Pyogenic granuloma (PG) is a vascular endothelial growth factor (VEGF)-related neoangiogenic process. Minor trauma, chronic irritation, certain drugs and pregnancy may favor PG. Viral triggers have not been reported up to date. A 52-year-old woman with hairy-cell leukemia presented because of a 3-month history of a giant pseudotumoral lesion on her left cheek. All prior antibacterial, antifungal and anti-inflammatory treatments had failed. Histology revealed PG with sparse and isolated epithelial cell aggregates. Immunohistochemistry (IHC) identified herpes simplex virus type-I (HSV-I) antigens in the nuclei and cytoplasm of normal-appearing as well as cytopathic epithelial cells, suggesting a chronic, low-productive HSV infection. No HSV-I signal was evidenced in the endothelial cells of the PG. Furthermore, IHC revealed VEGF in the HSV-I infected epithelial cells as well as within the PG endothelial cells. These results incited oral treatment with valaciclovir, and the PG promptly resolved after 2 weeks. These findings suggest that a chronic HSV-I infection might play an indirect, partial role in neoangiogenesis, presumably via HSV-I infection-related stimulation of keratinocytic VEGF production.

Background: Recurrences of herpes labialis (RHL) may be triggered by systemic factors, including stress, menses, and fever. Local stimuli, such as lip injury or sunlight exposure are also associated to RHL. Dental extraction has also been reported as triggering event. Case reports: Seven otherwise healthy patients are presented with severe and extensive RHL occurring about 2-3 days after dental extraction under local anaesthesia. Immunohistochemistry on smears and immunofluorescence on cell culture identified herpes simplex virus type I (HSV-I). Five patients reported more severe prodromal signs than usual. Although all the patients suffered from RHL, none had previously experienced RHL after dental care. Two patients required hospitalisation for intravenous acyclovir therapy, whereas the others were successfully treated with oral valaciclovir or acyclovir. Conclusion: Severe and extensive RHL can occur soon after dental extraction under local anaesthesia. Patients with a previous history of RHL seem to be at higher risk. It is not clear whether RHL is linked to the procedure itself, to the anaesthetic procedure or both. As the incidence is unknown, more studies are required to recommend prophylactic antiviral treatment in RHL patients who are undergoing extractions. Dentists should be aware of this potentially severe post-extraction complication.

Antiviral prophylaxis for RHL is not routinely recommended for dental procedures, regardless of a prior history of RHL.

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As TNF-α is a major factor in the immune defense against herpes zoster (HZ); an increased incidence and severity of HZ cases were suspected in patients undergoing treatment with TNF antagonists. Several studies and clinical experience provided evidence that the incidence of HZ increases by twofold to threefold in this patient category. The number of severe cases of HZ, with multisegmental, disseminated cutaneous, and/or systemic involvement, is also increased. Concerning psoriasis patients under biologicals, the clinician should be more alert for an eventual HZ event, in particular during the first year of biological treatment, and be aware of the possibility of more severe HZ cases. HZ may also undergo an age-shift toward younger patients. Rapid identification of risk factors for severe HZ, such as severe prodromal pains and/or the presence of satellite lesions, is recommended. The treatment recommendations of HZ in this patient group are identical to the recently published guidelines for the management of HZ. The live attenuated viral vaccine OKA/Merck strain anti-HZ vaccination is recommended before initiating biological treatment in psoriasis patients. The new adjuvanted anti-HZ vaccine will probably also benefit patients while on biological treatment.