ULCERATIVE & VESICULOBULLOUS DISORDERS - 1

Prof.Dr.Sumanth KN
 Learning Objectives: Students should be able to

n Classify immunological diseases (C4)

n Distinguish ulcerative and vesiculobullous disorders (C4, CT1)
n Explain the clinical features, investigations and management of
Herpes group of viral infections (C2)
 DEFINITION

n ULCER: Breach in the continuity of the epithelium associated with molecular

degeneration
n VESICLE: Elevated blisters containing clear fluid, less than 1 cm
n BULLAE: Elevated blisters containing clear fluid, more than or equal to 1 cm
CLASSIFICATION OF VESICULOBULLOUS DISEASES
Predominantly vesicular
n HSV infection
n Varicella
n Herpes zoster
n Hand foot & mouth disease
n Herpangina
n Dermatitis herpetiformis
Predominantly bullous
n Pemphigus vulgaris
n Bullous pemphigoid
n Benign mucous membrane
pemphigoid
n Bullous lichen planus
n Erythema multiformae
n Steven Johnson syndrome
n Bullous impetigo
n Traumatic bullae
n Epidermolysis bullosa
n Linear IgA disease
 CLASSIFICATION OF ULCERATIVE DISORDERS

n Traumatic ulcers: traumatic bite, chemical burn, thermal burn, necrotizing sialometaplasia
n Ulcers due to infections: ANUG, Vincent’s angina, tuberculous ulcer, deep fungal infections
n Neoplastic ulcers: Carcinoma, sarcoma, melanoma, Kaposi’s sarcoma
n Ulcers due to immunological injury: Aphthous ulcers, erythema multiformae, allergic stomatitis
n Ulcers due to hematological diseases: ulcers seen in agranulocytosis and leukemia
n Ulcers due to GIT disease: Crohn’s disease, ulcerative colitis, tropical sprue
n Miscellaneous: ulcers secondary to cancer chemotherapy and radiotherapy
Clinical classification of ulcerative & vesiculobullous diseases

n Acute multiple lesions

n Recurent lesions
n Chronic lesions
n Single ulcers
 ACUTE MULTIPLE LESIONS
n Herpes simplex infections
n Chickenpox
n Herpes zoster
n Herpangina
n Hand foot & mouth disease
n Acute lymphonodular pharyngitis
n Erythema multiformae
n Allergic stomatitis
n Ulcers due to chemotherapy
n ANUG
 Herpes group of viruses

n All are DNA viruses

n 80 known viruses in this group
n 8 viruses causes infection in humans
n HSV 1, HSV 2, Varicella zoster virus,
Cytomegalo virus, Epstein-Barr virus,
Human herpes virus 6 (HHV 6), HHV 7 &
HHV 8
n Latency is characteristic feature of all herpes
viruses
 Diseases caused by Herpes viruses

n HSV 1 – Primary herpetic gingivostomatitis, recurrent herpes labialis

n HSV 2 – Genital herpes, cervical cancer
n Cytomegalovirus – Oral ulcers, Viral sialadenitis in immunocompromised
n Epstein Barr virus – Infectious mononucleosis, Burkit’s lymphoma,
nasopharyngeal carcinoma, hairy leukoplakia
n HHV 6 – Roseola infantum
n HHV 8 – Kaposi’s sarcoma, lymphoma, Castleman’s disease
 Primary Herpes simplex

n Spreads from asymptomatic shedders with HSV present in saliva or vaginal

secretions
n HSV 1 causes infection above waist and HSV 2 in genital region
n Primary infection can occur in children after 6 months only with peak
incidence during 2-3 years age
n Primary infection may go un-noticed because of sub-clinical disease or viral
pharyngitis
 Herpetic gingivostomatitis

n Prodromal symptoms precede the lesions by 1-2

days
n Thin walled multiple vesicles on all parts of
mucosa with a red inflammatory halo
n They quickly rupture, leaving shallow round
discrete ulcers which may later coalesce &
form larger lesions
n Acute marginal gingivitis with gingival ulcers
Herpes labialis
 Herpes labialis

n Palpable, tender regional lymph nodes

n Labial or facial lesions can occur without oral lesions
n Self limiting disease. Fever disappears in 3-4 days whereas lesions
begin to heal in a week or 10 days. But virus will be present in
saliva for about a month
 Herpetic whitlow

n Infection of fingers of health

professionals may develop after
contacting oral lesions or saliva of
asymptomatic carriers
n Use of gloves can prevent HSV
infection
 Lab diagnosis

n Cytology (Tzanck test)

n HSV viral isolation (PCR, viral

culture)

n Antibody titers
 Treatment

n CURATIVE: In children antiviral medications like ACYCLOVIR can be

given within first 72 hours in a dosage of 200 mg five times/day for 10
days
n They decrease fever, pain, lesions & viral shedding
n Newer drugs like VALACYCLOVIR & FAMCICLOVIR – more effective
 Treatment

n SYMPTOMATIC: Routine cases are not treated with anti-virals

n Proper hydration & electrolyte balance
n Acetaminophen or aspirin
n Topical anesthetic mouth washes like dyclonine hydrochloride 0.5%
n Benadryl (diphenhydramine hydrochloride 5 mg/ml) with milk of magnesia
THANK YOU