A vesicle is a raised skin lesion filled with clear fluid that is less than 1 cm in diameter. A raised, clear fluid-filled lesion larger than 1 cm is referred to as a bulla. In childhood, there are many diseases that manifest as vesicular rashes, the most familiar of which is the rash seen with herpes simplex virus (HSV) infection. Other viral and bacterial infections also may present with vesiculobullous lesions as may many noninfectious processes, including allergic and immune-mediated diseases, mechanical disorders of the skin, burns, and insect bites.

Vesicular eruptions may be benign and self-limited or may be progressive and life threatening. Early identification of potentially serious disease and prompt attention to complications are critical, particularly in infants and immunocompromised hosts.

• Recurrent herpetic skin outbreaks in the same location almost always represent the reactivation of a latent infection rather than a new primary infection.

• Immunocompromised hosts may have disseminated disease due to HSV, varicella zoster virus (VZV), and coxsackievirus infections.

• Primary HSV lesions are often associated with fever and systemic symptoms, whereas secondary lesions or reactivation of HSV lesions are usually not.

• The reactivation of HSV or VZV, known as “shingles,” is typically preceded by a prodrome of pain, tingling, itching, or burning at the site.

• In assessing vesicular rashes in the neonate, a detailed maternal history is necessary to elicit possible HSV exposure.

• Lethargy, poor feeding, temperature instability, jaundice, irritability, or seizures in an infant with vesicular lesions should raise suspicion for neonatal HSV infection.

• Frequently accompanying genital HSV is painful inguinal adenopathy, dysuria, urinary retention, and vaginal discharge. However, most primary genital HSV infections are asymptomatic.

• Primary VZV infection or chickenpox is very contagious; therefore, a history of household or school exposure in a child with characteristic lesions is highly suggestive.

• Children vaccinated against VZV may still develop chickenpox, though the disease course is milder.

• When contact dermatitis is suspected, a detailed environmental exposure history is warranted.

• Symptoms of allergic contact dermatitis may not manifest for 6 to 24 hours after the exposure. Symptoms are often worse with second or subsequent exposures.

• A history of outdoor exposure can indicate rhus dermatitis—poison oak, poison ivy, or poison sumac.

• Grouped vesicles on an erythematous base are the hallmark of HSV infection; however, in immunocompromised patients, the erythematous base is not always apparent.

• HSV lesions on skin or mucous membranes may appear vesicular or, if they have ruptured, the lesions may appear eroded or ulcerated.

• Lesions of neonatal herpes often appear at 5 to 14 days of life; lesions appearing in the first 2 days of life suggest intrauterine exposure. Intrauterine-acquired HSV may not present with vesicles but rather scarring.

• The oral vesicles and ulcers of HSV tend to form more anteriorly on the gingivae, tongue, and hard palate; whereas, the lesions of hand-foot-and-mouth disease are typically more posterior on the soft palate, tonsillar pillars, and posterior oropharynx.

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