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.

Thank you for completing this module!

If you have any questions, please contact me...

Alisha.Plotner@osumc.edu

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