Viral Skin Diseases

Li Xin
The First Affiliated Hospital of Zhengzhou University,
Department of Dermato-venereology
Definition
● Viral skin diseases are mucocutaneous lesions
caused by virus.
● Different viruses have different organization
tropisms.
● Such as: Loading…
Herpes simplex virus cause herpes simplex.
Herpes virus causing herpes zoster due to the
characteristics of epidermal and neurotropic.
Human papilloma virus addicted to skin which
can cause all kinds of warts .
General Situation of Viral dermatosis
• chicken pox
• verruca vulgaris
• plane warts
• herpes simplex
• molluscum contagiosum
DNA virus

• hand-foot-and-mouth disease
• measles
• rubella

RNA virus

There are many kinds of viruses, which are divided into DNA viruses and RNA viruses
according to their nucleic acid types.
General Situation of Viral dermatosis
Viral dermatosis can be divided into three types according to clinical characteristics.

neobiotype Herpetic type Erythematous

Loading… rash type

• verruca vulgaris • chicken pox • measles

• plane warts • herpes simplex • rubella
• Condyloma acuminatum • hand-foot-and-mouth disease
• molluscum contagiosum • herpes zoster
Viral Skin Diseases
➢Herpes Simplex
➢Herpes Zoster
➢Warts
➢Molluscum Contagiosum
➢Hand-Foot-Mouth Disease
LOGO
Objectives

➢ To grasp the knowledge of the causes and

clinical features of viral skin diseases.

➢ To understand the knowledge of the

diagnosis and management of viral skin
diseases.

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 Have you ever suffered from any of these
diseases?

• 单纯疱疹病毒照⽚

The pattern of lesions was similar. Both were cluster blisters.

Herpes Simplex
Definition

Herpes simplex is caused by

herpes simplex virus ( HSV ).
The clinical characteristics are cluster
blister, self-limited, but prone to
recurrence.
Definition

Pathogeny
Herpes simplex is caused by
herpes simplex virus ( HSV ).
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The clinical characteristics are cluster
blister, self-limited, but prone to
recurrence.
 Pathogeny
• HSV contains double-stranded DNA and belongs to the herpesvirus family.

• Viruses are classified into type I and type II.

• Humans are the only host of herpes simplex virus.

• HSV can be present in the blister fluid, mouth, nose, and genital secretions

of an infected person.

• HSV has neurotropic and epidermal characteristics.

• Spread through close contact.

 Pathogeny
Types
• HSV contains double-stranded DNA and belongs to the herpesvirus family.

• Viruses are classified into type I and type II.

• Humans are the only host of herpes simplex virus.

• HSV can be present in the blister fluid, mouth, nose, and genital secretions

of an infected person.

• HSV has neurotropic and epidermal characteristics.

• Spread through close contact.

Types
HSV-1: mostly responsible for
herpes labialis and herpetic
gingivostomatitis

HSV-2: usually associated with

herpes genitalis
● HSV enters through small defects in skin or mucosa
and starts to replicate locally; then ascends via axons to
sensory ganglia where futher replication occurs. After
the primary infection, HSV become latent in the
sensory ganglia.

● Virus could be reactived by various trigger facters as

well as local or systemic immunosuppression
 Non-immune population

Primary infection Herpes simplex virus

Invisible infection
primary type （90%） Recurrent type
（1%~10%） Herpes on the lips and face
Herpetic gingivostomatitis
Eczema herpeticum Predisposing factor
Herpes whitlow Clinical Features Fever
Neonatal herpes simplex cold
menstruation
sun exposure
Genital herpes emotional agitation
indigestion
virus
Latent in the body
 Clinical Features
• Both HSV-1 and HSV-2 infections have similar clinical
manifestations that most commonly develop on skin and mucosa
junction.

• The incubation period is about 6-8 days.

• Erythematous macules or patches

→→ clusters of small blisters

→→ change into superficial

ulcer with crusts.

