Viral Infections
A. Warts (caused by the human papilloma-viruses). The lesions are most common on the hands, feet, and face. They are infectious and autoinoculable. Common in children, the elderly, or in patients with immunologic deficiencies or atopic dermatitis. Treatment is with mild destructive chemicals (salicylic and lactic acid preparations), liquid nitrogen therapy, or electrodesiccation.
Recurrences are common (25%). Cicatrix caused by treatment may be painful and is often confused with persistence of the wart, especially on the sole of the foot.
B. Herpes simplex viruses types I and II are DNA viruses. The early lesions are multiple, 1 to 2 mm in diameter, yellowish, clear vesicles on an erythematous base. The vesicles can ulcerate and become quite painful. Classic type I herpes occurs around the mouth, and type II occurs on the genitalia, but either type I or type II can occur anywhere on the skin. Diagnosis can be made from the clinical appearance, the serologic reaction in acute and convalescent sera for primary infections. Tzanck smear (Wright’s stain of material obtained from the base of the lesion showing multinucleated giant cells), biopsy, or viral culture. A prodrome of pain or discomfort or tingling is often reported a week to 10 days before the lesions are seen. Treatment is symptomatic with cool compresses, analgesics, and topical drying agents for the oozing, weeping stages. Acyclovir has only a modest effect on recurrent genital herpes and does not seem to influence subsequent episodes; it is thus not recommended for therapy for recurrent attacks in the immunologically competent host. It may be indicated in persons who experience frequent, severe recurrences with complications. Some clinical infection syndromes are listed below:
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Gingivostomatitis. Occurs periorally in children and young adults.
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Keratoconjunctivitis Ophthalmology consulta-tion is warranted. Usually heals without scarring.
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Vulvovaginitis.Herpes gladiatorum. Occurs on the head, neck, or shoulder. Common in wrestlers.
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Eczema herpeticum. Occurs in those with underlying skin disorders, most commonly in atopic dermatitis. It occurs more frequently in children than in adults. Consists of disseminated umbilicated vesicles confined to eczematous skin, which evolve into punched-out erosions that may become confluent.
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Hepatoadrenal necrosis and encephalitis.
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Herpetic whitlow (herpetic paronychia). Occurs on distal portion of fingers.
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Cold sores.
C. Herpes zoster (shingles). Reactivation of latent virus present in the sensory ganglia. Classic description is that of grouped vesicles on an erythematous base in one dermatome. Thoracic nerve dermatomes are most commonly involved followed by the major branches of the trigeminal nerve. Symptoms are pain, dysethesia, and pruritus. Healing requires 2 to 3 weeks, and the afflicted persons are infectious until the lesions have crusted over. Persons of any age can be affected, but the disease is more common and more severe in the elderly. Diagnosis is by clinical presentation, though Tzanck smear, biopsy, and viral culture may be performed. Treatment is oral acyclovir, 800 mg 5 times per day, which is effective if treatment is initiated within 2 days of the onset of the rash. Acyclovir is very effective for pain relief. Alternatively, famciclovir 500 mg PO TID for 7 days can be used and may be more effective at preventing postherpetic neuralgia. Capsaicin creams can be used for pain relief after the lesions have healed. Amitriptyline 25 to 150 mg QHS may be useful in the treatment of postherpetic neuralgia. For recurrent herpes zoster, particularly if more than one dermatome is involved, consider a work-up for malignancy or other causes of immunosuppression.
D. Molluscum contagiosum. Caused by a DNA virus. Appear as pearly papules up to 5 mm in diameter having a central dimple. Multiple lesions are usually present. The central core (molluscum body) can be expressed with a blade. The lesions are infectious, and autoinoculation is common. Children are most commonly affected. Spontaneous resolution may occur, but there is often an eczematous reaction before its resolution. Treatment can be limited to simple superficial curettage without anesthesia. The removal of the molluscum body,application of 50% trichloro-acetic acid, or liquid nitrogen cryotherapy are equally efficacious.
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