VIRAL SKIN INFECTIONS:

Viral infections commonly result in skin lesions and rashes.

Typically, a rash occurs, and resolution is seen after the immune
system clears the infection. This is a common pattern in
children. Some viruses lie dormant in the host's cells and
reactivate at a later time, sometimes years later. Another pattern
is a chronic infection. Viruses can infect the skin by direct
inoculation, by local spread, or by systemic infection.

Viruses are microscopic organisms whose survival is entirely

dependent on using the DNA of other living cells (called host
cells) to develop and multiply. The virus growth cycle has four
stages.

• First, the virus attaches to a receptor on the cell's

membrane.
• Second, the virus penetrates the cell either by fusing with
the membrane or by being engulfed by the cell and
delivered into its interior.
• Third, the virus is transported into the cell's nucleus where
the virus uses the host cell's DNA to reproduce.
• Finally, the infectious virus particles (virions) are
assembled and released from the host cell. The length of
this cycle varies and can last several hours to many years
(latent infection).

Three principal virus types cause the majority of viral skin

infection’s rash, sore and lesion problems, they are:

• poxvirus
• herpes simplex virus
• human papillomavirus
WARTS:

Papillomaviruses cause skin cells to proliferate and produce a

benign growth called a wart or papilloma.

Warts affect approximately 10% of the population. Anogenital

warts are a sexually transmitted infection, and partners can
transfer the virus with high efficiency. Immunosuppressed
patients are at increased risk for developing persistent HPV
infection.

Warts are common and benign epithelial growths caused by

human papillomavirus (HPV).

Warts are particularly numerous and troublesome in patients that

are immunosuppressed, most often due to medications such as
azathioprine or ciclosporin. In these patients, the warts almost
never disappear despite treatment.

SIGNS AND SYMPTOMS:

The common wart is the most common type: It is a

hyperkeratotic, flesh-colored papule or plaque studded with
small black dots (thrombosed capillaries) . Warts have a hard
‘warty’ or ‘verrucous’ surface. You can often see a tiny black
dot in the middle of each scaly spot, due to a thrombosed
capillary blood vessel. There are various types of viral wart.

 Common warts arise most often on the backs of fingers or

toes, and on the knees.
 Plantar warts (verrucas) include one or more tender
inwardly growing ‘myrmecia’ on the sole of the foot.
 Mosaic warts on the sole of the foot are in clusters over an
area sometimes several centimetres in diameter.
  Plane, or flat, warts can be very numerous and may be
inoculated by shaving.
 Periungual warts prefer to grow at the sides or under the
nails and can distort nail growth.
 Filiform warts are on a long stalk.
 Oral warts can affect the lips and even inside the cheeks.
They include squamous cell papillomas.
 Genital warts are often transmitted sexually and predispose
to cervical, penile and vulval cancer.

TRANSMISSION:

HPV infection follows inoculation of the virus into the

epidermis through direct contact, usually facilitated by a break
in the skin. Maceration of the skin is an important predisposing
factor, as suggested by the increased incidence of plantar warts
in swimmers. After inoculation, a wart usually appears within 2
to 9 months. The rough surface of a wart can disrupt adjacent
skin and enable inoculation of virus into adjacent sites, leading
to the development and spread of new warts.

DIAGNOSIS:

The clinical appearance alone should suggest the diagnosis. Skin

biopsy may be performed, if warranted.

TREATMENT:
To get rid of them, we have to stimulate the body's own immune
system to attack the wart virus.

Therapy is variable and often challenging. For stubborn warts,

laser therapy or injection with candida antigen may be helpful.
The immunomodulator imiquimod cream (Aldara) is a novel
topical agent recently approved for treating condyloma
acuminatum, and it might help with common warts as well,
usually as adjunctive therapy.
Just keeping the wart covered 24 hours of the day may result in
clearance. Duct tape is convenient and inexpensive.

Sexual partners of patients with condyloma warrant examination

and women require gynecologic examination.

