The biopsy specimen from the patient's right eyelid showed an epidermis with an ulcerated surface. The base of the ulcer contained cells with nuclei demonstrating the characteristic features of herpetic infection: marginated chromatin, nuclear molding, and occasional multinucleated forms (Figure 3). A culture was positive for HSV, and valacyclovir hydrochloride therapy (500 mg twice a day) was begun. The patient experienced marked improvement within 24 hours.

The most common site of primary cutaneous infection by HSV is the facial area supplied by the maxillary division of the trigeminal nerve.¹ When there is ocular involvement, it presents as unilateral follicular conjunctivitis with tender preauricular lymphadenopathy. Ocular HSV infection can occur in the absence of cutaneous or corneal lesions²; it can also be associated with multiple vesicles and ulcers on the upper and lower eyelids or with superficial punctate keratitis.³