ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA

POSTGRADUATE DIPLOMA IN
FAMILY MEDICINE

MODULE 13
Dermatology & STI

2nd Edition

Author:

Assoc. Prof. Dr. Chandran Rajagopal

MBBS, FCGP, FRSH,MAMS (Vienna), DRM ,Dip Ven,Dip STD&AIDS,
Diploma in Dermatology, Diplomate in Restorative & Aesthetic Medicine(Miami,
USA), Certified Master trainer AARAM USA,
Fellow American Academy of Dermatology
Fellow American Academy of Restorative & Aesthetic Medicine
Fellow American Academy Aesthetic and Restorative Surgery
Member Academy of Family Physicians of Malaysia
Fellow Indian Academy Medical Specialists(Family Medicine)
Certified Trainer,Teaching of Family Medicine (AFPM)
Certified Physican in management of Estrogen deficiency ,menopause and HRT ,
College of Physicians and Surgeons, University of Columbia,New York

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Chapter 6
Viral Exanthems during childhood are very common and some of these have been discussed earlier.

 Common winter and summer viruses including

 respiratory and enteroviruses

 respectively Chickenpox (varicella)

 Measles (morbilli)

 German measles (rubella)

 Roseola

 Fifth disease (erythema infectiosum)

Other viral syndromes include

Herpes simplex is a common viral infection that presents with localised blistering. It affects most people on
one or more occasions during their lives.
There are two main types of herpes simplex virus (HSV), although there is considerable overlap.
Type 1, which is mainly associated with facial infections (cold sores or fever blisters)

Type 2, which is mainly genital (genital herpes)

a. Both type 1 and type 2 herpes simplex viruses reside in a latent state in the nerves which supply
sensation to the skin. During an attack, the virus grows down the nerves and out into the skin or
mucous membranes where it multiplies, causing the clinical lesion. After each attack it ‘dies back’ up
the nerve fibre and enters the resting state again.

b. First or primary attacks of Type 1 infections occur mainly in infants and young children, which are
usually mild or subclinical. In crowded, underdeveloped areas of the world up to 100% of children
have been infected by the age of 5. In higher socioeconomic groups the incidence is lower, for example
less than half of university entrants in Britain have been infected.

c. Type 2 infections occur mainly after puberty, often transmitted sexually. The initial infection more
commonly causes symptoms.

d. After the initial infection, whether obvious or inapparent, there may be no further clinical
manifestations throughout life. Recurrences are more frequent with Type 2 genital herpes than with
Type 1 oral herpes.

Recurrences can be triggered by:

e. Minor trauma to the affected area

f. Other infections including minor upper respiratory tract infections

g. Ultraviolet radiation (sun exposure)

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 h. Hormonal factors (in women, flares are not uncommon prior to menstruation)

i. Emotional stress

j. Operations or procedures performed on the face

k. Dental surgery

l. In many cases no reason for the eruption is evident.

Recurrent infections differ from first infections in the smaller size of the vesicles and their close grouping. Recurrences
of Type 1 infection can occur on any site but they are most frequently on the face, particularly on the lips (‘herpes
simplex labialis’). They do not usually result in blisters inside the mouth. Recurrences of Type 2 infection may also
occur on any site but most often affect the genitals or buttocks. Recurrent HSV tends to always affect the same region,
but not necessarily the identical site.
Itching or burning is followed an hour or two later by small, closely grouped vesicles on a red base. They normally heal
in 7-10 days without scarring. Generally the affected person feels quite well but they may suffer from fever, pain and
have enlarged lymph nodes nearby.
Although the vesicles usually form an irregular cluster, they may be arranged in a line rather like shingles (zosteriform
distribution), particularly when affecting the lower chest or lumbar region.
White patches or scars may occur at the site of recurrent HSV attacks, which may be more obvious in those with brown
skin.

Complications

Eye infection

Herpes simplex may cause swollen eyelids and conjunctivitis with opacity and superficial ulceration of the
cornea (dendritic ulcer). The lymph gland in front of the ear is often enlarged and tender.

