This document discusses several common viral skin infections. It begins by introducing cutaneous manifestations of viral infections and how they are clinically diagnosed. It then covers the common DNA and RNA viruses that cause skin infections, including human papillomavirus, molluscum contagiosum, herpes simplex virus, varicella zoster virus, and coxsackie virus. For each virus, it describes the clinical features, pathogenesis, complications, investigations, and treatment approaches. It also provides details on viral exanthems including measles and rubella. Throughout it emphasizes the characteristic morphology, distribution, inclusion bodies, and clinical course of different viral skin infections.

1. VIRAL INFECTIONS

2. INTRODUCTION
• Cutaneous manifestations – common in viral
infections
• Characterized by definite morphology and
distribution - clinically diagnosed
• Light microscope - visualized only when
aggregated into inclusion bodies
 Intranuclear inclusion bodies are seen in the
herpes virus group and papilloma virus group
 Intracytoplasmic inclusion bodies are seen in
the poxvirus group

3. COMMON VIRAL INFECTIONS OF SKIN
DNA VIRUSES:
 Papova virus - Human Papilloma Virus - Genital & Non-genital
warts
 Pox virus - Molluscum Contagiosum, small pox, milker’s
nodules, Orf
 Herpes virus - Varicella Zoster Virus - Varicella, Herpes
Zoster; Herpes Simplex Virus I & I I- Herpes Simplex
RNA VIRUSES:
 Picornavirus – Coxsackie virus – Hand foot mouth disease
Retrovirus - HIV

4. MANIFESTATIONS DUE TO VIREMIA AND
HYPERSENSITIVITY
• Viral exanthems
 First disease - Measles (Rubeola)
 Third disease - Rubella (German Measles)
 Fifth disease - Erythema Infectiousum
 Sixth disease - Roseola Infantum
• Hypersensitivity reactions
 Pityriasis rosea
 Gianotti crosti syndrome

5. ETIOPATHOGENESIS
 Cell lysis - Herpes
 Cell proliferation - Pox, HPV
 Carcinogenesis - Cervical Ca, Hepatoma
 Exanthemata - Viraemia, Type 3 hypersensitivity
(Arthus) reaction, virus lodged in dermal
capillaries and replicate in epidermis
Persistent infection: Periods of latency and
reactivation (HSV, VZV)

7. HUMAN PAPILLOMA VIRUS INFECTION - WARTS
 Most common mucocutaneous viral infection
 Incubation period: few weeks to about one year
 Asymptomatic latent infection to warts to squamous
cell carcinoma
Direct or indirect contact (nail biters, shaving,
occupational, swimming pool); sexual transmission;
autoinoculation
Koebnerization – pseudo Koebner phenomenon

8. CLINICAL TYPES
Non genital: Verruca vulgaris (Common warts) – HPV
2
Verruca Plana (Plane warts) - HPV 3, 10
Filiform
Digitate
Palmoplantar
Periungual
Genital: Condyloma Acuminata – HPV 6,11, 16,18
Bowenoid papulosis – HPV 16
Buschke-Lowenstein tumor – HPV 6,11
Epidermodysplasia verruciformis

20. HISTOPATHOLOGY
 Hyperkeratosis
 Papillomatosis
 Acanthosis
 Vacuolation in the stratum granulosum and stratum spinosum
- koilocytes

22. TREATMENT
 Topical Keratolytics : Salicylic Acid, Urea, Wart solution (Lactic
acid/Salicylic Acid)
 Chemical cautery: Podophyllin, TCA
 Cryotherapy
 Electrocautery
 Radiosurgery
 Laser therapy
 Photodynamic Therapy
 Others: Formalin soaks, Imiquimod, 5FU, retinoids, immunotherapy,
Bleomycin, Interferon
 Systemic Immunomodulators: Levamisole, Cimetidine

23. SMALL POX
• Eradicated in 1977. Only humans, no carriers
• Eosinophilic inclusions - Guarnieri’s bodies
• IP=12-14 days
• Fever, chills, myalgia, rash 3-4 days later
• Firm papulovesicles, pustular in 10-12 day
• All in the same stage of evolution
• Edward Jenner - vaccinia virus

25. MOLLUSCUM CONTAGIOSUM
• MCV-1 to – 4 ; MCV 1 – children, MCV 4 – HIV infected
• Incubation period: 2 weeks to 6 weeks
 Transmission: contact, fomites, sexual
 Dome shaped, pearly white, discrete umbilicated papules - Face,
neck, trunk, peri-genitals (sexual transmission), eyelids (HIV).
 Pseudo Koebner’s phenomenon
 Giant Molluscum Contagiosum (1.5 cm) – HIV infected
 Differential – cryptococccosis, histoplasmosis, penicilliosis
 Tzanck – Henderson Patterson bodies

