enital and labial herpes simplex virus infections are frequently encountered by primary care physicians in the United States. Whereas the diagnosis of this condition is often straightforward, choosing an appropriate drug (eg, acyclovir, valacyclovir hydrochloride, or famciclovir) and dosing regimen can be confusing in view of (1) competing clinical approaches to therapy; (2) evolving dosing schedules based on new research;(3) approved regimens of the Food and Drug Administration that may not match recommendations of the Centers for Disease Control and Prevention or of other experts; and (4) dissimilar regimens for oral and genital infections. The physician must first choose an approach to treatment (ie, intermittent episodic therapy, intermittent suppressive therapy, or chronic suppressive therapy) based on defined clinical characteristics and patient preference. Then, an evidence-based dosing regimen must be selected. In this review, data from all sources are tabulated to provide a handy clinical reference.

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A 10-year-old white boy presented to the pediatric dermatology clinic with a diffuse, scaly, pruritic rash on the face, trunk, and extremities. The rash had been present episodically since birth and was worsening over the past 4 months. With allergies to peanuts, wheat, and pollens, a previous diagnosis of ''eczema'' was assumed by a general dermatologist. Topical and oral steroids and topical tacrolimus had been tried without success. The patient was born to nonconsanguineous parents, and no family members were known to have similar skin findings. Family history was positive for asthma and psoriasis. The child was otherwise healthy, developmentally normal, and asymptomatic.On examination, erythematous, scaly, annular and polycyclic plaques (Fig. 1) were present extensively on the neck, upper back, trunk, proximal extremities, and groin. Extensive erythematous, scaly, well-demarcated, lichenified plaques were present in the antecubital and popliteal fossae (Fig. 2). Mild erythema and scaling were present on the face. There was no significant involvement of the hands or feet, and gross appearance of the hair and nails was normal.Initial work up of the patient included microscopy of a potassium hydroxide preparation of skin scrapings, which was negative for fungus. Significant laboratory findings were a markedly elevated IgE (7904 U ⁄ mL) and an eosinophilia (8.7%). A biopsy specimen demonstrated findings consistent with psoriasiform dermatitis. A reassessment of history, clinical presentation, and histopathologic findings led to further investigation.

4864 Introduction: We report a case of PNP in a patient who was subsequently diagnosed with classical Hodgkins Lymphoma mixed cellularity type. PNP is an autoimmune mediated blistering disorder that presents with skin lesions demonstrating characteristics of erythema multiforme and pemphigus vulgaris. Case: A 76 year-old Hispanic male presented to the Emergency department with intermittent low fevers of 4 months duration associated with progressive weakness and fatigue; he now had mouth ulcers of 1-week duration along with anorexia. Physical exam was significant for a temperature of 102.4F, bilateral conjunctivitis with mild white discharge. Labs included WBC 5,000/mm3, hemoglobin 9.5 gm/dL, platelets 99,000/mm3; differential showed lymphocytes 22%, monocytes 11%, eosinophils 3%, and myelocytes 9%. Oral examination revealed dry mucosa with bleeding perioral ulcers. An ulcer biopsy was obtained and demonstrated necrotic keratinocytes and necrotic neutrophilic inflammation consistent with PNP. Chest CT showed a multinodular goiter, enlarged mediastinal and hilar nodes with calcified granulomas bilaterally as well as a new noncalcified nodule in the right lung. PET scan revealed FDG avid lymph nodes in the left supraclavicular, hilar and left axilla areas as well as multiple regions in the spleen and retroperitoneal nodes. A left axillary node biopsy showed classical Hodgkins lymphoma of mixed cellularity type. The patient was started on prednisone 75 mg per day in divided doses and his oral ulcerations and clinical status improved after 2 days of therapy. Subsequently the patient was started on gemcitabine, vinorelbine and liposomal doxorubicin (GVD) chemotherapy for his malignancy. Discussion: Although PNP has been described as being associated with hematologic malignancies such as Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia and Castleman's disease, it has rarely been demonstrated in association with classical Hodgkins disease. This case report highlights the need for a higher index of suspicion of underlying malignancy including classical Hodgkins disease when confronted with a patient presenting PNP. Disclosures: No relevant conflicts of interest to declare.