Throat infection

Throat infections may be very painful.

Eczema herpeticum
Eczema herpeticum is a disseminated viral infection characterised by fever and clusters of itchy blisters or
punched-out erosions. It is most often seen as a complication of atopic dermatitis/eczema.
Eczema herpeticum is also known as Kaposi varicelliform eruption because it was initially described by
Kaposi in 1887, who thought it resembled chickenpox/varicella.
What is the cause of eczema herpeticum?
Most cases of eczema herpeticum are due to Herpes simplex virus type 1 or 2.

Eczema herpeticum usually arises during a first episode of Herpes simplex infection (primary herpes). Signs
appear 5 to 12 days after contact with an infected individual, who may or may not have visible cold sores.
Eczema herpeticum may also complicate recurrent herpes. However, repeated episodes of eczema herpeticum
are unusual.
Eczema herpeticum can affect males and females of all ages but is more commonly seen in infants and
children with atopic dermatitis. Atopics appear to have reduced immunity to herpes infection. The dermatitis
can be mild to severe, active or inactive.
HSV in patients with atopic dermatitis or Darier disease may result in a severe rash known as eczema
herpeticum. Numerous blisters and scabs erupt on the face or elsewhere, associated with swollen lymph glands
and fever.

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Erythema multiforme

Recurrent erythema multiforme is an uncommon reaction to herpes simplex. Erythema multiforme mainly
appears on the hands, forearms and lower legs and is characterised by target lesions, which sometimes blister.

Nervous system

The nerves to the face may be infected by HSV, producing temporary paralysis of the affected muscles,
sometimes with each attack. Rarely neuralgic pain may precede each recurrence of herpes by 1 or 2 days
(Maurice's syndrome). Meningitis is rare.

Widespread infection

This is more likely to arise in debilitated patients and may be serious.

Treatment

Mild uncomplicated eruptions of herpes simplex require no treatment. They may be covered if desired, e.g.,
with a hydrocolloid patch.

As sun exposure often triggers facial herpes simplex, sun protection using high protection
factor sunscreens and other measures is important.

Severe infection may require treatment with an antiviral agent. Typical doses of oral antiviral drugs for cold
sores are:

aciclovir – 200mg five times daily for 5 days

valaciclovir – 1 g three times daily for 7 days

famciclovir – as a single dose of 3 x 500mg.

Antiviral drugs will stop the herpes simplex virus multiplying once it reaches the skin or mucous membranes
but cannot eradicate the virus from its resting stage within the nerve cells. They can therefore shorten and
prevent attacks but a single course cannot prevent future attacks. Repeated courses may be prescribed or the
medication may be taken continuously to prevent frequent attacks.

Topical aciclovir or penciclovir, in the form of a cream applied to affected areas, shortens the course of the
condition.

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Heres Zoster Virus

Shingles 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.

The virus remains in a resting phase in these nerve cells for years before it is reactivated and grows down the
nerves to the skin to produce shingles (zoster). This can occur in childhood but is much more common in
adults, especially the elderly.

Shingles patients are infectious (resulting in chickenpox), both from virus in the lesions and in some instances
the nose and throat. Anyone who has previously had chickenpox may subsequently develop shingles. They can
be male or female, young or old. In general, it is more common in older adults and certainly tends to be more
severe in this group.

Shingles is more common and more severe in patients with poor immunity. Blisters can occur in more than
one area and the virus may affect internal organs, including the gastrointestinal tract, the lungs and the brain.

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 devlop 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. Clinical features

The first sign of shingles is usually pain, which may be severe, in the areas of one or more sensory nerves,
often where they emerge from the spine. The pain may be just in one spot or it may spread out. The patient
usually feels quite unwell with fever and headache. The lymph nodes draining the affected area are often
enlarged and tender.

Within one to three days of the onset of pain, a blistering rash appears in the painful area of skin. Sometimes,
especially in children, shingles is painless.

