HerpeS SiMplex ViruS .iNfeCtiONS HSV is a double stand DNA virus There are two types of HSV. HSV type 1, associated with facial and oral infection. HSV type 2, affecting the genitalia.
epiDeMiOlOgy HSV infection is one of the commonest infections throughout the world. HSV1 infection commonly affecting children. HVS2 infection mainly occur after puberty
patHOpHySiOlOgy Close contact is required for HSV infection. Contact must involve mm or abraded skin. After an I.P (2-20days) , the primary attack will occur which is asymptomatic in 90% of cases. Following the 1ry attack there will be a latency period where the virus remain dormant in on of sensory ganglion. Reactivation of the virus will lead to recurrence of the infection.
)Herpetic Gingivostomstitis (1ry herpes Most cases occur between 1-5 years. After constitutional symptoms which may be sever the stomatitis began. The gums swollen, red and bleed easily. Vesicles presents as white plaques which seen on tongue, pharynx, palate and buccal mucosa. Regional L.N may be enlarged and tender. Fever subside after 3-5 days and recovery is completed in 2 weeks.
)Herpes Labialis (cold sores, fever blisteres The most common variety . Often occurred in childhood. Affecting the lips, but nose and cheeks Commonly caused by HSV type 1. 1/3 of patients will experience a recurrence. Of these 50% will experience at least 2 recurrence annually. Post herpetic E.M may occur.
Herpes Labialis Grouped and confluent vesicles on anerythematous base on the lips, 24 h after onset of symptoms.
Herpetic whitlowOccur as a direct inoculation of the. virus from oral or genital lesionsPainful, grouped, confluent vesicleson an erythematous & edematousbaseThe disease is a commonoccupational hazard for medical anddental personnel, who work in and.around the mouth
.Herpes Genitalis Most commonly caused by HSV type II. Age of onset: Young (sexually active adult). Risk increases with multiple sex partners. 1ry infections mostly asymptomatic but mild fever, headache, and local pain is noted. Distribution: Male: glans, shaft or sulcus of penis, scrotum and buttocks. Female: both labia, perinum and thigh.
Eczema Herpeticum Also known as Kaposi varicelliform eruption. It is a HSV infection occurring in atopic dermatitis patient. Characterized by systemic symptoms e.g. fever, malaise, irritability and lymphadenopathy. Clinical examination reveals generalized vesicles which often becomes heamorrhagic and crusting. Commonly affecting the face, neck and trunk. The primary attack is sever but the recurrence tend to be milder.
Disseminated Herpes Simplex It’s potentially fatal systemic HSV infection. Characterized by generalize mucocutaneous vesicles, pustules and erosions along with widespread visceral involvement (lung, liver, GIT & CNS) Risk Factors Includes:1. Immunodeficiency.e.g. AIDS, drugs, malignancy etc..2. Malnutrition3. Eczema herpeticum
Disseminated HSV in immuncompromized patient note the heamorrhagic and.necrotic skin lesions also this patient has infection of liver, lung and brain
1. Direct Microscopy Examination: Tzanck smear. smear2. Viral culture: It’s the most reliable way to make the diagnosis.3. Serology: Polymerase Chain Reaction (PCR). Useful in the diagnosis of culture –ve. or atypical lesion.
Most HSV infections are self-limited. However antiviral therapyshorten the course of the disease, prevent dissemination, andrecurrence.Treatment of 1ry attack .Acyclovir (Zovirax) 200mg orally 5 times for 7 daysTreatment of recurrence Acyclovir 400mg twice daily for one year suppresses recurrence by 75%
It’s acute localized viral infection caused by reactivation of varicella-zoster virus and characterized by unilateral pain and vesicular eruption limited to a dermatome innervated by a corresponding sensory ganglion.
EtiopathogEnEsis The causative virus is VZV ( varicella-zoster virus) The same virus causes varicella (chickenpox). During varicella the virus travel the sensory nerves to the sensory ganglion where it remain dormant and establish the latency. When immunity to the virus decreased the virus replicate within the ganglion then travel back the sensory nerve to skin resulting in dermatomal pain and skin lesion.
