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Received: 21 January 2019    Revised: 18 March 2019    Accepted: 1 April 2019

DOI: 10.1111/jocd.12975

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First‐ever HSV‐1 recurrence following superficial facial

chemical peel after 30‐year latency following neonatal primary
infection

Nathan Johnson MD

Department of Internal Medicine, Section

of Dermatology, Virginia Tech Carilion
School of Medicine/Carilion Clinic, Roanoke,
Virginia
Correspondence
Nathan Johnson, Department of Internal
Medicine, Section of Dermatology, Virginia
Tech Carilion School of Medicine/Carilion
Clinic, 1 Riverside Circle, Suite 300,
Roanoke, VA 24016.
Email: nmjohnson@carilionclinic.org
Abstract
Recurrence of orofacial herpes simplex infection is a well‐known potential complica‐
tion of chemical peeling procedures. Risk of reactivation is believed to correlate with
depth of peel, leading to the recommendation that all patients with history of primary
orofacial herpes simplex infection or recurrent herpes labialis receive prophylactic
antivirals prior to and after undergoing medium and deep peels. The following is a
case of herpes labialis following a very superficial peeling procedure in an other‐
wise healthy 30‐year‐old male after primary infection as a neonate with no history
of herpes simplex recurrence in the intervening 30 years. This case highlights the
importance of history‐taking and consideration of prophylactic antivirals in peels of
all depths in patients with any history of primary infection, regardless of length of
disease free period.

KEYWORDS
chemical peel, herpes labialis, herpes simplex, HSV‐1, lactic acid, α‐hydroxy acid

1 |  C A S E R E P O RT
A 30‐year‐old healthy male presented to the clinic with an erythema‐
tous, slightly tender papule on the right vermilion border of the upper
lip. The patient noted that the lesion was preceded the day before
by tenderness and a sensation of “fullness” prior to the appearance
of the lesion. The patient's history was notable for having received a
superficial α‐hydroxy acid (lactic acid) peel without additional high‐
concentration topical retinoid 5 days prior to first symptom. Patient
denied excessive discomfort during the cosmetic procedure and
noted no postprocedure erythema or peeling whatsoever.
The patient's clinical exam was consistent with early herpes labi‐
alis. On further questioning, he noted that he had a primary HSV‐1
infection in the neonatal period due to contact by a family member
with active herpes labialis. Infection at that time was moderate‐to‐
severe, nearly requiring hospitalization and initiation of antivirals,
but he made a full recovery without any sequelae. The patient had
never experienced HSV‐1 reactivation since initial infection. Patient
had been married for the past 5 years, and noted that he had never
had intimate contact with any individuals with history of HSV‐1.
Prior to the procedure, the patient had received counseling about
adverse effects of chemical peels including possible HSV‐1 reactiva‐
tion; however, due to having never experienced herpes reactivation
in over 30 years, and due to superficial nature of the peel, he did
not disclose this history and did not receive prophylactic valcyclovir.
Following diagnosis, the patient was treated with two doses of val‐
cyclovir 1 g separated by 12 hours, leading to full resolution of the
lesion in approximately 7 days.
2 | D I S CU S S I O N
Chemical peels are among the most common cosmetic procedures
performed due to success in facial rejuvenation, treating negative
consequences of photoaging, pigmentary dyschromias, rhytides, as
well as acne and preneoplastic epidermal lesions in some cases. Peel
solutions employ acids or combinations of acids which are left on the
skin for a fixed amount of time and penetrate the skin to a certain

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depth. Peels can be characterized as superficial (α‐ and β‐hydroxy
acids, TCA 10%‐25%, Jessner's Peel), medium (TCA 35%‐50%), or
deep (TCA > 50%, Baker‐Gordon Peel). Additionally, individual acids
fall on a spectrum in terms of inflammation induced, between mostly
noninflammatory (β‐hydroxy/salicylic acid) to significantly inflamma‐
1,2
tory (Jessner's solution). Acids are often combined with other non‐
acid topical treatments (eg, high‐dose retinoid, antioxidants, vitamin
C) to enhance the peel's effect or achieve other cosmetic outcomes.
Reactivation of herpes simplex is a well‐known risk of both
chemical and mechanical resurfacing procedures, especially when
involving lip and perioral skin. Risk of reactivation appears to cor‐
relate with depth of peel/degree of epidermal damage, as most
reports in the literature suggest that risk is highest in medium and
3
deep peels. This has also led to the recommendation to pretreat
all patients with history of herpes simplex with appropriate prophy‐
lactic antivirals if undergoing these procedures. Treatment regimens
vary, with most texts recommending valcyclovir 500 mg twice daily
starting either the morning before or the morning of the proce‐
dure, as this regimen was 100% effective when studied.4 However,
there are additional approaches, including valcyclovir 1 g, 3 times
per day, beginning 2 days prior to the procedure and continued for
10‐14 days after procedure.5 This extended treatment course was
justified by the claim that the skin must re‐epithelialize following the
6
peel for the medication to have full effect. Despite this, evidence
suggests that shorter treatment courses can be equally effective,
as demonstrated above. Acyclovir and famcyclovir are also effec‐
tive in preventing HSV reactivation. For acyclovir, higher‐dose, ex‐
tended treatment courses are generally considered more effective
(2400 mg daily starting on the day of the procedure for 16 days),
but intermediate doses (1200 mg daily for 10 days) demonstrated
efficacy.7 As for famciclovir, a study in which a cohort of 27 patients
with history of orofacial HSV received 250 mg twice daily for 2 days
before and 5 days after laser resurfacing procedures experienced no
reactivations.8 As for superficial chemical peels, the decision to pro‐
phylactically treat patients with history of orofacial herpes should
be an individual one, but the practice does not appear to have wide‐
spread support in the literature.
The uniqueness of this patient's case is highlighted by the ex‐
tended latency period between neonatal primary infection and re‐
activation of the virus without any clinically evident disease in the
period between the two events. The novelty, however, diminishes
with the understanding that even among patients with a negative
history of herpes simplex, implying an asymptomatic or remote his‐
tory of primary infection, 6.6% developed herpes reactivation.7
Additionally, as many as 70% of those who report no history
of primary infection or history of reactivations may have sero‐
logic evidence of previous infection, demonstrating that clinical
history is, at best, an imperfect prediction tool for reactivation. 8
Another surprising aspect of this case is that the application of
a very superficial acid solution (as opposed to medium and deep
peels) was the ultimate causative factor in disease reactivation,
whereas many years of exposure to more common causes of re‐
activation (eg, stress, fatigue, illnesses, extensive sun exposure)
did not. It is important, however, to acknowledge that one or more
of these confounding factors could have possibly played a role in
this particular reactivation, in conjunction with the chemical peel.
This case highlights the absolute importance of history‐taking and
patient selection when determining appropriateness for chemical
peeling procedures, as clearly any history orofacial herpes simplex
infection, regardless of lack of past HSV reactivations or depth
of peel, is associated with a risk of herpes simplex reactivation
following the peeling procedure. While universal treatment of all
patients undergoing superficial peal with history of orofacial HSV
would likely represent overtreatment based on the risk of reacti‐
vation, patients should always be made aware of this possibility,
and understanding should be documented on consent forms prior
to beginning the procedure.
ORCID
Nathan Johnson  https://orcid.org/0000-0002-8707-4373
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How to cite this article: Johnson N. First‐ever HSV‐1
recurrence following superficial facial chemical peel after 30‐
year latency following neonatal primary infection. J Cosmet
Dermatol. 2020;19:135–136. https​://doi.org/10.1111/
jocd.12975​