Case study - An unpleasant facial rash

When a young athlete developed a mysterious rash that did not respond to treatment, Dr Keith Barnard turned to a local consultant to solve the mystery.

A strapping 16-year-old young man was brought to see me by his father, who seemed set on a confrontation. 'Why hasn't anyone sorted out my Jason's skin?' he asked. 'I'm sure it's acne.' He goes on to say that he has brought the lad along twice and seen a different doctor each time, 'All they've done is give him antibiotics that don't work,' he complains.

Unidentified erythematous rash

Possible impetigo
The extensive erythematous vesicular rash extended across Jason's forehead, and down the right side of his face and onto his chin, where there was some crusting, but the left side of his face was quite clear.

The rash had first appeared only 12 days ago, and didn't look like acne. My first thought was that it might be impetigo, but looking at Jason's notes, I saw that my colleagues had also come to the same conclusion.

A five-day course of co-amoxiclav had been prescribed at Jason's first visit, and erythromycin after his second. This weakened my argument for impetigo, but I thought perhaps the rash might be a resistant strain of staphylococcus.

'Have any of your friends had a rash like this?' I asked. 'No,' said Jason, then added pleadingly 'I'm supposed to be playing for my county under-17s a week on Saturday.'

It transpired that Jason was an excellent rugby player and his position was hooker. He realised there was no way he could play with his face in such a mess, rubbing it against his opponents in the scrum.

As you might expect from a fit young athlete, I could find nothing else wrong with Jason, apart from some slightly swollen and tender submandibular lymph nodes. There was no other lymph node enlargement and no hepatosplenomegaly. Apart from feeling fed up and embarrassed by his rash, he felt well.

Dermatology consultation
As luck would have it, our local consultant dermatologist was doing an outreach clinic in a neighbouring surgery the next day, and he was sufficiently intrigued to see Jason as an extra. He called me on the phone that same afternoon to tell me he was certain this was a primary herpes simplex type 1 (HSV-1) infection and that I should start him on aciclovir immediately.

I was very impressed when, a week later, Jason came to show me his all but dry lesions, which were clearly healing rapidly. His father was in a much more conciliatory mood, and thanked me for the prompt referral. 'But will Jason be able to play on Saturday?' was his big question.

Thankfully, I was ready for this one. My consultant colleague had confessed that the reason he knew all about this condition was because he had just returned from a conference in Chicago, where cases of HSV-1 facial infections in certain sportsmen were making the news.

They had even been given specific names that I found rather amusing - herpes gladiatorum, when infection occurred in wrestlers, and herpes rugbiaforum, when it occurred in rugby players.

Armed with everything I had been told, I explained to father and son that HSV-1 infection is spread by direct skin-to-skin contact, in this case by Jason rubbing faces with an infected opposite number in the scrum. The lesions appear within seven to 14 days after exposure.

The final score
Regarding when Jason could play again, the guidance my dermatologist colleague had gleaned at his conference was that there must be no signs of systemic viral infection, the athlete must be free of any new lesions for at least three days before a competition, and that existing lesions must be dried and crusted. The participant must also have been taking appropriate antiviral therapy for at least 120 hours before the beginning of a competition.

Jason fulfilled all these conditions, so I was able to tell him he should be fit to play, especially as the big game was still five days away. I did suggest that he wear protective headgear, to which he readily agreed.

I had to warn Jason that it was possible he might get recurrent attacks, explaining that the anti-viral treatment did not effect a permanent cure, because HSV-1 can remain dormant for years.

  • Dr Barnard is a former GP in Fareham, Hampshire 

LEARNING POINTS

  • Primary HSV-1 infection is usually more severe than recurrences.
  • The presentation is usually as disseminated vesicles, punched-out erosions, and central crusting.
  • HSV-1 can be confirmed by detecting viral DNA using a polymerase chain reaction examination.
  • Ocular complications can occur, including conjunctivitis, scleritis, uveitis, and dendritic keratitis that may lead to corneal scarring.

 

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