It starts as a crop of closely-grouped red bumps in a continuous band on the area of skin supplied by one,
occasionally two, and rarely more neighbouring spinal nerves. New lesions continue to appear for several
days, each blistering or becoming pustular then crusting over. Shingles occasionally causes blisters inside the
mouth or ears, and can also affect the genital area.

The pain and general symptoms subside gradually as the eruption disappears. In uncomplicated cases recovery
is complete in 2-3 weeks in children and young adults, and 3 to 4 weeks in older patients.

Occasionally pain is not followed by the eruption - shingles "sine eruptione". These cases can be difficult to
identify because there is no characteristic rash.

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The chest (thoracic), neck (cervical), forehead (ophthalmic) and lumbar/sacral sensory nerve supply regions
are most commonly affected at all ages but the frequency of ophthalmic shingles increases with age. Rarely the
eruption may affect both sides of the body.

In elderly and undernourished patients the blisters are deeper. Healing may take many weeks and be followed
by scarring. Muscle weakness arises in about one in twenty patients because the muscle nerves are affected as
well as the sensory nerves. Facial nerve palsy is the most common result. There is a 50% chance of complete
recovery and in time some improvement can be expected in nearly all cases. Post-herpetic neuralgia (after-
pains)

Post-herpetic neuralgia is defined as persistence or recurrence of pain more than a month after the onset of
shingles. It becomes increasingly common with age affecting about a third of patients over 40 and is
particularly likely if there is facial infection. The pain may be continuous and burning with increased
sensitivity in the affected areas, or a spasmodic shooting type, or, rarely, of an itchy, crawling variety. The
overlying skin is numb or exquisitely sensitive to touch. Sometimes, instead of pain, the neuralgia results in a
persistent itch(neuropathic pruritus).

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
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 infectionusually flucloxacillin or erythromycin

Treatment of post-herpetic neuralgia

Post-herpetic neuralgia may be difficult to treat successfully. It may respond to any of the following.
Local anaesthetic applications eg lignocaine
Topical capsaicin
Tricyclic antidepressant medications such as amitriptyline
Serotonin and norepinephrine reuptake inhibitors such as duloxetine and venlafaxine, which are well tolerated
and safe
Anti-epileptic medication such as carbamazepine, sodium valproate or gabapentin and pregabalin
Transcutaneous electrical nerve stimulation and acupuncture may relieve pain in some patients
Botulinum toxin injections into the affected area
Opioids such as morphine may be prescribed for severe intractable pain. Nonsteroidal anti-inflammatories are
generally unhelpful.

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If you have significant discomfort which is not controlled by simple analgesics such as paracetamol, seek your
doctor's advice. You may be referred to a Pain Clinic at your local hospital.

Molluscum contagiosum is a common viral skin infection. It most often affects infants and young children
but adults may also be infected.
Molluscum contagiosum presents as clusters of small round bumps (papules) especially in the warm moist
places such as the armpit, groin or behind the knees. They range in size from 1 to 6 mm and may be white,
pink or brown. They often have a waxy, pinkish look with a small central pit (umbilicated). As they resolve,
they may become inflamed, crusted or scabby. There may be few or hundreds of spots on one individual.

Molluscum contagiosum

It is a harmless virus but it may persist for months or occasionally for a couple of years. It frequently induces a
type of dermatitisin the affected areas, which are dry, pink and itchy. Molluscum contagiosum may rarely
leave tiny pit-like scars. olluscum contagiosum can be spread from person to person (especially children) by
direct skin contact. This appears to be more likely in wet conditions, such as when children bathe or swim
together. Sexual transmission is possible in adults.
Lesions tend to be more numerous and last longer in children who also have atopic eczema. It can be very
extensive and troublesome in patients withhuman immunodeficiency virus infection.
Molluscum contagiosum may arise in areas that have been injured, often because they've been scratched. The
papules form a row; this is known as koebnerised molluscum.
Treatment
There is no single perfect treatment of molluscum contagiosum since we are currently unable to kill the virus.
The soft white core can be squeezed out of individual lesions. In many cases no specific treatment is
necessary.
Medical treatments include:
Minor surgery, curettage (topical anaesthetic cream may be applied first) or laser ablation
Cryotherapy
Cantharidine
Imiquimod cream
Wart paints containing salicylic acid or podophyllinWarts are tumours or growths of the skin caused by
infection with Human Papillomavirus (HPV). More than 70 HPV subtypes are known.

