Primary herpes simplex virus (HSV) infection can be severe, with patients complaining of burning and pain in involved areas, malaise, or low-grade fever. One or 2 days later, lesions appear. Recurrent HSV causes tingling, burning, or itching 1 day before the lesions appear. HSV can cause chronic erosions in patients who are immunosuppressed.

HSV type 1 (HSV-1) commonly infects nongenital skin, usually the face and most often the lips or mouth. Oral HSV presents as multiple shallow ulcerations in the mouth or grouped clear vesicles on the vermilion border of the lip. Impetiginization is common (Fig. 28-1).

HSV type 2 (HSV-2) usually infects anogenital skin. It appears as grouped vesicles or papules, 1 to 4 mm in diameter on a red base (Fig. 28-2). Usually, there are five to ten lesions in the group. There may be considerable edema. Most individuals with HSV-2 do not present with a primary infection, but with a “first recurrence.”

HSV may also infect by inoculation, causing herpetic whitlow on the fingers. This condition is seen most often in health care workers, particularly dentists, dental technicians, and anesthesiologists.