Herpetic gingivostomatitis
Herpes whitlow
Eczema herpeticum
Herpetic gingivostomatitis
Herpetic gingivostomatitis is the most common
clinical type of primary infection with HSV-1.
Herpetic gingivostomatitis
• Small painful vesicles appear on pharyngeal and
oral mucosa, soon ulcerate, and increase in number
to involve buccal mucosa, tongue, soft palate, floor
of mouth, lips and cheeks.
Herpes whitlow
• HSV infection of the fingers may be develop from
primary oral or genital herpes by autoinoculation, or
may occur through occupational exposure.
Eczema herpeticum
• HSV infection of the skin is much more severe in
patients with pre-existing skin lesions including
eczema, burns, or other blistering skin diseases.
Genital herpes
• Genital herpes usually occurs in sexually active
population aged 15-45.
Neonatal herpes simplex
• Majority of cases are caused by HSV-2, and often
acquired by vaginal delivery of infected mother.
• Incubation is 4-7 days usually.
• Neonatal HSV infection may occur as lesions on the
skin, eye, and mouth, or as encephalitis or
disseminated splanchnic infection.
Neonatal herpes simplex
● Congenital infection may be accompanied with
jaundice, hepatosplenomegaly, disseminated
intravascular coagulation, encephalitis and seizures
with or without mucocutaneous lesions.

● Without treatment, visceral infection has a high

mortality.
Diagnosis and Differential Diagnosis
● Diagnosis is made mainly depending on the
typical clinical presentations.
● Change in specific antibody titer can be
used to diagnosis primary infection but not
to recurrent lesions.
● The differential diagnosis can be any of the
following: herpes zoster, chicken pox and
impetigo.
Treatment
Antiviral therapy
(1).Primary mucocutaneous infection
• Acyclovir 200mg 5 times daily need to be given
orally for 7 to 10 days from the onset.
• Famciclovir 250mg 3 times daily.
• Valaciclovir 500mg twice daily are alternatives.
(2).Long-term suppressive therapy
This can be considered in patients who have
frequent reactivation episodes( more than six
occurences per year)
A dose of acyclovir 400mg twice daily
remarkably reduces the frequency of viral attacks.
(Treatment 6 to 12 months)
Treatment
(3). Neonatal herpes simplex
Intravenous acyclovir [30-60mg/(kg·d)]
need to be given for 10 to 21 days.

General measures
Cleansing mouthwashes with
benzalkonium bromide 1:1000 clean the
involved mucous membrance.
Apply topical antibacterials to prevent
bacterial superinfection.
Herpes Zoster
Herpes Zoster
• Herpes Zoster is caused by the varicella-zoster virus
(VZV), which is characterized by small blisters
clusters along the peripheral nerve in zonal
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distribution by unilateral side, often accompanied
by significant neuralgia.
 Lesions are in zonal distribution along the
Herpes Zoster peripheral nerve , just occurring in
unilateral side.
 The lesion often appears erythema, soon to form
soybean size miliary papules by clustered
Herpes Zoster distribution without fusion, becoming blisters
quickly.
Herpes Zoster

● Etiology
● Clinical Features
● Diagnosis and Differential Diagnosis
● Treatment
Etiology
• Human is the only host of VZV.
• The virus may enter blood through the respiratory
tract mucosa to form viremia, presented by chicken
pox or talent infection, then the virus can become
latent in the spinal cord root ganglia or nerve
sensory ganglion.
• After certain stimuli such as trauma, fatigue, cancer,
or weakness after illness which may decrease the
host immune response, the latent virus is activated
resulting in downstream along the sensory nerve
axon, to reach the region dominated by nerve and
replicate locally, resulting in blisters, and the nerve
is involved reducing inflammation , necrosis,
accompanied by neuropathic pain.
LOGO Clinical Features
● Small blisters clusters on the basis of erythema;
● The lesions along the peripheral nerve in zonal
distribution by unilateral side;
● accompanied by significant neuralgia.

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LOGO A typical manifestation

● Mild fatigue, fever, anorexia and other systemic

symptoms are earliest symptoms, soon followed by skin
lesions.
● Skin burning or burning conscious, touch-sensitive
obvious pain in the affected area, persisting for 1-5 days,
without any prodromal symptom.
● The lesion often appears erythema, soon to form soybean
size miliary papules by clustered distribution without
fusion, becoming blisters quickly.

