Viral Skin infections

The main viral diseases of the skin are:

1. Herpes simplex.
2. Herpes zoster.
3. Warts.
4. Molluscum contagiosum

Herpes simplex
It is one of the most common infections of the humans throughout the
world.

Aetiology:

– Herpes simplex is caused by Herpes Simplex Virus (HSV) type 1

which causes facial infections and type 2 which causes genital
infections.
– Both HSV1- and HSV-2 persist in sensory nerve ganglia after primary
infection in a state of latency.
– The virus may travel peripherally along the nerve fibre to replicate in
the skin or mucous membrane causing recurrent disease.
– The virus can be shed in saliva and genital secretions from
asymptomatic individuals.
– Incubation period: 2-12 days.
Clinical features
1) Primary herpes simplex infection:
– This occurs in individuals who are infected for the first time.
– It is usually subclinical (asymptomatic) but when clinical lesions
develop, the severity is generally greater than in recurrences.
– Primary infections occurs mainly in infants and young children.
– Constitutional symptoms as fever and malaise are common, vesicles
show no tendency to grouping and regional lymph nodes are usually
enlarged and tender. Spontaneous healing occurs within 1-2 weeks.
Clinical types of primary infections:
a) Herpetic gingivostomatitis:
– This is the most common clinical manifestation of primary infection
by HSV-1.
– Most cases occur in children between 1-5 years of age.
– After an incubation period of 5 days, the stomatitis begins with fever,
malaise, restlessness and excessive dribbling. Drinking and eating are

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 very painful and the breath is foul. The gums are swollen, inflamed
and bleed easily.
– Vesicles presenting as white plaques occur on the tongue and oral
mucosa. The plaques develop into ulcers with a yellowish
pseudomembrane.
– The regional lymph nodes are enlarged and tender. The fever subsides
after 3-5 days and recovery is usually complete in 2 weeks.
b) Herpes genitalis:
– Infection in the genital area is usually sexually transmitted.
– HSV-2 is the usual cause.
– Herpetic penile ulcers are the commonest cause of penile ulcers.
– In the male they occur on the glans, prepuce and shaft of the penis.
– In the female, ulcers occur on the external genitalia and mucosae of
the vulva, vagina and cervix.
– Pain and dysuria are common.
c) Keratoconjunctivitis:
– Primary herpes infection of the eye causes a severe and often purulent
conjunctivitis with superficial ulceration of the cornea.
– The eyelids are grossly oedematous and there may be vesicles on the
surrounding skin.
d) Inoculation herpes simplex:
It occurs secondary to direct inoculation of the virus into an abrasion in
the skin.

e) Eczema herpeticum ( Kaposi's varcilliform eruption):

The occurrence of herpes simplex infection on top of atopic eczema.
f) Neonatal herpes simplex:
– It is acquired as the child passes through an infected birth canal of the
mother.
– The risk to the neonate from primary herpetic vulvovaginitis in the
mother at the time of delivery is so great that caesarean section is
indicated and prophylactic acyclovir should be considered for the
neonate.
2) Recurrent infection:
– It occurs in persons previously infected with the virus.
– If the virus is reactivated causing recurrent disease.
– Recurrences may occur without an evident cause or they may be
triggered by:
- Minor trauma
- Immunodefeciency
- Febrile illness as URTI.
- Ultraviolet radiation,

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 - Trigeminal neuralgia,
- Dental surgery,
- Menstruation
- Emotional stress.
– Recurrent infections differ from primary herpes simplex in the smaller
size of the vesicles, their grouping, absence of constitutional
symptoms.
– Itching or burning precedes the development of small, closely grouped
vesicles on an erythematous base.
– They become crusted and healed in 7-10 days without scarring.
Clinical types of recurrent infections:
a) Herpes facialis (labialis):
– Favorite sites are the lips, around the nose and cheeks.
– Recurrences tend to be in the same region.
b) Herpetic keratoconjunctivitis:
– It occurs as punctuate or marginal keratitis or as dendritic corneal
ulcer.
c) Herpes genitalis:
– It usually presents with clusters of small vesicles which produce non-
indurated ulcers on the glans or shaft of the penis.
– Similar lesions may occur on the labia, vagina or cervix.