Warts
Warts are particularly common in childhood and are spread by direct contact or autoinocculation. This means
if a wart is scratched, the viral particles may be spread to another 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.
area of skin. It may take as long as twelve months for the wart to first appear.
What do they look like?
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.

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Genital warts are often transmitted sexually and predispose to cervical, penile and vulval cancer.

In children, even without treatment, 50% of warts disappear within 6 months; 90% are gone in 2 years. They
are more persistent in adults but they clear up eventually.

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. Treatment

Many people don't bother to treat them because treatment can be more uncomfortable and troublesome than
the warts - they are hardly ever a serious problem. However, warts may be painful and they often look ugly
and cause embarrassment.

To get rid of them, we have to stimulate the body's own immune system to attack the wart virus. Persistence
with the treatment and patience is essential!

Occlusion

Just keeping the wart covered 24 hours of the day may result in clearance. Duct tape is convenient and
inexpensive.

Chemical treatment.

Chemical treatment includes wart paints containing salicylic acid or similar compounds, which work by
removing the dead surface skin cells. Podophyllin is a cytotoxic agent, and must not be used in pregnancy or in
women considering pregnancy.

The paint is normally applied once daily. Perseverance is essential - although 70% of warts will go with wart
paints, it may take twelve weeks to work! Even if the wart doesn't go completely, the wart paint usually makes
it smaller and less uncomfortable.

First, the skin should be softened in a bath or bowl of hot soapy water. The hard skin should be rubbed away
from the wart surface with a piece of pumice stone or emery board. The wart paint or gel should be applied
accurately, allowing it to dry. It works better if covered with plaster or duct tape (particularly recommended
when the wart is on the foot).

Stronger preparations such as Upton's paste are used for thick verrucas, applied every few days. It is important
to protect the surrounding skin with adhesive plaster before applying Upton's paste, and to apply a plaster over
the paste to keep it in place.

If the chemical makes the skin sore, stop treatment until the discomfort has settled, then recommence as above.
Take care to keep the chemical off normal skin.

3% formalin solution can be used to soak multiple mosaic plantar warts several times a week. Protect
unaffected skin with Vaseline, and apply cotton wool soaked in the solution, left in place for about ten minutes
before rinsing off.

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Cryotherapy

The wart is frozen with liquid nitrogen repeatedly, at one to three week intervals. This is uncomfortable for a
few minutes and may result in blistering for several days. Success is in the order of 70% after 3-4 months of
regular freezing. Dermatologists debate whether a light freeze to stimulate immunity is sufficient, or whether a
harder freeze is necessary to destroy all the infected skin. A hard freeze might cause a permanent white mark
or scar.

Electrosurgery

Electrosurgery (curettage & cautery) is used for particularly large and annoying warts. Under local anaesthetic,
the growth is pared away and the base burned by diathermy or cautery. The wound heals in about two weeks;
even then 20% of warts can be expected to recur within a few months.

Other treatments

There are numerous treatments for warts and none offer a guarantee of cure. They include
topical fluorouracil, bleomycin injections, laser vaporisation, pulse dye laser, oral acitretin and immune
modulators such as imiquimod cream.

References

Viral exanthems
Lycia A Scott MD, and Mary Seabury Stone MD
Dermatology Online Journal 9 (3): 4 Department of Dermatology, University of Iowa Hospitals and Clinics,
Iowa City, Iowa. lycia-scott@uiowa.edu oseph M Lam†
Characterizing Viral Exanthems ,Departments of Paeditrics & Dermatology, University of British Columbia,
1803–1805 West Broadway, Vancouver, BC, V5Z 1K1, Canada