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Common Viral Diseases of Skin

Herpes Simplex (HS)
The basic lesions are vesicles but these can take many different forms on the mucocutaneous surface.
The clinical features are divided into primary disease and recurrent disease.
Oral and facial lesions are usually due to Herpes Simplex type 1 while anogenital lesions are mostly due to Herpes Simplex type 2.
  1. Primary Infections
    Primary infection with herpes simplex occurs primarily by direct exposure through mucocutaneous contact with another infected individual. It is defined as the first infection with the virus in a seronegative patient. The infection can be subclinical but below are listed the symptomatic clinical presentations.
    1. Primary gingivo-stomatitis
      Primary herpetic infection (usually type 1 herpes simplex) of the mouth and pharynx is more common in the children. Vesicles inside the mouth on the buccal mucosa and gums coalesce to form plaques covered with a grey-membrane. The vesicles are very painful and the infection may accompany with high fever, tender lymphadenopathy and generalized complaints.
    2. Primary genital herpes
      Primary genital herpes, generally by type 2 virus, is a common sexually transmitted disease characterized by multiple grouped, umbilicated vesicles, oedema, fever, pain and dysuria, with regional lymphadenopathy in men and vulvovaginitis in woman. The incubation period is from 3 to 14 days.
    3. Herpetic whitlow
      Herpetic whitlow refers to painful vesicles with clear serous fluid on the fingers or hands. It is a common occupational hazard for medical and dental personnel. The inoculation usually occurs in areas of abraded or broken skin. The vesicles will subsequently progress to form superficial ulcers.
    4. Herpetic keratoconjunctivitis
      Primary herpes can involve the conjunctiva and cornea. The eyelids are usually swollen and there are vesicles and ulcers on them.
    5. Aseptic meningitis, encephalitis
    6. Primary herpes hepatitis
  2. Recurrent Infections
    The virus remains in the dorsal root ganglion, from which secondary infections are repeatedly seeded to the skin over a period of years. Recurrent attacks then occur and presents as grouped umbilicated vesicles on an erythematous and somewhat edematous background.
    1. Recurrent facial-oral herpes simplex (cold sores)
      The cold sore usually appears at the vermilion border of the lip. The erythematous papule becomes vesicular and then ulcerates. The open sore heals in 5 to 7 days.
    2. Recurrent genital herpes also recur easily and these are mainly due to type 2 virus. The number of recurrences is about 3 or 4 per year.
    3. Keratitis
      Reactivation less commonly affects the eye, recurrent lesions are usually restricted to the cornea and the conjunctiva is not involved.
    4. Recurrent lumbosacral herpes simplex
      Recurrent herpetic lesions appearing on the lumbal area and buttocks may cause "sciatic pain".
    5. Herpes infection in the immunocompromised patient
      Reactivation of herpes is very common in patients with defective cellular immunity from hematological malignancies, Human Immunodeficiency Virus (HIV) infection and those receiving immunosuppressive agents or transplant patients. Herpes infection recurs more frequently, have a more severe and prolonged course and may present atypically e.g. in the form of granuloma.
Common causes of recurrent infection
  1. Stress
  2. Fever
  3. Onset of menstrual cycle
  4. Sun exposure
  5. Mechanical trauma
  6. Sexual activity (in genital herpes)
  1. Diagnosis
    1. Tzanck test – Multi nucleated giant cells seen.
    2. Viral culture from scrapped tissues or fluids.
    3. Immunofluorescence in scrapings from lesions to detect viral antigens.
    4. Electron microscopy to demonstrate the virus.
    5. Serology which may be useful for diagnosing primary infections. It is very difficult to interpret in recurrent infections because of high levels of existing antibody and recurrences usually do not cause a rise in titre. So serology is not routinely performed in the Social Hygiene Clinic. Also, commercially available serological tests cannot reliably distinguish its types 1 and 2 infection.

  1. Treatment
    1. Facial-oral herpes, Genital herpes
      1. Topical antibiotic cream
      2. Topical acyclovir cream
      3. KMnO4 wet compress
      4. Oral acyclovir therapy is only used in severe and extensive situation. e.g. acyclovir 200 mg 5 x daily x 5/7 with 24 hours of active new lesion or 400 X TDS X 7 days.
      5. Oral Famciclovir 125 mg tds x 5/7 or oral valaciclovir is an alternative
    2. Herpetic Keratitis
      1. Idoxuridine 0.5% eye drops.
      2. Acyclovir ophthalmic ointment.
    3. Treatment of herpes infections in the Immunocompromised patient
      1. Intravenous (IV) acyclovir
    4. Recurrent infections (>6 attacks per year)
      1. Prophylactic oral dose acyclovir for several months has been shown to reduce severity and frequency of relapse e.g. Acyclovir 400 mg bd. i.e. suppressive dose.
      2. In acyclovir resistant cases drugs can be used are : a. Foscarnet  b. Cidofovir  c. Trifluridine.
Herpes Zoster (HZ)
Varicella represents a primary lesion, herpes zoster (shingles) represents reactivation of the virus from the dorsal root ganglion and results in the classic dermatomal distribution. Herpes zoster is a common condition. There is a correlation between age and incidence of the condition. The disease usually affects the elderly and the immunocompromised patients. Constitutional symptoms are followed by tingling and pain, erythema, and vesicle formation in a dermatomal distribution.