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Treatment
– Topical treatment:
- Drying lotion as 5% aluminum acetate for the vesicular stage.
- Antibiotics for secondary infection.
- Acyclovir cream.
- Systemic treatment:
- It is used only in severe cases.
- Acyclovir is the treatment of choice. The usual oral dose is
200mg five times daily or 800mg twice daily for 5 or more
days.

Varicella (chickenpox) and herpes zoster (shingles)

Varicella and herpes zoster are caused by the same virus; varicella zoster
virus (VZV). Varicella is the primary infection with a viraemic stage,
after which the virus persists in sensory nerve ganglion cells while zoster
is the result of reactivation of this residual latent virus.

Varicella (chickenpox)

Varicella is the primary infection with varicella zoster virus

(VZV). Transmission by direct contact with the lesions or by the
respiratory route. Patients are infectious to others from 4 days before to 5
days after the onset of the rash. Highest incidence is in children aged 2-10
years. It confers lasting immunity with one attack usually confers
permanent immunity.
Maternal varicella in the first 20 weeks of pregnancy is associated
with about 2% risk of fetal damage, including CNS and ocular defects,
and limb hypoplasia. If the mother has varicella within 4 days before to 2
days after term, the neonate would have no maternal antibody and is at
risk of severe varicella, with a mortality rate of up to 30% in the absence
of treatment.

Clinical features:
The incubation period is usually 14-17 days. After 1-2 days of
fever, often slight or absent in children, the eruption started with faint
macules that develop rapidly into vesicles. Within a few hours the
contents of vesicles become turbid and the pustules are surrounded by red
areolae.
In 2-4 days a dry crust forms and soon separate, to leave a shallow
pink depression which heals without scarring.
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 The vesicles appear in 3-5 crops over 2-4 days. They are most
numerous on the trunk, then on the face, scalp, limbs and oral mucosa.
Their distribution is centripetal.
A characteristic feature is the presence of lesions at different stages
in each site (vesicles, pustular, umblicated and then crusted).
There is mild pruritus.

Complications:
Complications are rare in healthy children and are common in the
immunocompromized.
Varicella in the immunocompromized may be severe, and
progressive, with a mortality of 10%.

Prevention of varicella:
Pre-exposure prophylaxis: A live attenuated vaccine is effective in
preventing varicella in healthy children and in reduction of its incidence
and severity in children with leukemia but does not affect the incidence of
zoster. Two doses of vaccine are given 3 months apart.
Post exposure prophylaxis: Done by specific zoster immune
globulin which if administered within 10 days of contact reduces the
severity of varicella but does not prevent it. It should be given to neonates
whose mothers develop varicella within the period from 7 days before to
7 days after delivery.
Treatment:
- Varicella in the healthy child requires only symptomatic treatment:
Antipruritic lotions and antihistamine for itching and antibiotics for
secondary infection.
- An antiviral is indicated for varicella in adults and for severe varicella
at any age in the immunocompromized. Treatment should be started as
early as possible, preferably within the first 1 or 2 days.
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Herpes zoster (shingles)

Zoster is an acute skin infection characterized by an eruption of

grouped vesicles following the distribution of a peripheral nerve (usually
sensory). The middle-aged and elderly individuals are most often
affected. The disease is also more frequent in immunocompromised
persons.
Maternal zoster in pregnancy is not associated with intrauterine
infection. Zoster occurring in infancy follows maternal varicella, the
baby’s primary infection having occurred in utero.
Etiology:

Varicella zoster virus (VZV) is the cause of the disease as a result of

reactivation of the latent virus. Other than immunosuppression and age
the factors involved in reactivation are unknown.

Incubation period: 2-3 weeks.

Clinical features:
 The first manifestation of zoster is usually pain, which may be
severe and may be accompanied by fever, headache, malaise, and
tenderness localized to areas on one or more dorsal roots.
 After 2-3 days, the eruption appears as closely grouped vesicles on
an erythematous base within the distribution of a sensory nerve.
 Mucous membranes within the affected dermatomes are also
involved.
 New vesicles continue to appear for several days. The regional
lymph nodes are enlarged and tender.
 The vesicles become pustular then crusted and heal in 2-4 weeks
with scars.
 The pain subsides gradually as the eruption disappears.
 The eruption is almost invariably unilateral and usually affects one
dermatome. The thoracic (commonest), cervical, trigeminal and
lumbosacral dermatomes are the most commonly affected.
 Recurrence of the disease is very rare as one attack gives
permanent immunity.
Ophthalmic zoster (Herpes zoster ophthalmicus):
Herpes zoster may affect any of the divisions of the trigeminal
nerve but the ophthalmic division is the most commonly in the form of
uveitis and keratitis.

