MaculeA macule is a change in surface color, without elevation or depression and, therefore, nonpalpable, well or ill-defined, variously sized, but generally considered less than either 5 or 10mm in diameter at the widest point.

PatchA patch is a large macule equal to or greater than either 5 or 10mm, depending on one's definition of a macule. Patches may have some subtle surface change, such as a fine scale or wrinkling, but although the consistency of the surface is changed, the lesion itself is not palpable

PapuleA papule is a circumscribed, solid elevation of skin with no visible fluid, varying in size from a pinhead to either less than 5 or 10mm in diameter at the widest point.

NoduleA nodule is morphologically similar to a papule, but is greater than either 5 or 10 mm in both width and depth, and most frequently centered in the dermis or subcutaneous fat. The depth of involvement is what differentiates a nodule from a papule.

Plaque

A plaque has been described as a broad papule, or confluence of papules equal to or greater than 1 cm, or alternatively as an elevated, plateau-like lesion that is greater in its diameter than in its depth.

VesicleA vesicle is a circumscribed, fluid-containing, epidermal elevation generally considered less than either 5 or 10 mm in diameter at the widest point.

BullaA bulla is a large vesicle described as a rounded or irregularly shaped blister containing serous or seropurulent fluid, equal to or greater than either 5 or 10 mm, depending on one's definition of a vesicle.

Pustule

A pustule is a small elevation of the skin containing cloudy or purulent material usually consisting of necrotic inflammatory cells.

Cyst

A cyst is an epithelial-lined cavity containing liquid, semisolid, or solid material.

Ulcer

An ulcer is a discontinuity of the skin exhibiting complete loss of the epidermis and often portions of the dermis and even subcutaneous fat.

Erosion and Fissure

An erosion is a discontinuity of the skin exhibiting incomplete loss of the epidermis, a lesion that is moist, circumscribed, and usually depressed.

A fissure is a crack in the skin that is usually narrow but deep.

Telangiectasia

A telangiectasia represents an enlargement of superficial blood vessels to the point of being visible.

ScarA scar is the replacement of normal tissue by fibrous connective tissue at the side of an injury.

HERPESVIRUS INFECTIONS

The human herpes viruses are comprised of a DNA genome surrounded by a protein capsule that is enclosed within an envelope.The average dimension is about 200 nm. These viruses are subclassified into alpha, beta, and gamma subtypes according to their virulence in tissue culture.

Human herpesviruses 1, 2 (simplex types), and 3 (varicella-zoster virus) belong to the alpha group, Epstein-Barr virus (HHV-4) to the gamma group, and cytomegalovirus (HHV-5) is a member of the beta group.

Diagram of the lytic (keratinocytes) and latent (neuronal) phases of HHV-1 infection. Bottom, Viral adhesion to cell-surface receptor, intranuclear propagation, assembly, release, and cell lysis in a keratinocyte.

Primary Herpetic Gingivostomatitis

Etiology

Herpes simplex virus (HSV) Over 95% of oral primary herpes due to

HSV-1 Physical contact is mode of transmission

Clinical Presentation

88% of population experience subclinical infection or mild

transient symptoms• Most cases occur in those between 0.5 and 5

years of age.• Incubation period of up to 2 weeks• Abrupt onset in those with low or absent

antibody to HSV-1• Fever, anorexia, lymphadenopathy, headache,

in addition tooral ulcers

Clinical Presentation

Coalescing, grouped, pinhead-sized vesicles that ulcerate

Ulcers show a yellow, fibrinous base with an erythematous halo

Both keratinized and nonkeratinized mucosa affected

Gingival tissue with edema, intense erythema, pain, and

tendernessLips, perioral skin may be involved7- to 14-day course

Diagnosis

Usually by clinical presentation and pattern of involvement

Cytology preparation to demonstrate multinucleate virus infected giant epithelial cells

Biopsy results of intact macular area show intraepithelial vesicles or early virus-induced epithelial (cytopathic) changes

Viral culture or polymerase chain reaction (PCR) examination

of blister fluid or scraping from base of erosion

Differential Diagnosis

Herpangina

Hand-foot-and-mouth disease

Varicella

Herpes zoster (shingles)

Erythema multiforme (typically no

gingival lesions)

TreatmentSoft diet and hydration

Antipyretics (avoid aspirin)

Chlorhexidine rinses

Systemic antiviral agents (acyclovir,

valacyclovir) if early in course or in

immunocompromised patients

Compounded mouth rinse

Prognosis

Excellent in immunocompetent host

Remission/latent phase in nearly all

those affected who have

adequate antibody titers

Etiology

• Herpes simplex virus

• Reactivation of latent virus

Clinical PresentationProdrome of tingling, burning, or pain at site of recurrenceMultiple, grouped, fragile vesicles that ulcerate and coalesceMost common on vermilion border of lips or adjacent skinIntraoral recurrences characteristically on hard palate orattached gingiva (masticatory mucosa)In immunocompromised patients, lesions may occur in any oral site and are more severe (herpetic geometric glossitis).

DiagnosisCharacteristic clinical presentation and historyViral culture or PCR examination of blister fluid or scrapingfrom base of erosionCytologic smearDirect immunofluorescence examination of smear

Differential Diagnosis

Erythema multiformeHerpes zoster (shingles)HerpanginaHand-foot-and-mouth disease

TreatmentAcyclovir or valacyclovir early in prodromeSupportiveAcyclovir may be used for prophylaxis for seropositive transplantpatientsGanciclovir may be used for human immunodeficiency virus(HIV)-positive patients, especially those co-infected withcytomegalovirus.For recurrent herpes labialis, see “Therapeutics” section.

EtiologyPrimary and recurrent forms due to varicella-zoster virus (VZV)Primary VZV (chickenpox): a childhood exanthemSecondary (recurrent) VZV (herpes zoster / shingles) infection: most common in elderly or immunocompromised adults

Clinical PresentationVaricella (chickenpox)

Fever, headache, malaise, and pharyngitis with a 2-week incubation

Skin with widespread vesicular eruptionOral mucosa with short-lived vesicles that

rupture forming shallow, defined ulcers

Clinical Presentation

Herpes zoster (shingles) Unilateral, dermatomal, grouped vesicular eruption of skin

and/or oral mucosa Vesicles may coalesce prior to ulceration and crusting.

Lesions are painful.Prodromal symptoms along affected dermatome may occur.Pain, paresthesia, burning, tinglingPostherpetic pain may be severe.

DiagnosisClinical appearance and symptoms

Cytologic smear with cytopathic effect present (multinucleated giant cells)

Viral culture or PCR examination of blister fluid or scraping

from base of erosion Serologic evaluation of VZV antibody

Biopsy with direct fluorescent examination using fluoresceinlabeled VZV antibody