Vice President of Medical Affairs, Professor, Department of Dermatology, Ajou University School of Medicine, Korea
Sungnack Lee, MD is a member of the following medical societies: American Dermatological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Rosalie Elenitsas, MD, Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System
Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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