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Ramsay-Hunt syndrome:

It is due to involvement of the geniculate ganglion and constitutes

of vesicles on the external ear, facial palsy and auditory symptoms as
tinnitus, deafness and vertigo.

Complications:
- Post herpetic neuralgia: This is the commonest and most intractable
complication of zoster and is defined as persistence or recurrence of
pain more than a month after the onset of zoster.
- Ocular complications.
- Secondary bacterial infection and gangrene.
- Encephalitis.
- Facial palsy.
Treatment:
- Topical treatment:
As for herpes simplex.
- Systemic treatment:
Analgesics for pain.
Antibiotics for secondary bacterial infection.
Antiviral as acyclovir, famciclovir are used in severe cases.

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 Warts (Verrucae)

Warts are common contagious cutaneous growths caused by human

papilloma virus (HPV). They are common in children and young adults
and rare in the elderly.
Mode of transmission:
Warts spread by direct or indirect contact. Trauma and maceration greatly
predispose to inoculation of the virus.
Clinical types:
1. Common warts:
- They are firm papules with a rough horny surface and range in size
from 1 mm to over 1 cm.
- Most commonly situated on the back of the hands and fingers.
- The lesions are usually symptomless.
2. Planter warts:
- Appear as a sharply defined rounded lesion, with a rough keratotic
surface surrounded by a smooth collar of thickened horn.
- Most planter warts are beneath pressure points, the heel or the
metatarsal heads.
- Warts may be single or numerous.
- A cluster of small satellite warts may develop around a large wart.
- Pain is a common symptom.
3. Plane (flat) warts:
- They are smooth, flat or slightly elevated, and usually skin colored or
grayish yellow.
- They are round or polygonal in shape and vary in size from 1 to 5
mm.
- The face, dorsa of the hands and the shins are the sites of predilection
and they are generally multiple.
- New warts may form at the site of trauma (Koebner phenomenon).
4. Filiform and digitate warts:
- Filiform warts are slender, thin and commonly occur on the face and
the neck.
- Digitate warts show finger-like growths usually occur on the scalp.
5. Anogenital warts (condylomata acuminata):
- Genital warts are the most common sexually transmitted disease.
- These warts are often asymptomatic, but many cause discomfort,
discharge or bleeding.
- The typical anogenital wart is soft, pink, elongated and sometimes
pedunculated.
- These lesions are usually multiple, especially on moist surfaces.

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- The sites of predilection are frenulum, corona and glans in men, the
posterior fourchette in women and perianal area and groin in both
sexes.
- They are closely linked with cervical carcinoma.
- The lesions should be differentiated from condylomata lata of syphilis.

Treatment:
1. Chemical treatment:
- Salicylic acid 15-20%
- Podophyllin 10-25% for anogenital warts.
- Formalin 2-3% for plantar warts.
2. Electrocautery.
3. Cryotherapy.
4. Laser.

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 Molluscum contagiosum

It is a contagious disease caused by Molluscum contagiosum virus

(MCV) (poxvirus).
The disease is common. Infection follows contact with infected persons
or contaminated objects. It is common in children and young adults.
Mollusca contagiosa are contagious, and infected children should avoid
contact with other children with atopic dermatitis or immunosuppression.
They should also avoid contact sports and shared wash clothes or towels.
Clinical features:
- The incubation period is 2 weeks to 6 month.
- The primary lesion is a shiny, pearly white, hemispherical,
umbilicated papule which on squeezing a white cheesy material can be
expressed. It averages 3-5 mm in diameter
- The lesions are usually multiple and occur mainly on the face, trunk
and extremities.
- Most cases are self limiting within 6-9 months

Treatment:
- Spontaneous disappearance of the lesions may occur.
- The choice of treatment will depend on the age of the patient, and the
number and site of the lesions.
- Two methods are available for treatment:
o Destruction of the lesions can be achieved by: cryotherapy,
curettage and diathermy, simple mechanical methods or by
laser.
o Production of an inflammatory response that can hasten
clearance can be achieved by: topical preparation (phenol
liquid, salicylic acid, imiquimod).
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