Box 3: Treatment of Warts

Destructive Methods
• Cryosurgery*
• Electrodessication
• Curettage

• Laser therapy
Chemotherapeutic Agents
• Podophyllin
• Canthacur

• 5-fluorouracil
Caustics and Acids
• Salicylic acid*

• Trichloracetic acid
Immunotherapies
• Imiquimod

• Candida antigen
*
First line therapy

PREVENTION AND SCREENING:

For common warts, no approaches have been documented to
prevent transmission. For genital warts (condyloma), the
risk correlates with the number of sexual partners. A
quadrivalent HPV vaccine (Gardasil) has been available
since 2006, and this represents the newest approach to
 preventing genital HPV infection and ultimately cervical
cancer in women. The vaccine is safe and 100%
effective and is recommended for girls and women ages
9 to 26 years

SMALLPOX (VARIOLA):

Smallpox is an infectious disease unique to humans, caused by

either of two virus variants, Variola major and Variola minor.
Smallpox is transmitted by the respiratory route, and the virus is
moved to the skin via the bloodstream.
CAUSE:
Smallpox is caused by infection with variola virus, which
belongs to the genus Orthopoxvirus, the family Poxviridae and
subfamily chordopoxvirinae. The two classic varieties of
smallpox are variola major and variola minor.

The lifecycle of poxviruses is complicated by having multiple

infectious forms, with differing mechanisms of cell entry.
Poxviruses are unique among DNA viruses in that they replicate
in the cytoplasm of the cell rather than in the nucleus. In order to
replicate, poxviruses produce a variety of specialized proteins
not produced by other DNA viruses, the most important of
which is a viral-associated DNA-dependent RNA polymerase.

SIGNS AND SYMPTOMS:

The incubation period between contraction and the first obvious

symptoms of the disease is around 12 days. Once inhaled,
variola major virus invades the oropharyngeal (mouth and
throat) or the respiratory mucosa, migrates to regional lymph
nodes, and begins to multiply. In the initial growth phase the
virus seems to move from cell to cell, but around the 12th day,
lysis of many infected cells occurs and the virus is found in the
bloodstream in large numbers (this is called viremia), and a
second wave of multiplication occurs in the spleen, bone
marrow, and lymph nodes. The initial or prodromal symptoms
are similar to other viral diseases such as influenza and the
common cold: fever (at least 38.5 °C (101 °F)), muscle pain,
malaise, headache and prostration. As the digestive tract is
commonly involved, nausea and vomiting and backache often
occur. The prodrome, or preeruptive stage, usually lasts 2–4
days. By days 12–15 the first visible lesions—small reddish
spots called enanthem—appear on mucous membranes of the
mouth, tongue, palate, and throat, and temperature falls to near
normal. These lesions rapidly enlarge and rupture, releasing
large amounts of virus into the saliva.

A rash develops on the skin 24 to 48 hours after lesions on the

mucous membranes appear. Typically the macules first appear
on the forehead, then rapidly spread to the whole face, proximal
portions of extremities, the trunk, and lastly to distal portions of
extremities. The process takes no more than 24 to 36 hours, after
which no new lesions appear. At this point Variola major
infection can take several very different courses, resulting in
four types of smallpox disease based on the Rao classification:
ordinary, modified, malignant (or flat), and hemorrhagic.
Historically, smallpox has an overall fatality rate of about 30%;
however, the malignant and hemorrhagic forms are usually fatal.

TRANSMISSION:

Transmission occurs through inhalation of airborne variola

virus, usually droplets expressed from the oral, nasal, or
pharyngeal mucosa of an infected person. It is transmitted from
one person to another primarily through prolonged face-to-face
contact with an infected person, usually within a distance of 6
feet (1.8 m), but can also be spread through direct contact with
infected bodily fluids or contaminated objects (fomites) such as
bedding or clothing. Rarely, smallpox has been spread by virus
carried in the air in enclosed settings such as buildings, buses,
and trains. The virus can cross the placenta, but the incidence of
congenital smallpox is relatively low. Smallpox is not notably
infectious in the prodromal period and viral shedding is usually
delayed until the appearance of the rash, which is often
accompanied by lesions in the mouth and pharynx. The virus
can be transmitted throughout the course of the illness, but is
most frequent during the first week of the rash, when most of
the skin lesions are intact. infectivity wanes in 7 to 10 days when
scabs form over the lesions, but the infected person is
contagious until the last smallpox scab falls off.

