Painful rash in 15 year-old female

Presenter: Leslie Mills, DO
Dermatology Program: West Palm Hospital/PBCGME
Program Director: Robin Shecter, DO
Submitted on: May 2, 2016

CHIEF COMPLAINT:  A 15-year-old female presented to the Emergency Department with a painful rash involving her face, neck, and ears.


Signs and symptoms:  The patient first noticed tenderness and pressure involving the face with subsequent edema that was most pronounced in the periorbital region after returning from Georgia 4 days prior to admission. The lesions began as intensely pruritic, erythematous papules and vesicles that quickly ulcerated with clear-yellow drainage. Associated symptoms included ocular pain. She denied oral lesions, fever or chills. She denied recent trauma, sick contacts, arthropod assault or exposure to animals, outdoor activities, or new products.

Previous Treatment:  None (Patient recently discontinued prednisone 10mg and triamcinolone ointment for a similar rash that involved her lower extremities only)

Other information:  Past medical history – Eczema, food and environmental allergies
Family history – Brother with eczema and asthma
Social history – Lives in house with parents, attends high school, denies tobacco, alcohol, or illicit drug use
Surgical history – None
Medications – Zyrtec
Allergies – NKDA


Multiple, tender, discrete, 2-3mm punched-out erosions with hemorrhagic crusts primarily involving the face, neck, and ears with clear-yellow drainage, erythema, and significant periorbital edema.

Associated physical findings included hyperlinear palms and thickened, dry, scaly plaques involving the face, neck, flexural surfaces, and extremities.





HSV-1 DNA PCR – positive
HSV-2 DNA PCR – negative
Viral culture – herpes simplex virus
Bacterial culture – staphylococcus aureus


Epidermal necrosis, enlarged epithelial cells with intranuclear inclusions, and multinucleated giant cells with polymorphonuclear leukocyte invasion of the epidermis and dermis.


1.   Varicella zoster virus infection
2.   Bullous impetigo
3.   Erysipelas
4.   Contact dermatitis
5.   Bullous drug eruption

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