Photo Rounds

Blisters on face and ear

A 6-year-old girl was brought to a family physician (FP) with blisters on her right ear and on the right side of her face and neck that had been there for 3 days. Her mother noted that the blisters began when the child developed a fever. The family had arrived in the United States one week earlier and the child had never received the varicella vaccine, but had chickenpox at 4 years of age. On physical exam, the girl had a temperature of 101° F and the vesicles and bullae had significant erythema and weeping of yellow fluid.

What's your diagnosis?


The FP diagnosed herpes zoster with possible Ramsay Hunt syndrome in this patient. The zoster also appeared superinfected by a bacterial infection, which was causing the extensive erythema, weeping of yellow fluid, and some honey crusting.

Herpes zoster oticus (Ramsay Hunt syndrome) includes the triad of ipsilateral facial paralysis, ear pain, and vesicles in the auditory canal and auricle. Disturbances in taste perception, hearing (tinnitus, hyperacusis), lacrimation, and vestibular function (vertigo) may occur. Fortunately, the child did not have facial paralysis, but did have ear pain and vesicles on the auricle. The child also admitted to some ringing in the right ear.

The FP prescribed oral acyclovir and cultured the weeping fluid to determine if this was truly a bacterial superinfection. The child was started on oral cephalexin 3 times a day to cover Streptococcus pyogenes and Staphylococcus aureus. Oral acetaminophen was prescribed for the pain and fever. The physician called his ear, nose, and throat (ENT) colleague who agreed to see the patient later that day.

The FP and ENT physician decided to follow her without immediate hospitalization since she was taking fluids well and did not appear systemically ill. The following day, the patient was already improving and later that week the culture grew out Staphylococcus aureus that was methicillin sensitive. The child fully recovered from the superinfected herpes zoster without any sequelae. The tinnitus resolved, as well.

Photo courtesy of UTHSCSA Dermatology division. Text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Zoster. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:712-717.

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