DIAGNOSIS:

If a clinical case is observed, smallpox is confirmed using

laboratory tests.Microscopically, poxviruses produce
characteristic cytoplasmic inclusions, the most important of
which are known as Guarnieri bodies, and are the sites of
viral replication. Guarnieri bodies are readily identified in
skin biopsies stained with hematoxylin and eosin, and
appear as pink blobs. They are found in virtually all
poxvirus infections but the absence of Guarnieri bodies
cannot be used to rule out smallpox. The diagnosis of an
orthopoxvirus infection can also be made rapidly by
electron microscopic examination of pustular fluid or
scabs.. Strains may be characterized by polymerase chain
reaction (PCR) and restriction fragment length
polymorphism (RFLP) analysis. Serologic tests and
enzyme linked immunosorbent assays (ELISA), which
measure variola virus-specific immunoglobulin and antigen
have also been developed to assist in the diagnosis of
infection

TREATMENT:
Smallpox vaccination within three days of exposure will prevent
or significantly lessen the severity of smallpox symptoms in the
vast majority of people. Vaccination four to seven days after
exposure likely offers some protection from disease or may
modify the severity of disease. Other than vaccination, treatment
of smallpox is primarily supportive, such as wound care and
infection control, fluid therapy, and possible ventilator
assistance. Flat and hemorrhagic types of smallpox are treated
with the same therapies used to treat shock, such as fluid
resuscitation.

No drug is currently approved for the treatment of smallpox.

However, antiviral treatments have improved since the last large
smallpox epidemics, and studies suggest that the antiviral drug
cidofovir might be useful as a therapeutic agent. The drug must
be administered intravenously, however, and may cause serious
kidney toxicity.

VACCINE:

After vaccination campaigns throughout the 19th and 20th

centuries, the WHO certified the eradication of smallpox in
1979. Smallpox is one of the two infectious diseases to have
been eradicated, the other being rinderpest.

Chickenpox (varicella)

Chickenpox is a highly contagious disease caused by the

varicella-zoster virus (Herpes zoster). Exposure to VZV in a
healthy child initiates the production of host
immunoglobulin G (IgG), immunoglobulin M (IgM), and
immunoglobulin A (IgA) antibodies; IgG antibodies persist
for life and confer immunity. Cell-mediated immune
responses are also important in limiting the scope and the
duration of primary varicella infection. After primary
infection, VZV is hypothesized to spread from mucosal and
epidermal lesions to local sensory nerves. VZV then
remains latent in the dorsal ganglion cells of the sensory
nerves. Reactivation of VZV results in the clinically distinct
 syndrome of herpes zoster (i.e., shingles), and sometimes
Ramsay Hunt syndrome type II

Chickenpox during pregnancy may cause viral pneumonia,

premature labour and delivery and rarely maternal death.
Also, approximately 25% of fetuses become infected.
Offspring may remain asymptomatic, or develop herpes
zoster at a young age without previous history of primary
chickenpox infection.

TRANSMISSION:

Chickenpox is highly contagious and is easily spread from

person to person by breathing in airborne respiratory droplets
from an infected person's coughing or sneezing or through direct
contact with the fluid from the open sores. A person who is not
immune to the virus has a 70-80% chance of being infected with
the virus if exposed in the early stages of the disease.. It also can
be transmitted indirectly by contact with articles of clothing and
other items exposed to fresh drainage from open sores. Patients
are contagious up to five days (more commonly, one to two
days) before and five days after the date that their rash appears.
When all of the sores have crusted over, the person is usually no
longer contagious.

Chickenpox is usually more severe in adults and very young

infants than children. Winter and spring are the most
common times of the year for chickenpox to occur.

SIGNS AND SYMPTOMS:

In children, chickenpox usually begins as an itchy rash of red

papules (small bumps) progressing to vesicles (blisters) on
the stomach, back and face, and then spreading to other
parts of the body. Blisters can also arise inside the mouth
The spread pattern can vary from person to person. Also,
 depending on the individual case, there may be only a
scattering of vesicles or the entire body may be covered
with between 250 to 500 vesicles. The vesicles tend to be
very itchy and uncomfortable. Some children may also
experience additional symptoms such as high fever,
headache, coldlike symptoms and vomiting and diarrhoea.
Most adults who get chickenpox experience prodromal
symptoms for up to 48 hours before breaking out in rash.
These include fever, malaise, headache, loss of appetite and
abdominal pain. The condition is usually more severe in
adults and can be life-threatening in complicated cases.
Chickenpox is rarely fatal, although it is generally more
severe in adult males than in adult females or children.