29. TREATMENT
 Expression / Curettage
 Chemical cautery, Electrodessication, Cryotherapy.
 Topical: Imiquimod, KOH, Phenol, Cantharidine,
Cidofovir.
 Systemic: Levamisole, Cimetidine, cidofovir

30. HERPES SIMPLEX VIRUS
 HSV 1: Facial (above waist)
 HSV 2: Genital (sexual)
 Incubation Period : 3-7 days
 First clinical episode - true primary infection or non primary
 Persist in sensory ganglion - period of latency
 Recurrent infection

31. CLINICAL FEATURES
 Grouped vesicles on erythematous base followed by
erosions and healing
 Primary attack: severe with lymphadenopathy and systemic
complaints
 Non primary : lower frequencies of systemic symptoms,
shorter duration of pain, fewer lesions, shorter healing time
 Recurrences: mild with shortened clinical course, smaller
size of the vesicles, close grouping and absence of systemic
symptoms
 Predisposing factors: trauma, sunburn, stress, coitus,
premenstrual, high grade fever, infections, surgery,
dermabrasion

32. HERPES SIMPLEX- CLINICAL TYPES
 Herpes Simplex Virus I :
Herpes Labialis, Herpetic Gingivostomatitis, Herpetic
whitlow, Herpetic gladiatorum, Herpes sycosis,
Keratoconjunctivitis
 Herpes Simplex Virus II:
Herpes progenitalis, Herpetic vulvovaginitis, recurrent
lumbosacral herpes, HSV infection in newborn
 Complicated:
Eczema herpeticum, Disseminated HSV
 Herpes Simplex Virus in HIV:
Chronic, recurrent, ulcer, eschar formation and
dissemination
Chronic HSV more than 1 month – AIDS defining

37. COMPLICATIONS
 Radiculoneuropathy
 Dissemination
 Meningitis / encephalitis
 Erythema multiforme
 Eczema herpeticum
 Ocular complications

38. INVESTIGATIONS
 Tzanck smear : Multinucleated giant cells
 Histopathology : Ballooning degeneration,
intraepithelial blisters, inclusion bodies
 HSV antibody titre : IgG/IgM
 Culture
 Immunofluoroscence, PCR
 Electron microscopy

40. TREATMENT
 Symptomatic
 Topical: Acyclovir, Penciclovir, Cidofovir
 Systemic:
Antiviral Primary
(10 days)
 Resistant – foscarnet, cidofovir
Recurrence
(5 days)
Suppressive
6months-1yr
Acyclovir 200mg
5times/day
400mg tid 400 mg bd
Valaciclovir 1gm bd 500mg bd 500-1000 mg bd
Famciclovir 250mg tid 125mg bd 250mg bd

41. VARICELLA ZOSTER VIRUS
Chicken pox and zoster (shingles)
Transmission: Droplet infection - nasopharynx
Varicella : primary viraemia
Zoster: Reactivation of residual latent virus in
the sensory nerve ganglion

42. VARICELLA - CLINICAL FEATURES
 Incubation period: 2-3 weeks
 2-10 years
 Prodromal symptoms
 Pleomorphic, centripetal distribution, dewdrops on rose petal
appearance
 Vesicles, papulovesicles, crusting, haemorrhagic, umbilicated
lesions

44. COMPLICATIONS
 Secondary infection
 Encephalitis
 Pneumonitis
 Hepatitis
 Varicella in HIV- Progressive, haemorrhagic, complicated
 Chronic varicella- Hyperkeratotic lesions, Acute retinal
necrosis
 Reye syndrome
 Congenital varicella syndrome

45. TREATMENT
 Symptomatic:
Rest, Antibiotics, Anti-inflammatory, Calamine lotion
 Antivirals - Indicated in adult varicella; reduces severity, duration &
infectivity in childhood chicken pox
 Acyclovir : 800 mg 5 times/day
 Valcyclovir : 1gm tds - contraindicated in immunosuppresed
individuals - Thrombotic thrombocytopenic purpura and hemolytic
uremic syndrome
 Prophylaxis:
Vaccine, Immunoglobulin, Acyclovir

46. HERPES ZOSTER
 Reactivation of latent virus in the dorsal root ganglion of
sensory nerve
 Older age group >50 years
 Unilateral, dermatomal, grouped vesicles
 Cranial (V, VII commonly), spinal (thoracic commonly)
 Pre-herpetic, herpetic and post-herpetic neuralgia

48. HERPES ZOSTER : CRANIAL NERVE
INVOLVEMENT
V Nerve:
 Ophthalmic division: Herpes Zoster Ophthalmicus
Hutchinsons sign (vesicles on nose tip)
Ocular complications: uveitis, keratitis, conjunctivitis,
scleritis, ocular palsy
 Maxillary division: uvula / tonsils
 Mandibular division : tongue / buccal mucosa

