Ulcerative and vesiculobullous disorders - 2

Prof. Dr. Sumanth k n

 Learning objectives

• Explain the clinical features, investigations and management of

Herpes group of viral infections (C2)
• Differentiate other acute ulcerative/ vesiculobullous diseases (C3)
 Varicella zoster virus infection

• Cause primary & secondary infections

• Primary – Chickenpox (Varicella)
• Secondary – Herpes zoster (Shingles)
• After the primary infection, the virus becomes latent in the dorsal root ganglia of
the spinal nerves or extra-medullary ganglia of cranial nerves
 Chickenpox

• Generalised primary infection

• Fever associated with exanthematous lesions
• Children coming in contact of a person with Herpes zoster develop chickenpox
 Herpes zoster

• “Zoster” means girdle (something that encircles the body) like

• Varicella virus gets reactivated & causes lesions of unilateral dermatomes

• Pre-disposing factors: Age, deblitating disorders, immunodeficiency, cancer chemo-therapy,

hematologic malignancies
Clinical features
 Clinical features

• Prodromal period of 2-4 days with shooting type of pain, paresthesia, burning, tenderness
along the course of the affected nerve
• Unilateral vesicles with erythematous base, appear in clusters, along the course of the nerve
• Nerves commonly affected are C3, T5, L1, L2 & first division of trigeminal nerve
 Clinical features

• May affect motor nerves. HZ of sacral region may cause paralysis of the bladder. If
thoracic nerves are involved, can paralyze diaphragm

• HZ of facial nerve can lead to James-Ramsay-Hunt syndrome with paralysis of face &
unilateral vesicles on pinna
Oral manifestations
 Oral manifestations

• Unilateral pain & segmental distribution of lesions

• Acute multiple vesicles
• Vesicles similar to HSV infection
• Affects keratinized & non-keratinized mucosa
• Intact vesicles may not be seen, but ulcerations can be seen often
 Diagnosis

• History of prodromal period

• Acute onset of lesions
• Unilateral distribution of lesions
• Diagnostic problem occurs in Zoster sine herpete in which only pain along the nerve path
without any eruptions will be present
 Complications
• Scarring of face
• Paralysis of muscles
• Dental anomalies
• Osteomyelitis
• Pulpal necrosis & root resorption
• Post-Herpetic neuralgia
• Exfoliation of teeth
 Investigations

• Cytology (Tzanck test) positive

• Fluorescent antibody stained smears
• Rising antibody titre
• Tissue culture for virus
• LA test for neuralgia
• Radiographs for osteomyelitis
 Management

• Antivirals like Acyclovir 800 mg five times/day for 10 days

• Newer drugs like Famciclovir, Valacyclovir
• Systemic corticosteroids/ intralesional corticosteroids – controversial
• Topical capsaicin, tricyclic anti-depressants, gabapentin for post-herpetic neuralgia
 Coxsackie viral infections

• Belongs to Entero virus group

• RNA viruses
• Name is derived from a town of upper New York state where the virus was first
discovered
• Has two groups. Group A has 24 types of viruses & Group B has 6 types
• Can cause hepatitis, meningitis, myocarditis, pericarditis, acute respiratory disease.
Only group A cause oro-facial infections viz Herpangina, Hand foot & mouth disease,
Acute lymphonodular pharyngitis
 Herpangina
• Caused mainly by A4
• A1 to A10, A16 to A22 can also cause
• Lesions start as macules, quickly evolve
into papules, then to vesicles & rupture
to form ulcers
• Affects usually children
 Comparison of Herpes simplex & Herpangina

• Herpangina
• Herpes simplex
• Occur in epidemics
• Can occur any time
• Milder disease
• Comparatively severe form of
disease • Affects posterior parts of oral cavity
• Affects anterior part of oral • Absence of gingival involvement
cavity • Smaller lesions
• Gingiva is involved
• Larger lesions
 Diagnosis & treatment

• Tzanck test negative

• Self limiting disease
• Supporting treatment including proper hydration, topical anesthesia, or anesthetic mouth
rinses
• Specific antiviral drugs are not available
 Hand, foot & mouth disease

• Caused by A16
• Non pruritic lesions on
extensor surfaces of hands &
feet
• Extensive oral lesions preceded
by prodromal period
• Supportive treatment
 Acute lymphonodular pharyngitis

• Caused by A10
• Affects posterior parts of oral
cavity
• Yellow-white nodules appear on
soft palate which do not ulcerate
• Self limiting disease
THANK YOU