EpiDEMioLogY AGE AND SEX: There is no racial or sex predilection. Most cases are older than 50 years . RISK FACTORS:1. Diminished immunity with ageing.2. Immunosuppresions.3. HIV-infection.
CLiniCaL piCtURE PRODROMAL STAGE DAYS 3-5 ACUTE VESICULATION DAYS 3-5 CRUST FORMATION WEEKS 2-3 ? POST HERPETIC NEURALGIA MONTHS-YEAR
sKin LEsionsCloselygrouped vesicles & pustules.On an erythematous base.They may appear umbilicated.Segmental ( dermatoml ) distribution.New lesions continue to appear for a week.
sitEs of pREDiLECtions Thoracicregion ( >50% of cases ) Trigeminal region ( 10 - 20%) Lumbosacral and cervical ( 10 - 20%)
Typical grouped vesicles and pustules on an erythematous baseinvolving thoracic dermatomes on the chest wall.
Ophthalmic herpes zoster due to involvement of ophthalmic branch.of the trigeminal nerve with secondary dissemination
DiffEREntiaL DiagnosisProdromal Stage (Localized Pain)Migraine, cardiac or pleural disease, an acute abdomen.Cutaneous EruptionHerpes simplex virus infection,Contact dermatitis,Erysipelas,Bullous impetigo.
DiagnosisClinical picture usually diagnostic.Confirmed by Tzanck test.Viral culture to rule out HSV infection.
tREatMEnt The disease is self limited. The goals of treatment are.1. Minimize the pain. (Analgesic)2. Speeding the healing. (Topical & systemic antibiotic if 2ry bacterial infection)3. Prevention of dissemination. (Acyclovir 800mg / 6 hourly for 7-10 days)
Warts (( verrucaIt is a common, discrete benignepidermal hyperplasia inducedby different types of humanpapilloma virus (HPV)
epidemiology Warts are very common infection allover the world. Both sexes are equally affected. All ages but rare in infancy & common in school years. The highest incidence of common warts is between the age of ( 9 – 16 years). While for genital warts between 20 - 40 years. Warts more common in immuncompromized patients.
mode of transmission Major mode is skin-to-skin contact. Minor trauma with breaks in the skin facilitates transmission. Habitual nail bitter or children who suck their hand are at risk of auto-inoculation Shaving may spread warts over the beard. Genital wart is the commonest STD.
aetiology Warts caused by human papilloma vrius. There are over 80 subtypes of HPV. It is a double stand DNA virus belong to papovavirus family. The incubation period range from 1-6 months. Different subtypes of HPV are more or less causing specific clinical mainfestation. Some subtypes are oncogenic ( e.g cervical carcinoma caused by HPV 16 &18 ).
common Warts (verruca (vulgaris HPV subtypes 1, 2, 4, 26, 27 Papules / nodules with rough surface. They may occur singly or in groups. Can occur any where but most commonly over dorsal aspect of fingers & hands. Characteristic by black dots on the surface which represents thrombosed capillaries. New warts may appear at sit of trauma (koebner phenomenon). Periungual warts and filiform warts are variants of common warts.
Common warts: Multiple papules and nodules with rough.surface on the dorsum of both hand
Verruca vulgaris: Numerous nodules and papules with rough surfaceon the dorsum of left hand.
Periungual warts: Nodules with rough surface distributed aroundThe nails of the right hand.
Filiform warts: Multiple elongated ( thread like( projections onthe face of child.
plane Warts (verruca (plana HPV subtypes 3, 10, 27, 38. Slightly elevated papule with smooth surface. The number range from few to many hundreds. Skin-colored, light brown, pink, or hypopigmented. Shape may be round, oval, polygonal, or linear lesions ( auto-inoculation by scratching ). Common sit is the face or beard area, but may be seen on dorsa of hands
Verruca plana (flat warts( : Flat-topped, smooth surface, skin-color. numerous papules on the face
Verruca plana (flat warts( : Flat-topped, smooth surface, and.erythematous numerous papules on the dorsum of right hand
planter Warts ( verruca plantaris ) HPV subtypes 2, 4. Rough hyperkeratotic surface studded with black dots ( thrombosed capillaries ). Usually single but may be multiple. Affecting the planter aspects of feet or hands. When multiple warts coalesce into large flat plaque it is called mosiac wart. Paring using surgical scalpel will produces pinpoint bleeding spots. D.D : Callosities and Corns.
