Viral: HSV, chicken pox, shingles, viral warts, molluscum contaginosum

Question 1

What is Shingles?

Answer 1

Herpes Zoster Infection, following primary infection with VZV, virus lies dormant in the dorsal root or cranial nerve ganglia

Question 2

RF for shingles?

Answer 2

Increasing age
HIV
Other immunosuppressive disorders

Question 3

What are the most commonly affected dermatomes in Shingles?

Answer 3

T1-L2

Question 4

What are the clinical features you might hear in the Hx of a pt presenting with Shingles?

Answer 4

Prodromal period:
Burning pain over the affected dermatome for 2-3 days
Pain may be severe and interfere with sleep
Around 20% of pts will experience headache, fever, lethargy
Dermatomal rash

Question 5

Describe the rash seen in Shingles

Answer 5

Initially erythematous, macular rash over the affected dermatome
Quickly becomes vesicular
characteristically well demarcated and does not cross the midline

Question 6

Management of shingles?

Answer 6

Remind pts they are potentially infectious
Analgesia- NSAIDs + paracetamol are first line, may give neuropathic agents if they are not responding . Oral corticosteroids in first 2 weeks if pain is severe and not responding
Antivirals within 72 hrs for most patients

Question 7

What advice related to infection control for shingles would you give?

Answer 7

May need to avoid pregnant women and the immunocompromised
They are infectious until vesicles have crusted over, usually 5-7 days
Covering lesions reduces the risk

Question 8

When do you NOT need to commence antivirals in Shingles?

Answer 8

If patient is <50 years and has a ‘mild’ truncal rash associated with mild pain and no underlying RF

Question 9

Complications of shingles?

Answer 9

Post-herpetic neuralgia- most common
Herpes zoster ophthalmicus- affecting the ocular division of trigeminal n
Ramsay Hunt syndrome (herpes zoster oticus)

Question 10

Key features of post herpetic neuralgia?

Answer 10

Most common complications
More common in older pts
Affects between 5-30% of pts
Most commonly resolves with 6 months but may last longer

Question 11

Outline the spread of chicken pox?

Answer 11

Highly infectious
Via resp route
Can be caught from someone with shingles
Infective period: 4 days before rash, until 5 days after the rash first appeared
Incubation period= 10-21 days

Question 12

Clinical features of chicken pox?

Answer 12

Fever initially
Itchy, rash starting on head/trunk before spreading
Initially macular then papular then vesicular
Systemic upset is usually mild

Question 13

Management of chicken pox?

Answer 13

Supportive
Keep cool, trim nails
Calamine lotion
Avoid school until all lesions have crusted over
Immunocompromised and newborn pts–> receive VZIG, if chicken pox develops should consider IV aciclovir

Question 14

What are complications of chicken pox?

Answer 14

Secondary bacterial infection of the lesions
NSAIDs may increase this risk
In small no of pts group A strep infection results in necrotising fasciitis

Question 15

Rare complications of chicken pox?

Answer 15

Pneumonia
Encephalitis
Disseminated haemorrhage chickenpox
Arthritis, nephritis and pancreatitis (v rare)

Question 16

What is molluscum contagiosum?

Answer 16

common skin infection caused by molluscum contagiosum virus (MCV), a member of the Poxviridae family.

Question 17

Transmission of molluscum contagiosum?

Answer 17

Directly by close personal contact, indirectly via fomites

Question 18

Describe a molluscum cotagiosum rash?

Answer 18

Pinkish/pearly white papule with central umbilication which are up to 5mm.
Lesions appear in clusters anywhere in the body but commonly on trunk and flexures

In adults, sex may lead to lesions developing on genitalia, pubis, thighs and lower abdomen

Question 19

How to advise on molluscum?

Answer 19

Reassure that it is self- limiting
Spontaneous resolution occurs within 18 months
Explain that lesions are contagious and avoid sharing towels, clothing and baths with unaffected people
Encourage not to scratch
Exclusion from school, gym or swimming isn’t necessary

Question 20

When should you consider treatment for Molluscum?

Answer 20

If lesions are troublesome, or considered unsightly

Question 21

Treatment options for molluscum?

Answer 21

Squeezing with fingernails, post bath
Cryotherapy for older children/adults
Eczema/itching may develop around the lesion, if itching problematic- emollient and mild topical corticosteroid.
IF skin looks infected- prescribe topical abx

Question 22

When should you refer a pt with molluscum?

Answer 22

HIV +ve with extensive lesions- to HIV specialist
Eye lid margin or ocular lesions and associated red eye- ophthalmologist
Adults with anogenital lesions–> GUM for screening of STIs

Question 23

What is eczema herpeticum?

Answer 23

Severe primary infection of the skin by herpes simplex virus 1 or 2

Question 24

How does eczema herpeticum present?

Answer 24

more commonly seen in children with atopic eczema and often presents as a rapidly progressing painful rash

Question 25

How does the eczema herpeticum rash present?

Answer 25

Monomorphic punched out erosions (circular, depressed, ulcerated lesions) usually 1-3mm

Question 26

Management of eczema herpeticum?

Answer 26

admission and IV aciclovir