Which of the following is NOT preceded by a vesicular stage?

Correct answer: C. Recurrent aphthous stomatitis

• A. Herpangina (coxsackie A) produces VESICLES on the soft palate, tonsillar pillars and uvula in a febrile child, which then ulcerate. Hand-foot-and-mouth disease similarly begins with vesicles.
• B. Herpes zoster begins with VESICLES in a unilateral dermatomal distribution that stop abruptly at the midline, following reactivation of varicella-zoster virus in a sensory ganglion.
• C. CORRECT — this is the exception. RECURRENT APHTHOUS STOMATITIS begins directly as a painful ULCER. There is a prodrome of burning or tingling for a day or two, but no vesicle ever forms. The lesion appears as a shallow, round-to-oval ulcer with a yellow-grey fibrinous base and an erythematous halo, on NON-KERATINISED, movable mucosa — labial and buccal mucosa, ventral tongue, floor of mouth, soft palate.
• D. Primary herpetic gingivostomatitis begins with clusters of small VESICLES that rupture within hours to leave coalescing ulcers, accompanied by fever, malaise, lymphadenopathy and a diffusely erythematous, painful marginal GINGIVITIS.

Note: The two-question shortcut for oral ulcers: was there a VESICLE first, and is the lesion on KERATINISED or NON-KERATINISED mucosa? Aphthae — no vesicle, non-keratinised, movable mucosa. Recurrent herpes — vesicles first, KERATINISED bound-down mucosa (hard palate, attached gingiva, vermilion).