The blisters clear up within one to three weeks but may leave a
few scars. These are often depressed (atrophic) but they
may less often be thickened (hypertrophic).

DIAGNOSIS:

Diagnosis of chickenpox is usually made on the presence of its

characteristic rash (initial red papules that evolve into vesicles
containing fluid) and that different stages of lesions are present
simultaneously. A clue to the diagnosis is in knowing that the
patient has been exposed to an infected contact within the 10-21
day incubation period. Patients may also have prodromal signs
and symptoms.

Vesicular fluid can be examined with a Tsanck smear, or better

with examination for direct fluorescent antibody. The fluid can
also be "cultured", whereby attempts are made to grow the virus
from a fluid sample. Blood tests can be used to identify a
response to acute infection (IgM) or previous infection and
subsequent immunity (IgG).

Prenatal diagnosis of fetal varicella infection can be performed

using ultrasound, though a delay of 5 weeks following primary
maternal infection is advised. A PCR (DNA) test of the mother's
amniotic fluid can also be performed, though the risk of
spontaneous abortion due to the amniocentesis procedure is
higher than the risk of the baby developing foetal varicella
syndrome.

TREATMENT:

For most healthy patients with chickenpox symptomatic

therapy is usually all that is required. Trimming
children's fingernails to minimize scratching.
Paracetamol to reduce fever and pain (do not use
aspirin in children as this is associated with Reye's
syndrome). Calamine lotion and/or oral
antihistamines to relieve itching. Consider oral
aciclovir (antiviral agent) in people older than 12
years who may be at increased risk of severe
varicella infections. Immunocompromised patients
with chickenpox need intravenous treatment with
the antiviral aciclovir. In cases of inadvertent
exposure to the virus, varicella-zoster immune
globulin if given within 96 hours of initial contact can
reduce the severity of the disease though not
prevent it. Chickenpox can now be prevented by
vaccination with live attenuated varicella vaccine.
Exposure to varicella virus may cause severe
problems in pregnant women whom have not had
chickenpox before.

PREVENTION:

Hygiene measures

The spread of chicken pox can be prevented by isolating

affected individuals. Contagion is by exposure to respiratory
droplets, or direct contact with lesions, within a period lasting
from three days prior to the onset of the rash, to four days after
the onset of the rash. It can take from 10-21 days after contact
with an infected person for someone to develop chickenpox.
This is how long it takes for the virus to replicate and come out
in the characteristic rash in the new host.

Also, sufferers are frequently asked to cut their nails short or to

wear gloves to prevent scratching and to minimize the risk of
secondary infections.

The condition resolves by itself within a couple of weeks but

meanwhile patients must pay attention to their personal hygiene.
Also, staying in a cold surrounding can help in easing the
itching as heat and sweat makes it worse.

It is important to maintain good hygiene and daily cleaning of

skin with warm water to avoid secondary bacterial infection.

The chicken pox virus (VZV) is susceptible to

disinfectants, notably chlorine bleach (i.e., sodium
hypochlorite). Also, like all enveloped viruses, VZV is
sensitive to desiccation, heat and detergents.
Therefore these viruses are relatively easy to kill

Vaccine

The vaccination requires only two shots. The first vaccination is

given at about 1 year of age, and the second (booster) is given at
4 years of age. If an older person has not had chickenpox, the
shot may be given at any time. Protection from one dose is not
lifelong and a second dose is necessary five years after the
initial immunization, which is currently part of the routine
immunization schedule in the US.

Infection in pregnancy and neonates

For pregnant women, antibodies produced as a result of

immunization or previous infection are transferred via the
placenta to the fetus. Women who are immune to chickenpox
cannot become infected and do not need to be concerned about
it for themselves or their infant during pregnancy.
Varicella infection in pregnant women could lead to viral
transmission via the placenta and infection of the fetus. If
infection occurs during the first 28 weeks of gestation, this can
lead to fetal varicella syndrome (also known as congenital
varicella syndrome). Effects on the fetus can range in severity
from underdeveloped toes and fingers to severe anal and bladder
malformation. Possible problems include:

