Photo Quiz

Facial Rash with Oral Lesions


Am Fam Physician. 2020 Aug 15;102(4):243-244.

An 82-year-old patient presented with a worsening facial rash that appeared one week earlier. The rash initially presented as vesicles on the right side of the face accompanied by intermittent pruritus and facial dysesthesia. Ten days before the rash developed, the patient was treated with azithromycin (Zithromax) and nystatin for pharyngitis and thrush but discontinued these medications when the rash began. The medical history was significant for hypertension, atrial fibrillation, and coronary artery disease. The patient reported subjective fevers, odynophagia, and otalgia.

Physical examination revealed extensive eroded ulcerations with significant serosanguineous crusting on the right external ear, lower face, and jaw (Figure 1) and lesions on the right buccal mucosa and on half of the tongue (Figure 2). There were no vesicles or bullae. The patient also had right-sided facial droop. Superficial wound culture demonstrated mixed gram-positive cocci likely representative of skin flora.






Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Allergic contact dermatitis.

B. Bullous impetigo.

C. Disseminated herpes zoster.

D. Orofacial herpes simplex virus infection.

E. Ramsay Hunt syndrome.


The answer is E: Ramsay Hunt syndrome. Ramsay Hunt syndrome is an infectious disease process caused by reactivation of latent varicella-zoster virus in the geniculate ganglion of the facial nerve.1 It is associated with a facial nerve palsy and may be accompanied by a vesicular rash of the ear and mouth, hearing loss, ear pain, and vertigo.2 The close anatomic proximity of the facial nerve and vestibulocochlear nerves explains the involvement of the eighth (vestibulocochlear) cranial nerve common in Ramsay Hunt syndrome.2 This syndrome is estimated to occur in five per 100,000 people in the United States, with increasing incidence in those older than 60 years.3,4

The lesions of Ramsay Hunt syndrome are characterized by ipsilateral grouped vesicles or small bullae on an erythematous base that

Address correspondence to Weston Connelly, DO, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Bolognia J, Schaffer JV, Cerroni L, eds. Dermatology. 4th ed. Elsevier; 2018....

2. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 6th ed. Elsevier; 2016.

3. Bohaty BR, Bernhard JD, Craft N, et al. VisualDx. Ramsay-Hunt syndrome. Updated April 8, 2020. Accessed January 25, 2020.

4. Kim YH, Chang MY, Jung HH, et al. Prognosis of Ramsay Hunt syndrome presenting as cranial polyneuropathy. Laryngoscope. 2010;120(11):2270–2276.

5. Zimmerman J, Jesse S, Kassubek J, et al. Differential diagnosis of peripheral facial nerve palsy: a retrospective clinical, MRI and CSF-based study. J Neurol. 2019;266(10):2488–2494.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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