50. HERPES ZOSTER : CRANIAL NERVE
INVOLVEMENT
VII nerve :
Ramsay Hunt syndrome:
 Earache, vesicles on pinna, facial palsy
 Hearing loss, vertigo and taste sensation impaired

51. COMPLICATIONS
 Secondary infection
 Post herpetic neuralgia
 Scarring
 Nerve Palsy
 Encephalitis : in disseminated zoster

52. HERPES ZOSTER IN HIV
 Younger patient
 Severe pre, herpetic and post-herpetic neuralgia
 Multi-dermatomal, cranial nerve involvement
 Haemorrhagic, disseminated
 Protracted course, verrucous lesions
 Acute retinal necrosis

54. TREATMENT
 Symptomatic
 Antivirals:
Acyclovir 800mg x 5times/day
Famciclovir 500 mg tds
Valaciclovir 1gm tds
Duration : 1week in immunocompetent
2weeks in immunosuppressed
 Steroids : in cranial nerve involvement

55. TREATMENT OF POST HERPETIC NEURALGIA
 Steroids
 Analgesics
 Amitryptilline, Doxepine
 Phenytoin, Carbamazapine, Sodium valproate
 Gabapentine
 Methylcobalamine
 Topical EMLA cream
 Topical capsaicin
 Intralesional Steroids

56. HAND-FOOT-AND-MOUTH DISEASE
• Coxsackie virus A16, A5, A7, A9, and B 1, 2, 3;
enterovirus 71
• IP - 4-6 days
• Vesicles  painful erosions and ulcers on an
erythematous base on buccal mucosa, tongue,
palate, uvula.
• Gray-white vesiculopustules on palms, soles,
dorsal or lateral surfaces of hands and feet.,
buttocks, thighs, and external genitalia
• Cervical and submandibular lymphadenopathy
• Encephalitis, aseptic meningitis, and myocarditis
• Hand hygiene

58. VIRAL EXANTHEMS

59. MEASLES (RUBEOLA/ MORBILLI)
• Preschool children; IP - 10-12 days
• 3 C’s —cough, coryza and conjunctivitis
• Koplik’s spots - blue white spots with a red halo on
buccal mucosa opposite the premolar teeth
• Maculopapular rash begins on the 4th day; face,
behind the ears  trunk and extremities in 24-36
hrs maximum intensity in 3 days fades after 5-
10 days with desquamation
• Pneumonia, bronchitis, otitis media, gastroenteritis,
myocarditis, encephalitis
• Vitamin A supplementation; Vaccination at 9 -15
months

61. RUBELLA (GERMAN MEASLES/ 3 DAY MEASLES)
• > 15 years ; IP-12 to 25 days
• Posterior auricular Lymphadenopathy 4 to 7 days
before; maximal at onset; resolve in a week
• Forcheimer spots - petechiae of soft plate
• Maculopapular rash begins on neck or facetrunk
and extremities in a dayconfluent on face 2nd
day confluent on trunk, fades in face3rd day fully
fades
• Arthralgia, arthritis, encephalitis, thrombocytopenia
• Congenital rubella syndrome
• Vaccination at 15 months or older; 3 months
contraception

63. ERYTHEMA INFECTIOSUM
• 2-15 years
• 3 overlapping stages - facial erythema (slapped
cheek); Fades in 4 days 2 days laternet
pattern erythema – on extremities ; extends to
trunk and buttocks for 6-14 daysrecurrent
phase - fades and reappears in the next 2 to 3
weeks
• Papular-purpuric gloves and socks syndrome;
petechial exanthems
• Arthritis, transient aplastic crisis, chronic anemia
• In utero infection- hydrops fetalis, congenital
anemia

66. ROSEOLA INFANTUM EXANTHEM SUBITUM, “SUDDEN RASH”, 3
DAY FEVER
• 6 months- 2 years of age
• IP - 5-15 days
• Inappropriately well for the degree of fever
• Mild to moderate lymphadenopathy
• Seizures
• Rash begins as the fever subsides
• Pale-pink, almond-shaped confluent macules on
trunk and neckfade in a few hours to 2 days
without scaling or pigmentation

68. PAPULAR ACRODERMATITIS OF CHILDHOOD
GIANOTTI-CROSTI SYNDROME
• Hepatitis B (ayw), EBV (commonest), CMV,
coxsackie, respiratory virus, parvoviruses,
rotavirus, and HHV 6
• Vaccination –MMR, oral polio, DPT, hepatitis B.
• 2-6 yrs, males common
• Asymptomatic, symmetrical, edematous,
erythematous, monomorphous, papules and
papulovesicles, on face, extensors of upper and
lower extremities
• Lymphadenopathy, hepatomegaly and anicteric
hepatitis
• Self limited, lasts for 2-8 weeks.