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A teenaged boy awakened 2 days prior to presentation with a few skin lesions, which rapidly spread to the rest of his right eyelids (Figure 1). The rash caused a burning sensation; otherwise, he was feeling well. He was not taking any regular medication. His visual acuity was 20/20 OU. Examination revealed clusters of target lesions on the right upper and lower eyelids. There were papillae in the upper palpebral conjunctiva and follicles and a few pustules in the lower palpebral conjunctiva. The cornea was unremarkable with no staining, and results of a dilated ophthalmoscopy examination were normal. Ocular movements were full, and there was no proptosis. A few solitary lesions were found scattered on his nose and right cheek; however, his body was not affected. He had a tender right submandibular lymphadenopathy but was apyrexial.
A healthy teenaged boy presented with multiple target lesions and erythema on his right eyelids.
Prescribe oral flucloxacillin
Prescribe oral aciclovir
Prescribe oral cimetidine
Human herpesvirus 1, or Herpes simplex virus type 1 infection (HHV-1)
C. Prescribe oral aciclovir
This teenaged boy presented with periocular target lesions. The abrupt eruption suggested a hypersensitivity reaction.1 An infection was likely the cause, given the prodromal symptoms and submandibular lymphadenopathy with conjunctivitis. Herpes simplex virus is the most commonly identified etiology, accounting for more than half of adult patients.2 In children, Mycoplasma pneumonia and fungal infection are more frequent.3 The lesions on this patient were not waxy papules or umbilicated, which would have suggested Molluscum contagiosum virus.
Early treatment with aciclovir has been demonstrated to lessen and reduce the duration of skin lesions.4 The patient took 200 mg of oral aciclovir 5 times daily and guttae chloramphenicol 4 times daily for a week. A week later, the lesions had scabbed over (Figure 2) and the conjunctivitis had resolved. The eye was quiet, and there was no corneal involvement. The scabs started to shed in the second week. He felt well, and the lymphadenopathy had resolved.
Scabs formed in place of the previous target lesions, and the conjunctival papillae and follicles resolved 9 days after the lesions first erupted.
After using polymerase chain reaction, we detected HHV-1 from swabs of the lesions. The result of the bacterial swab was normal, as were the results of the blood tests.
The eyelid lesions caused by HHV-1 are consistent with a delayed-type hypersensitivity reaction.2 The herpetic DNA fragments are transported to the skin sites by peripheral blood mononuclear cells and expressed on keratinocytes. This leads to the recruitment of HHV-1–specific CD4+ helper T cells, which respond to the viral antigens by producing interferon-γ. The latter upregulates cytokines and chemokines that amplify an acute cutaneous inflammatory cascade.2
Primary HHV-1 infection usually presents in the unilateral facial area supplied by the maxillary division of the trigeminal nerve.5 The findings for this patient of greater upper papillary and lower follicular reactions on the palpebral conjunctivae also corresponded with a published report.6 It is important to check for corneal involvement; as many as 17% of patients with HHV-1 can be affected.6
Herpes simplex virus remains latent within the trigeminal ganglion after its initial infection, and one of the main issues is that a quarter of patients can have a recurrence after the primary disease, of which up to 50% occur within 2 years.7 Topical aciclovir applied to the skin lesions does not appear to prevent herpes-associated multiforme lesions.8 However, 400 mg of acyclovir twice daily has been shown to be effective in the reduction of recurrent disease.9 Other options include 500 mg to 1 g of valaciclovir per day or 125 to 250 mg of famciclovir per day, which offer greater oral bioavailability than aciclovir and can be used in patients who do not respond to aciclovir.10 The antiviral dose may be tapered once the patient is free of recurrence for 4 months and eventually stopped.
In summary, HHV-1 eyelid infections can present with various lesion types and severity, such as in this otherwise healthy teenaged boy. Early antiviral treatment should be commenced to reduce the duration of the cutaneous disease.
After a week, the conjunctival follicles settled and the target lesions began to scab over. These lesions completely resolved at 1 month.
Corresponding Author: Patrick J. Chiam, FRCOphth, Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham B18 7QH, England (email@example.com).
Published Online: July 28, 2016. doi:10.1001/jamaophthalmol.2016.0934
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Additional Contributions: I thank the patient for granting permission to publish this information.
Chiam PJ. Eruption of Eyelid Target Lesions. JAMA Ophthalmol. 2016;134(10):1189–1190. doi:10.1001/jamaophthalmol.2016.0934
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