• Damage to brain: encephalitis, microcephaly,

hydrocephaly, aplasia of brain
• Damage to the eye: optic stalk, optic cup, and lens
vesicles, microphthalmia, cataracts, chorioretinitis, optic
atrophy
• Other neurological disorder: damage to cervical and
lumbosacral spinal cord, motor/sensory deficits, absent
deep tendon reflexes, anisocoria/Horner's syndrome
• Damage to body: hypoplasia of upper/lower extremities,
anal and bladder sphincter dysfunction
• Skin disorders: (cicatricial) skin lesions, hypopigmentation

Infection late in gestation or immediately following birth is

referred to as "neonatal varicella". Maternal infection is
associated with premature delivery. The risk of the baby
developing the disease is greatest following exposure to
infection in the period 7 days prior to delivery and up to 7 days
following the birth. The baby may also be exposed to the virus
via infectious siblings or other contacts, but this is of less
concern if the mother is immune. Newborns who develop
symptoms are at a high risk of pneumonia and other serious
complications of the disease.

SHINGLES:
It is a painful blistering rash caused by reactivation of varicella,
the chickenpox virus. It is correctly known as herpes zoster.
Chickenpox or varicella is the primary infection with the virus,
Herpes zoster, also called ‘varicella-zoster’. During this
widespread infection, which usually occurs in childhood, virus
is seeded to nerve cells in the spinal cord, usually of nerves that
supply sensation to the skin.

Cause
Shingles is a reactivation of the varicella-zoster virus, a type of
herpes virus that causes chickenpox. After you have had
chickenpox, the virus lies inactive in your nerve roots and
remains inactive until, in some people, it flares up again. When
the virus becomes active again, you get shingles instead of
chickenpox.
Anyone who has had even a mild case of chickenpox can get
shingles. People who have a weak immune system are
vulnerable to reactivation of the virus that causes shingles.
Many factors can weaken your immune system, including aging,
injury, and illness. Some medicines slow down the immune
system. For example, medicines that destroy cancer cells
(chemotherapy) can interfere with the immune system.

Chickenpox or shingles in the early months of pregnancy can

harm the fetus, but luckily this is rare. The fetus may be infected
by chickenpox in later pregnancy, and then develop shingles as
an infant.

It is not clear why shingles affects a particular nerve fibre. In

some cases, it may be set off by pressure on the nerve roots, by
radiotherapy at the level of the affected nerve root, by spinal
surgery, by an infection such as sinusitis or by an injury (not
necessarily to the spine).

Occasional clusters of shingles cases are reported. It is

suggested that contact with someone who has chickenpox or
shingles may cause one's own virus to reactivate.
SYMPTOMS:
When the virus that causes chickenpox reactivates, it causes
shingles. Early symptoms of shingles include headache,
sensitivity to light, and flu-like symptoms without a fever. You
may then feel itching, tingling, or pain where a band, strip, or
small area of rash may appear several days or weeks later. A
rash can appear anywhere on the body but will be on only one
side of the body, the left or right. The rash will first form
blisters, then scab over, and finally clear up over a few weeks.
This band of pain and rash is the clearest sign of shingles.
The rash caused by shingles is more painful than itchy. The
nerve roots that supply sensation to your skin run in pathways
on each side of your body. When the virus becomes reactivated,
it travels up the nerve roots to the area of skin supplied by those
specific nerve roots. This is why the rash can wrap around either
the left or right side of your body, usually from the middle of
your back toward your chest. It can also appear on your face
around one eye. It is possible to have more than one area of rash
on your body.
Shingles develops in stages:
Prodromal stage (before the rash appears)

Pain, burning, tickling, tingling, and/or numbness occurs in the

area around the affected nerves several days or weeks before a
rash appears. The discomfort usually occurs on the chest or
back, but it may occur on the belly, head, face, neck, or one arm
or leg.

Flu-like symptoms (usually without a fever), such as chills,

stomachache, or diarrhea, may develop just before or along with
the start of the rash.

Swelling and tenderness of the lymph nodes may occur.

Active stage (rash and blisters appear)

A band, strip, or small area of rash appears. It can appear
anywhere on the body but will be on only one side of the body,
the left or right. Blisters will form. Fluid inside the blister is
clear at first but may become cloudy after 3 to 4 days. A few
people won't get a rash, or the rash will be mild.