Major complications of herpes zoster

  1. Acute phase
    1. Ocular involvement-Herpes ophthalmitis
    2. Secondary infection
    3. Cutaneous or visceral dissemination
  2. Chronic phase
    1. Post-herpetic neuralgia
    2. Scarring
    3. Motor neuropathy, post-infection encephalomyelitis, paralysis.
  1. Treatment
    1. Topical antibiotic cream may be useful in lesions with secondary infection
    2. Systemic agents
      1. Oral acyclovir 800 mg 5 times daily for 1 week
      2. Oral Famciclovir 250 mg 3 times daily for 1 week
      3. Oral Valaciclovir 1 gram 3 times daily for 1 week
    3. Indications of systemic anti-viral treatment.
      1. Patients get skin rashes within 3 days of onset, especially for the elderly group.
      2. Patients suffer from ophthalmopathy within 3 days of onset.
      3. Immunocompromised patient whenever vesicles present.
  2. Molluscum Contagiosum
    1. It is caused by a large DNA virus of the pox group.
    2. The umbilicated pearly lesions, often multiple, are more common in childhood and resolve spontaneously after becoming inflamed.
    3. The lesions occur anywhere on the body. Lesions occurring on the genitalia or lower abdomen in adults are almost sexually transmitted. In children, the lesions can be left behind as it is harmless and involute spontaneously. In adults, either cryotherapy or extirpation with a strile needle can be used as treatment.
    4. In patients with genital lesions, both the patient and the sexual partner should be screened for other sexually transmitted diseases.
  3. Warts
    1. Viral warts are caused by the Human Papilloma virus (HPV). More than 70 subtypes exist. Warts are contagious and spread easily if there is local breaks on the skin.
    2. Their morphology varies with the viral subtype and anatomical site.
    3. Spontaneous resolution may occur.
    1. Common Warts
      They are mostly due to HPV type 2. The lesions are discrete, firm papules with a rough surface  . They are usually multiple.
    2. Plane Warts
      These are usually caused by HPV type 3. The lesions are flat-topped, flesh-colored papules, mainly on the face, hands and limbs.
    3. Plantar Warts (Verucca Plantaris)
      Plantar warts are common, especially in school-children who may acquire them from swimming-bath floors. HPV1 and HPV2 are the commonest causative viruses. The lesions are characteristically flat with a callus on the surface and are often very painful. They usually occur on the palm and sole.
    4. Anogenital Warts – HPV 6, 11
      Please refer to Chapter 30 in STD Section.
    Type of wart Site of involvement HPV types
    1. Verruca vulgaris (common wart) Most common type wart
    On Hands and fingers
    2 (most common), 4, 27
    2. Verruca Plana (Flat wart) Face, hands 3, 10
    3. Verruca plantaris (palmoplantar warts)
    i) Superficial palmoplantar wart (Mosaic wart)
    ii) Deep palmoplantar wart (Myrmecia wart)

    Palms & soles

    1,2, 4,57
    2 (most common)
    1 (most common)

    4. Condyloma acuminata (anogenital wart) Genital, perianal, perineum
    Most common 6,  11, (low risk)
    Other 16, 18,31,33,45 (High risk)
    5. Laryngeal papillomatosis Larynx, respiratory tract 6, 11
    6. Bowenoid papulosis Genitalia 16
    7. Epidermodysplasia verruciformis Extensive 5,8
    1. Pityriasis Rosea
      1. Acute self-limiting erythematous eruption characterized by red, oval patches and papules with marginal collarette of scale
        1. Sites:  trunk, proximal aspects of arms and legs
        2. Etiology: human herpes virus 7 [HHV-7]
    1. Most start with a “herald” patch which precedes other lesions by
      1-2 weeks  long axis of lesions follow lines of cleavage producing
    2. “Christmas tree” pattern on back
      1. ​Varied degree of pruritus
      2. Clears spontaneously in 8-12 weeks

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