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Dermatologic Manifestations of Herpes Simplex Workup

  • Author: Joseph S Eastern, MD; Chief Editor: William D James, MD  more...
Updated: Mar 07, 2016

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.[10]

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.

Contributor Information and Disclosures

Joseph S Eastern, MD Clinical Assistant Professor, Department of Internal Medicine, Section of Dermatology, University of Medicine and Dentistry of New Jersey; Clinical Assistant Professor, Seton Hall University School of Graduate Medical Education

Joseph S Eastern, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, International Society for Dermatologic Surgery, Medical Society of New Jersey

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD Herman Beerman 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, American Medical Association, American Society of Dermatopathology, Pennsylvania Academy of Dermatology

Disclosure: Received royalty from Lippincott Williams Wilkins for textbook editor.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

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 Academy of Dermatology

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Malcolm Schinstine, MD, PhD; Paul Krusinski, MD; Gisela Torres, MD; and Stephen K Tyring, MD, PhD, MBA, to the development and writing of this article.

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Characteristic cluster of vesicles on an erythematous base. Photo courtesy of Dr. John Reeves.
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