Verruca plantaris (planter warts ): Hyperkeratotic surfaces involving the planteraspects of right foot with coalesce forming mosaic warts
) callositis (d.d of planter WartCallositis are circumscribed plaque of hyperkeratosis induced by repeated friction or trauma. Commonly seen over weight bearing area.The surface is somewhat smooth and the epidermal ridges continue without interruption.Paring using surgical scalpel will not produces the pinpoint bleeding spots
.Callosities : Hyperkeratotic plaque over weight bearing area paring with surgical blade does not revels any bleeding spot
genital Warts (condyloma (accuminata HPV subtypes 6, 11, 16, 18. Cauliflower papules, nodules or plaques. Can occur solitary, multiple or in large masses. It is the most common STD. Seen in external genitalia of both sexes , perianal region and in anal canal . May affects the urethral meatus, urethra, vagina or cervix. Huge warts at risk of malignant changes. Important D.D is condyloma lata (2 ry syphilis).
Condyloma accuminata (genital wart( : small cauliflower.erythematous nodules on the shaft of penis
Condyloma accuminata: Multiple, soft skin-colored papules on the.glanus penis and shaft
Condyloma accuminata perianal: Multiple fleshy papules becoming confluent.cauliflower-like mass around the ananus
COURSE AND PROGNOSISImmuno-competent individuals, cutaneous HPV infectionsusually resolve spontaneously.- 50% of warts will resolve within 1 year.- 70% of warts will resolve within 2 years.Immuno-compromised patients, cutaneous HPV infections maybe very resistant to all modalities of therapy.
DIAGNOSIS1. History and examination:2. Acetowhitening test: Acetic acid 3.5% causes some cubclinical warts to develop shiny white surface color.3. PCR.4. Pap smear: For cervical and anal warts.
TREATmENT Treatment depend on no. of lesions, site of wart and cosmetic disability. Keratolytics. Chemical cautery. Retinoic acid. Cryotherapy. Electrocautery. Topical 5-flurouracil. Podophyllin 20%. Imiquimod 5%. Laser therapy.
CRyOThERAPy Using liquid nitrogen ( -196 Co ). Quite effective. The procedure is minimally painfull. Heals without scarring. Can be used for all warts.
Mark the lesion 2 mm. Start freezingMaintain freezing for 10 sec. weeks later 3
PODOPhyllIN 20% It is a cytotoxic agent that arrest mitosis. The treatment most commonly used for ganital warts. Contarindicated during pregnancy.
mOllUSCUm CONTAGIOSUm.Molluscum contagiosum is a self-limited viral skin infection, characterized clinically by skin-colored papules that are often umbilicated, occurring in children & sexually active adults.
AETIOlOGy Molluscum contagiosum virus (MCV). It’s a large double strand DNA virus belong to pox virus family. ( The largest virus known )
EPIDEmIOlOGy Skin-to-skin contact is essentials for transmission of the infection. MC is a common disease in children and adults. Both sexes are equally affected. In children occur on exposed skin. In adults may occur in genital skin (STD).
ClINICAl PICTURE Incubation period 4 - 8 weeks. The lesion is asymptomatic. The charactarestic skin lesion is a PAPULE :1. Size : Ranging from 2 – 10 mm.2. Number : Single to hundred. (no specific distribution)3. Color: Pearly white, translucent or skin-colored.4. Surface: Smooth surface with umbilicated center.5. Squeezing of lesion will extruded milky - white material.
Molluscum Contagiosum : Discrete, solid, skin-colored papules, 1 to 2.mm in diameter ,with central umbilication
Molluscum Contagiosum : Single pearly - white papule on the shaft. of penis