cutaneous viral infections alisha plotner, md assistant professor division of dermatology
TRANSCRIPT
Cutaneous Viral Infections
Alisha Plotner, MDAssistant Professor
Division of Dermatology
Learning Objectives
Diagnose viral infections of the skin based on their clinical findings.
Plan treatment approaches for viral infections of the skin.
VERRUCA/CONDYLOMACutaneous Viral Infections
Warts
Due to human papilloma virus (HPV), which is a double stranded DNA virus
Can infect epithelial keratinocytes (skin, genital, mucosa)
Well over 70 different HPV viral strains
Can present anywhere in body, including fingers, hands, feet, genitals
HPV Types
Plantar warts – HPV 1
Periungual warts – HPV 2
Flat warts – HPV 3
Benign genital warts HPV 6 or 11
Genital warts with malignant potential HPV 16, 18, 31, 33
Genital Warts
Most common sexually transmitted disease
HPV types 6 and 11 are most common
HPV types 16, 18, 31, 33 can induce squamous cell cancer
Can appear as verrucous papules in genital surface or genital area
Are potentially contagious even after treatment has produced visible resolution
Can be associated with cervical cancer and anal cancer
Individuals with suppressed cell mediated immunity are at particular risk for developing genital and anal cancer, including HIV and organ transplant patients
Wart Treatment
Destructive
Scalpel or curette
Salicylic Acid
Liquid nitrogen
Laser
Inhibit HPV proliferation
5-fluorouracil
Podophylotoxin
Immune modulating
Imiquimod
Interferon
MOLLUSCUM CONTAGIOSUMCutaneous Viral Infections
Molluscum Contagiosum
Due to a large DNA virus classified as a pox virus
More common in children, especially with atopic dermatitis or immunosuppressed adults, especially with advanced HIV
Often presents with a small (1-3mm) shiny, skin colored papule with a central dimple
Patients with advanced HIV may exhibit extremely large molluscum
May resolve spontaneously or be treated, if symptomatic
Molluscum treatment
Spontaneous resolution Curettage Salicylic acid Liquid nitrogen Cantharidin Imiquimod
HERPES VIRUS INFECTIONSCutaneous Viral Infections
Oral & Genital Herpes Simplex Virus (HSV)
Are double-stranded DNA virus and generally spread by direct skin to skin contact
HSV-1 – cause 80% oral-labial, 20% genital herpes cases
HSV-2 – cause 80% genital, 20% oral-labial herpes cases
In the U.S. population, prevalence of HSV-1 antibodies (indicating infection) is 80-90% and prevalence of HSV-2 antibodies is 20%
HSV Cutaneous Manifestation
Manifest as pain, burning, tingling prior to the appearance of the lesions
Lesions are localized groups of vesicles on an erythematous base
Vesicles rupture producing a painful superficial ulcer
After initial contact, virus replicates in mucocutaneous tissue, travels down axon, establishes latency in dorsal root ganglion
HSV-1 and HSV-2 Treatment
Oral or IV antiviral agents
Acyclovir or valacyclovir
Episodic or prophylactic dosing
Prophylactic dosing decreases asymptomatic viral shedding
Neonatal Herpes
Acquired from exposure to HSV shed by mother into birth canal at time of delivery
Most common in mothers with a primary genital HSV infection, but can occur with recurrent genital HSV
Skin lesions are groups vesicles on an erythematous base
Approximately 75% of affected infants will have skin lesions
Neonatal HSV can be a severe multi system fatal infection
If neonatal HSV is suspected, cultures should be obtained and treatment started immediately.
Varicella (Chicken Pox)
Caused by varicella zoster virus (VZV)
Prodrome of low grade fever and generalized malaise
Lesions manifest as small vesicles on an erythematous base (dew drops on a rose petal)
Varicella (chicken pox, cont.)
Individual lesions present as vesicles that rupture and produce superficial ulcers that scab and heal over
Crops of lesions erupt that produce lesions in many different stages
Eruption is prominent on face and extremities
Varicella Zoster
Caused by varicella zoster virus
After an episode of varicella, virus remains latent in dorsal root ganglia and trigeminal ganglion
Reactivation leads to viral proliferation and retrograde axonal transport to skin
Most common in elderly and immunosuppressed patients
Varicella Zoster Manifestations
Presents initially as erythematous plaque along a dermatomal distribution with sharp cut off at midline
Pain, burning, tingling often precedes the eruption
Vesicles soon develop in the plaque, which rupture and scab
Varicella Zoster Complications
V1 dermatomal involvement can lead to visual impairment
Post herpetic involvement can lead to persistent pain for months after the eruption resolves
Disseminated lesions can occur
Varicella Zoster Treatment
Zoster is treated with antiviral medications
Valacyclovir, acyclovir, famciclovir can be given orally, if initiated within 48 hours
Post-herpetic neuralgia is treated with gabapentin, tricyclic antidepressants, nerve blocks
Summary
Warts are caused by the human papilloma virus (HPV) Different types of warts are caused by differing HPV subtypes
Molluscum contagiosum is a cutaneous pox virus infection seen commonly in children and immunosuppressed adults
HSV 1 and 2 cause both orolabial and genital herpes infections
Varicella zoster virus causes chicken pox (varicella) upon initial infection. Later in life the dormant virus can reactivate causing shingles (zoster).
Cutaneous Viral Infections Quiz
References
Bolognia, Jorizzo, and Schaffer. Dermatology, 3rd Edition. Saunders, 2012.
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