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➢ Lesions are in zonal distribution along the
peripheral nerve , just occurring in
unilateral side, generally do not exceeding
the midline.
➢ Intercostal nerve, cervical nerve, the
trigeminal nerve and sacral nerve area are
often involved.
➢ Neuralgia may occur before and during
the onset of lesions.
A typical manifestation
• The course of the disease often lasts for 2-3 weeks,
3-4 weeks among the elderly, leaving a temporary
redness or pigmentation.
Special performance
• Eye shingles (herpes zoster ophthalmicus)
The ophthalmic of the trigeminal nerve are
involved, common in the elderly, severe pain, the
cornea can result in formation of ulcerative keratitis.
Special performance
• Ear shingles (herpes zoster oticus)
The facial nerve and hearing nerve are involved,
manifested by herpes in ear canal or tympanic
membrane.
 Special performance

Ramsay-Hunt syndrome
Geniculate ganglion of facial nerve are involved while
violating the motor and sensory nerve fibers, which may
result in facial paralysis, earache, and ear canal triad of
herpes.
Special performance

•Post-herpetic
neuralgia (PHN)
 Before,
Special performance

● Others
Frustrated type (only neuralgia without rash)
Incompetence type (only erythema, papules
without blisters)
Bullous type
Blood type
Gangrene type
Pan-onset type (more than 2 ganglions are
involved)
 Diagnosis and Differential Diagnosis
Clinical presentation

Early erythema, concentrated blister, Late blister fluid turbidness, scab, the whole
distributed along the nerve, not beyond the course of the disease about 7 days
midline
Diagnosis and Differential Diagnosis
● Differential Diagnosis:
Intercostal neuralgia
Pleurisy
Appendicitis other painful diseases

Sciatica
Urinary tract stones
Migraine
Herpes simplex
impetigo
Prevention and Treatment
The disease is self-limited, the principles of therapy
including anti-viral, pain relief, anti-inflammatory
and preventing complications.
•Drug therapy

•Topical therapies

•Physical therapy
Prevention and Treatment
• Drug therapy
(1)Antiviral drugs
Acyclovir 800 mg, orally, 5 times a day
valaciclovir 1000 mg, orally, 3 times a day
famciclovir 250 mg, 3 times a day orally.
Course of treatment is 7 days.
(2)Pain relief
Gabapentin, pregabalin and neurotrophic drugs,
such as oral or intramuscular vitamin B1, B12 can
be applied.
Prevention and Treatment

(3) Corticosteroids
Prednisone 30-40 mg/d should be taken during
7 days post-infection in elderly patients without
other related diseases, for 7-10 days orally.
Inhibit inflammatory process and shorten the
course of acute phase of herpes related pain, but
efficacy for prevention of PHN is not as definitive.
Prevention and Treatment
Topical therapies
(1) Drug for external use
Calamine lotion
Acyclovir cream
Penciclovir cream
3% boric acid solution
1:5000 nitrofurazone solution
(2) Eye care
3% acyclovir eye ointment
Iodine monophosphate eye drops
Prevention and Treatment

• Physical therapy
Ultraviolet light
Spectrum therapy
Infrared
Acupuncture
Warts
Warts
• Warts are new benign growths on the skin and
mucous membrance, caused by viruses from the
HPV family.
• Four types of warts including:
Verruca Vulgaris
Verruca plantaris
Verruca plana
Genital wart
Etioloy
• The disease is transmitted primarily by direct or
indirect contact.
• The source of infection may be patients and healthy
carriers of the pathogens.
• Through the broken skin and tiny abrasion in the
mucosa, HPV enter and replicate inside the cell,
inducing abnormal differentiation and proliferation
of epithelial cells, causing benign epithelial
neoplasms.
Clinical Features
• Verruca vulgaris
The lesions commonly occur in the back of the
hand, fingers, feet and skin around nails, and other
part of the body.
A typical lesion size is like soybean or lager,
grayish brown, brown or skin colored papules, with
a rough surface, hard texture, and may presented as
papilloma hyperplasia.
The lesion around the nails is called periungual wart,
beneath the nail plate called subungual wart.

Wart with protruding thin filaments on the top is

called

verrucal filiformis, often occurring on the neck,

forehead

and eyelids. Wart with irregular surface is called

digitate
Clinical Features
beneath the nails is called subungual wart

Wart with protruding thin filaments on the

top is called verrucal filiformis

Wart with irregular surface is called digitate

wart
Clinical Features
Verruca plantaris
Verruca plantaris commonly occur on sole of the
foot.