A rash may occur on the forehead, cheek, nose, and around one
eye (herpes zoster ophthalmicus), which may threaten your sight
unless you get prompt treatment.

Pain, described as "piercing needles in the skin," may occur

along with the skin rash.

Blisters may break open, ooze, and crust over in about 5 days.
The rash heals in about 2 to 4 weeks, although some scars may
remain.

Postherpetic neuralgia (chronic pain stage)

It is defined as persistence or recurrence of pain more than a

month after the onset of shingles. The overlying skin is numb or
exquisitely sensitive to touch. Sometimes, instead of pain, the
neuralgia results in a persistent itch.

It is the most common complication of shingles. It lasts for at

least 30 days and may continue for months to years. Symptoms
are:

Aching, burning, stabbing pain in the area of the earlier shingles

rash.

Persistent pain that may linger for years.

Extreme sensitivity to touch.

The pain associated with postherpetic neuralgia most commonly

affects the forehead or chest. This pain may make it difficult for
the person to eat, sleep, and perform daily activities. It may also
lead to depression.
TRANSMISSION
Shingles cannot be passed from one person to another.
However, the virus that causes shingles, the varicella zoster
virus, can be spread from a person with active shingles to a
person who has never had chickenpox. In such cases, the person
exposed to the virus might develop chickenpox, but they would
not develop shingles. The virus is spread through direct contact
with fluid from the rash blisters, not through sneezing, coughing
or casual contact. Someone with shingles can expose you to
chickenpox if you come into contact with the fluid in the
shingles blisters. If you cover the shingles sores with a type of
dressing that absorbs fluid and protects the sores, you can help
prevent the spread of the virus to other people.

A person with shingles can spread the virus when the rash is in
the blister-phase. A person is not infectious before blisters
appear. Once the rash has developed crusts, the person is no
longer contagious.

Shingles is less contagious than chickenpox and the risk of a

person with shingles spreading the virus is low if the rash is
covered.

DIAGNOSIS:
A doctor is usually able to make a diagnosis of shingles based
on its characteristic symptoms. A full medical history will be
taken and the doctor may take a sample of the fluid within the
blister so that it can be tested in a laboratory for presence of
shingles virus.

TREATMENT:
If you think you may have shingles, see your doctor as soon as
possible. Antiviral treatment can reduce pain and the duration of
symptoms, but it is much less effective if started more than one
to three days after the onset of the shingles.

 Rest and pain relief are important - try paracetamol

initially
 A bland, protective application should be applied to the
rash. Try povidone iodine or calamine lotion.
 Capsaicin cream may be helpful for pain relief for post-
herpetic neuralgia.
 Oral antiviral medication is recommended in the following
circumstances:
 Facial shingles

 Those with poor immunity

 The elderly

 Antiviral medication available for shingles on prescription

include:
 Aciclovir (this is the only one available in New
Zealand)
 Valaciclovir

 Famciclovir

In severe or extensive cases aciclovir may be given

intravenously for a few days.
 In some circumstances, systemic steroids may also be
recommended.
 Oral antibiotics may be needed for secondary infection,
usually flucloxacillin or erythromycin

If there is reason to think that shingles is present, your doctor

may not wait to perform tests before treating you with antiviral
medicines. Early treatment may help shorten the length of the
illness and prevent complications such as postherpetic neuralgia.
PREVENTION:
If you have shingles

• Keep the rash covered.

• Do not touch or scratch the rash.
• Wash your hands often to prevent the spread of varicella
zoster virus.
• Until your rash has developed crusts, avoid contact with
o pregnant women who have never had chickenpox or
the varicella vaccine;
o premature or low birth weight infants; and
o immunocompromised persons (such as persons
receiving immunosuppressive medications or
undergoing chemotherapy, organ transplant
recipients, and people with HIV infection).

VACCINE:
A herpes zoster vaccine has been produced which can prevent
varicella reactivation. The vaccine (called Zostavax®) is
estimated to be 14 times more potent than the chickenpox
vaccine and can be given to people aged 50 years or older. It
should not be given to people with weakened immune systems.
The herpes zoster vaccine can reduce the incidence of shingles
by half. In people who do get shingles despite being vaccinated,
the symptoms are usually less severe and after-pains are less
likely to develop.