Can herpes present with images similar to dermatitis or folliculitis?

Herpes Can Present with Atypical Appearances Resembling Dermatitis or Folliculitis

Yes, herpes can present with atypical appearances that may resemble dermatitis or folliculitis, making clinical diagnosis challenging without laboratory confirmation. 1

Clinical Presentations of Herpes That May Mimic Other Conditions

Atypical Herpes Presentations

• Herpes infections often present with classic vesicular lesions that progress to shallow ulcers, but can manifest atypically, especially in immunocompromised patients 1
• Most persons with genital herpes have mild and atypical lesions that cannot be diagnosed by physical examination alone 1
• In immunocompromised patients (particularly those with CD4+ counts <100 cells/μL), herpes can present as extensive, deep, nonhealing ulcerations rather than typical vesicles 1

Herpes Folliculitis

• Herpes virus infections presenting as folliculitis are uncommon but well-documented in the literature 2, 3
• Herpetic folliculitis can manifest as a dense perivascular and periadnexal lymphohistiocytic infiltrate that may be mistaken for cutaneous lymphoma 2
• Herpetic folliculitis appears to be a relatively common finding in herpes zoster, occurring in 28% of cases in one study 3
• Herpes folliculitis can present as crusty erythematous folliculitis with small grouped vesicles and reactive lymph nodes 4

Herpes Mimicking Dermatitis

• The clinical differentiation of genital HSV infection from other infectious and non-infectious etiologies of genital ulceration is difficult 1
• Herpes can be misdiagnosed as contact dermatitis or other inflammatory dermatoses when presenting atypically 5
• Patients with atypical presentations are often treated with topical antibiotics or steroids without improvement before the correct diagnosis is established 5

Diagnostic Challenges and Pitfalls

Common Misdiagnoses

• Herpes folliculitis may be misdiagnosed as bacterial folliculitis, leading to inappropriate treatment 4, 5
• Herpes zoster in the genital region may be misdiagnosed as genital herpes (HSV infection) 6
• Non-infectious causes of genital ulceration, such as inflammatory bowel disease (Crohn disease), mucosal ulcerations associated with Behcet syndrome, or fixed drug eruption, may be confused with genital herpes 1

Laboratory Confirmation Is Essential

• Because mucosal HSV infections cannot be diagnosed accurately without laboratory confirmation, especially in HIV-seropositive patients, laboratory diagnosis should be pursued in all cases 1
• Exclusive reliance on clinical diagnosis could lead to both false positive and false negative diagnoses 1
• Viral culture, HSV DNA PCR, and HSV antigen detection are available methods for diagnosis 1
• PCR is the most sensitive method for diagnosis, though not widely available 1

Special Considerations in Immunocompromised Patients

• Immunocompromised patients may present with more severe, persistent, and atypical herpes infections 1
• HIV-infected children with severe immunocompromise may have involvement of the esophagus, CNS, genitals, and disseminated disease involving multiple organs 1
• The appearance of folliculitis, especially in an immunocompromised patient, should raise the suspicion of herpes virus infection 7
• Viral folliculitis due to herpes simplex virus or molluscum contagiosum might be considered a sign of immunosuppression 5

Diagnostic Approach for Suspected Atypical Herpes

1. Consider herpes in cases of treatment-resistant folliculitis or dermatitis, especially in immunocompromised patients 2, 7, 5
2. Collect specimens from vesicles or ulcers for laboratory testing:
   • Open vesicles with a sterile needle and collect content with a swab 1
   • Submit for viral culture, PCR, or direct immunofluorescence testing 1
3. Consider skin biopsy for histopathological examination when presentation is atypical 2, 3
4. Look for multinucleated giant keratinocytes in the follicular epithelium, which is consistent with herpes folliculitis 2

Conclusion

When evaluating skin lesions that appear to be dermatitis or folliculitis but are unresponsive to standard treatments, clinicians should maintain a high index of suspicion for atypical herpes presentations. Laboratory confirmation through viral culture, PCR, or histopathology is essential for accurate diagnosis, especially in immunocompromised patients.