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Recurrent Herpes Simplex‐2 Infection on the Palm

To the Editor: A 29-year-old woman visited us with a pruritic and painful lesion on the right palm of three days’ duration. She had suffered from recurrent vesicular eruptions on her right palm three times within the previous six months. She had been diagnosed with eczema and treated with topical corticosteroids by another dermatologist. Although her father has recurrent herpes simplex labialis, she had no past history of herpes simplex on the orofacial or genital area. Physical examination revealed a well-defined, edematous erythema surmounted by small vesicles measuring 3 mm in diameter on the right palm (Fig. 1). Her right axillar nodes were not palpable. Herpes simplex virus (HSV)-2 antigen, not HSV-1 antigen, was detected in the vesicular contents by the shell-vial culture method (1). Serological titers showed HSVIgM 0.86 (n: <0.8), HSV-IgG 80 (n: <2), VZVIgM 0.21 (n: <0.8), and VZV-IgG>128 (n: <2). Oral administration of acyclovir (1,000 mg/day) rapidly improved her symptoms. The skin lesion resolved within two weeks. HSV infections are generally classified into several groups: herpes simplex labialis, herpes simplex genitalis, herpetic whitlow, herpetic gingivostomatitis, and lumbosacral herpes simplex infection. HSV infection of the hand is rare compared to orofacial or genital herpes (2). It has been known that not only HSV-1, but also HSV-2, is isolated from the infection site of HSV infection of the hand and finger. According to Lowhagen et al. (2) out of a total of 69 finger and hand isolates, 54% were typed as HSV-1 and 46% as HSV-2. Recurrent HSV infections of the hands are frequently seen in young adults and caused by HSV-2 (3). Autoinoculation is the likely route of transmission in the first episode of HSV infection of the hand (4). HSV infection of the hand may occur in children secondary to autoinoculation of the hands from gingivostomatitis herpetica. Recurrent HSV infection of the hand in adults is often associated with genital herpes (4). It has also been reported that hand to hand transmission of HSV may occur (5). The transmission mechanism is not clear in the present case. Gross and Doerr (6) reported atypical HSV-2 manifestations on the hands in immunodeficient patients. Dilley et al. (7) described a granulomatous lesion of the palm caused by HSV infection in a patient with previously undiagnosed AIDS. Our case showed no immunological abnormalities in clinical and routine blood examination. Herpes simplex infection on the palm resembles contact dermatitis, pompholyx, insect bite, and autoimmune bullous dermatosis. The present case was misdiagnosed and treated as eczema. We emphasize that herpes simplex infection should be listed as a differential diagnosis for vesicular eruption of the palm.