Early lesions are like small shiny papules, then

gradually grow up to a size of soybean and form
pale yellow or brown flat-surfaced corpus callosum-
like papules or plaques under pressure, with a round
or oval shape, and a rough hard surface surrounded
 by a slightly protruding keratin ring.

Clinical Features
Clinical Features
Clinical Features
Clinical Features
• Verruca plana
Typical lesions are flat-topped elevations with the
size from rice to soybeans, in a round or oval shape,
smooth surface, hard texture, normal color or light
brown.
Clinical Features
Clinical Features
➢ Linear rash
➢ Flat papules
➢ The lesions can be arranged in a string of beads
after scratching, which is called self-inoculation
response.
Clinical Features
• Genital warts

Genital warts also

called condyloma
acuminatum.
Histopathology
• The common features are characterized by vacuolization
of cells in granular layer and spinous layer and virus
particles in nuclear under electron microscope.
Diagnosis and Differential Diagnosis
• History

•Typical skin lesions

•Pathological examination

•HPV DNA test

Treatment
Topical medication
(1) 0.05%-0.1% Vitamin A acid cream or adapalene
cream, administered topically 1 or 2 times per day for
flat wart.
(2) 5-fluorouracil ointment, 1 or 2 times per day for
external use, used with caution in the face due to
pigmentation.
(3) Bleomycin 10mg with 1% procaine dilution 20ml
injected in the wart root, 0.2-0.5 ml each wart, once per
week for refractory common warts and plantar warts.
Treatment
Physical therapy
Including freezing, electrocautery, curettage, and
laser surgery, which are suitable to treat small lesions.

Internal medication
There are no specific anti-HPV drugs.
Immunomodulatory agents can be tried.
Traditional Chinese medicine may get better effects
in some patients.
 Molluscum
Contagiosum
Molluscum Contagiosum
Molluscum Contagiosum is a contagious skin disease
caused by molluscum contagiosum virus (MCV)
infections.
Etiology
● MCV is a pox virus, the most common type is
MCV-1.
● Almost all children patients are caused by MCV-1
type, however, approximately 60%
immunocompromised persons are caused by MCV-
2.
● Close contact is the main routine of transmission,
which can also be transmitted through sex or
 indirectly routine in swimming pools and other

Clinical Features
• The disease mostly occurs in children, the sexual
active population and immunocompromised
persons.
• Incubation period is 1 week to half a year.
• Lesions can occur in any part of the back, limbs,
trunk or face among children.

• A typical lesion is a hemispherical papules in 3-5

mm size, pearl gray, the wax-like luster, umbilical
concave, cream cheese-like substance that contains
molluscum bodies.
Clinical Features
Diagnosis and Differential Diagnosis
• Typical clinical manifestations
• Pathological examination
Prevention and Treatment
• Scratching usually should be avoided to prevent the
spread of this disease.

• Therapy topically such as Victoria A acid ointment

or cantharidin can be used.

• Removing molluscum bodies using curved forceps

in sterile conditions is very effective and topical
iodine to prevent bacterial infection.
Hand, Foot and Mouth
Disease
• Hand, Foot and Mouth Disease (HFMD) is a viral skin
disease characterized by blister occurring in hand, foot
and mouth, mainly in children.
• This disease is mainly transmitted through the fecal-
oral route.
• It can also be spread by droplets through the respiratory
tract.
• The disease is related with Coxsackie virus.
Clinical features
•The disease is commonly seen in children
under 5 years.
•Incubation period:3 to 7 days
•Fever, headache, anorexia and other prodromal
symptoms may occur before 1 to 3 days of red
spots appear on hand, foot and mouth, which
develop into 2-4 mm blisters with thin wall and
clear liquid, surrounded by a pink areola.
•The lesions heal within a week and the

Clinical features
Clinical features
Clinical features
Diagnosis and Differential Diagnosis

● Typical clinical manifestations

● Epidemiological history

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HFMD should be differentiated from Erythema
multiforme, herpes pharyngitis and chicken pox, etc.
 Prevention and Treatment
• The patients should be isolated to prevent the spread of
the disease in nursery.

• Supportive and symptomatic measures are needed.

Thank you