Are We Too Cavalier About Antiviral Prophylaxis?

February 2013 | Volume 12 | Issue 2 | Original Article | 199 | Copyright © February 2013

Oge C. Onwudiwe MD,a Ellen S. Marmur MD,b and Joel L. Cohen MDc

aAllPhases Dermatology, Alexandria, VA bDepartment of Cosmetic and Dermatologic Surgery, Mount Sinai School of Medicine, New York, NY cAbout-Skin Dermatology and DermSurgery, Englewood, CO

Herpes simplex virus (HSV) prophylaxis may be underutilized in cosmetic surgery at a time when cosmetic procedures are increasing. Our goal is to review the data regarding HSV prophylaxis in order to remind cosmetic surgeons when to consider adding this regimen to their patient perioperative care.

J Drugs Dermatol. 2013;12(2):199-205.


Millions of Americans seek elective cosmetic procedures for the treatment of dyschromia, allergy/sensitivity, abscess, scabbing/skin necrosis, scars, dynamic and static rhytids, actinic damage, and other stigmata associated with the aging face. The most recent statistics from the American Academy of Cosmetic Surgery state that approximately 13.7 million minimally invasive procedures were performed in the United States in 2009. When compared with 2005 statistics, there was a 370% increase for laser resurfacing procedures, a 245% increase in the use of fillers, and a 252% increase in chemical peels.1 The statistics from the American Society for Aesthetic Plastic Surgery (ASAPS) show a decline of some of these procedures from 2005 to 2010 in the United States (Figure 1), likely due to the economic downturn and overall recession. It is of importance to note that when the ASAPS statistics of 2010 are compared with the previous year (2009), the demand for cosmetic procedures rebounded by almost 9%.2 In descending order, the administration of neurotoxins, hyaluronic acid–based injectable fillers, laser hair removal, laser skin resurfacing, and chemical peels were the top 5 nonsurgical procedures performed in the United States in 2010.2 Nearly 2 million laser skin resurfacing and hyaluronic acid–filler procedures were performed in the United States in 2010.2 According to ASAPS, this roughly accounts for one-third of all the top 5 nonsurgical procedures performed, and this figure is expected to rise. When performed correctly and without sequelae, these procedures can produce desirable cosmetic results. Unfortunately, these procedures are not without potential complications and can sometimes cause hyperpigmentation, hypopigmentation, scars, contractures, persistent erythema, telangiectasias, milia, and bacterial, viral, and fungal infections.3,4 Here within, the focus will shift to herpes simplex virus (HSV) reactivation as a complication in the aforementioned procedures and whether prophylaxis is warranted.

Herpes Simplex Virus

HSV is a double-stranded virus of the Herpesviridae family. Protein-coding genes are found within both DNA strands.5 Typically, the virus initiates the process of infection via contact with mucosal surfaces or nonintact skin.6,7 Subsequently, neutralizing antibodies to HSV develop in the serum.7 Infection and reactivation of HSV-1 primarily occurs in the distribution of the maxillary (V2) and mandibular (V3) regions of the trigeminal nerve.8 HSV manifests itself clinically in various ways, such as cutaneous orofacial or genital lesions, encephalitis, neonatal HSV, and keratoconjunctivitis.6 In 85% to 90% of primary cutaneous HSV cases, the infection tends to be subclinical. Of those that do present with lesions clinically, the overwhelming majority are typically vesicular eruptions limited to either the oral or genital regions, and less commonly, the ocular area.9 After primary infection, HSV establishes latency in sensory ganglia, where it lies dormant and persists for life.10
Many factors have been shown to precipitate HSV reactivation, such as trauma, ultraviolet light, fever, menstruation, and emotional stress.5,11 Other less common precipitants include photodynamic therapy.12 Trauma associated with surgical procedures is believed to be the most common factor that precipitates HSV infection postoperatively.13 Reactivation of orolabial HSV has a tendency to be of shorter duration and less intense than primary orolabial lesions or recurrences in the genital area. The associated pain and discomfort of orolabial herpes reactivation is typically mild, usually lasts approximately 4 days, and the lesions, on average, disappear within 7 days.11
The typical signs and symptoms of HSV reactivation include burning, itching, and skin tingling followed by vesicle formation, crusting, and erosions.14 This more common presentation, however, may be altered in patients who have undergone resurfacing.15 The exposed dermis allows for potential extension of viral particles over the entire treatment area13 and a possible more severe presentation of reactivation.
HSV has been reported to occur after dermatologic procedures such as laser resurfacing,16-18 dermabrasion,19,20 chemical peels,13,21 and Mohs micrographic surgery (Figure 2).22 In procedures like laser resurfacing, where the skin has been either completely