Answer:
Latent herpes simplex virus (HSV) may be activated by the trauma of resurfacing procedures resulting in a rapid dissemination across the entire treated area. It often starts with an unusually severe facial or perioral burning pain that is unexpected or delayed. Within 24 hours, blistering or sometimes directly ulcerating lesions appear which rapidly spread to other treated areas made susceptible by the de-epithelialization of the resurfacing procedure. Prior to the introduction of acyclovir in 1985, a history of HSV was considered a contraindication for chemical peel since a post-treatment outbreak can result in permanent scarring. Prophylactic treatment with acyclovir has allowed patients with a positive HSV history to undergo resurfacing safely. The referenced article retrospectively examines 181 patients who underwent chemical peel or dermabrasion from 1983 to 1990 including some who had undergone treatment prior to acyclovir's introduction. The rate of infection in those with a positive HSV history who did not receive acyclovir prophylaxis was 50% compared to 8.3% in those who received prophylaxis. It found use of high-dose acyclovir (2400 mg/d) starting 2 days before the procedure and continued for 2 weeks afterwards virtually eliminated post-treatment outbreaks and was well tolerated by patients. Active infection was treated with 4000mg/d until lesions became dry and then followed with 2400mg/d for 2 weeks. Since the authors noted that 6.6% of patients with a negative history also developed outbreaks, they recommend that all patients should undergo prophylaxis regardless of history. This view is refuted in a discussion, which follows the paper. Stuzin et al feel more judicious use of acyclovir is appropriate given the low incidence of post-treatment outbreaks and the easy treatability of any such episodes with higher levels of acyclovir.