pathogenesis of hpv
spread by direct contact -> virus enters basal cell -> cellular proliferation
characteristic lesions of hpv
- verruca vulgaris
- scaly, rough, spiny papules or nodules
- can be single or grouped papules on hands and fingers or elsewhere
- punctate black dots = thrombosed capillaries, evident after shaving off outer keratinous surface
types of hpv
common warts/ verruca vulgaris = hpv 2 1 27 29
anogenital warts = 6 and 11
flat warts/ verruca plana = 3 10 28 49
palmar/plantar = 1
characteristic lesions of anogenital warts
- condyloma acuminata
- epidermal and dermal nodules/papules on perineum, genitalia, crural folds, anus
- can form large exophytic cauliflower like masses
- 1-3 mm sessile warts on penis shaft
characteristic lesions of flat warts
- verruca plana
- 1-4 mm, slightly elevated, flat-topped papules with minimal scale
- frequent on face, hands, neck, lower legs
- pinkish or hyperpigmented
characteristic lesions of palmar and plantar warts
- thick endophytic and hyperkeratotic papules
- can be painful with pressure
diagnosis of hpv
- hx and pe
- dermoscopy: (+) black dots
- histopath: koilocytes (viral particles around nucleus
- 3-5% acetic acid to visualize genital warts
benign vs cancerous hpv
benign: 1, 2, 6, 11
cancer: 16, 18, 6 (rare)
treatment for hpv
- physical destruction: cryotherapy, electrocautery and curettage!!, scissory excision
- topicals: imiquinod 5% cream (genital!!), salicylic acid, tca 70-90%, 5% potassium hydroxide
- also examine sexual partner
t/f children always need to be treated for hpv
false, it can regress spontaneously
prevention of hpv
- nongenital: direct exposure to lesions or fomites
- genital: use condoms, monogamy
- vaccine (quadrivalent or bivalent)
etiology of molluscum contagiosum
- pox virus
- benign and affects young children
- sexually transmitted in adults
- great concern: immunocompromised or atopic dermatitis
characteristic lesions of molluscum contagiosum
- smooth dome-shaped, opalescent papules with central core, can get to 3 cm
- enlarge = central dell or umbilication + white curd like substance
- surrounding erythema = immune response = GOOD SIGN
- patients scratch –> bacterial infection = BAD SIGN
transmission of molluscum contagiosum
- direct skin or mucous membrane contact
- fomites (baths, towels, close contact sports)
- autoinoculation
- koebnerization
- vertical transmission
prognosis and clinical course of molluscum contagiosum
- spontaneous clearance
- prolonged course (months to years)
- indicative of advanced state of hiv if high viral load or low cd4 tcell count
treatment of molluscum contagiosum
- watch and wait!!
- cantharidin*
- curettage (painful)
- incision and drainage
- cryotherapy (painful)
- other topical modalities*
- oral cimetidine
prevention of molluscum contagiosum
- avoid trauma to sites of involvement and scratching
- use antipruritics
- treat all existing lesions to avoid autoincoulation
t/f pox virus is the same as chickenpox
false!!!
clinical course of varicella
- acute highly contagious exanthem during childhood
- prodrome of mild fever, malaise and myalgia
- infectious for 1-2 days -> exanthem appears, 4-5 days -> vesicles crust
- incubation period 14-15 d
- self-limited and benign in healthy children
characteristic lesions of varicella
- begins on the face and scalp -> trunk, sparing extremities
- rose colored macules -> papules, vesicles, pustules, and crusts (dew drops on a rose petal)
- can involve oral mucosa
- crusts fall off spontaneously in 7-10 days
hallmark: lesions in all stages are present on the body at the same time
transmission of varicella
respiratory tract or direct contact (wear gloves!!)
complications of varicella
- 2ndary bacterial infection + scarring
- cns sequelae uncommon (encephalitis and acute cerebellar ataxia)
- reye’s syndrome (encephalitis + fatty liver) rare
- pneumonia
treatment for varicella
- antivrials beneficial within 24 hours of rash onset
- valacyclovir, famciclovir, acyclovir
characteristic lesions of herpes zoster
- UNILATERAL dermatomal pain and paresthesia + rash
- from reactivation and multiplication of endogenous latent vzv in sensory ganglia
- most common debilitating complication: chronic pain / postherpetic neuralgia
- common locations: trigeminal nerve (ophthalmic division), trunk from t3 to l2
risk factors for herpes zoster
- older age
- cellular immune dysfunction (immunosuppresed)
- hiv infection, bone marrow transplant, leukemia, lymphoma, cancer chemo, corticosteroids
transmission of herpes zoster
- direct contact and airborne
- less contagious than varicella
course and prognosis of herpes zoster
- 12-24 hrs: vesicles
- day 3: pustules
- day 7-10: dry and crust
- crusts persist for 2-3 wks
hutchinson’s sign and ramsay hunt syndrome
hutchinson’s sign: involvement of nasal branch of the nasociliary nerve + ophthalmic complications (uveitis, keratitis, blindness)
ramsay hunt syndrome (facial and auditory nerves): facial palsy + herpes zoster of external ear or tympanic membrane +/- tinnitus
diagnosis of varicella and zoster
- clinical
- tzanck smear: (+) multinucleated giant cell
- definitive diagnosis: isolation of virus in cell culture
- pcr and elisa
treatment for varicella and zoster
- antiviral therapy: famciclovir, valacyclovir, acyclovir
- analgesics: lidocaine patch, capsaicin patch, opioids, tcas
- phn: gabapentin, pregabalin
prevention of varicella and zoster
- vaccine, varizig, pep acyclovir
- isolation
- airborne and contact precautions
hsv1 vs hsv2
hsv1: orofacial
hsv2: genital
clinical course of hsv
- primary infection: asymptomatic, can transmit
- recurrence: not asymptomatic
pathogenesis of hsv
virus contacts skin -> replicates in dermis/epidermis -> infects and becomes latent in trigeminal or sacral sensory genitalia -> recurs where nerve innervates (not whole dermatome)
course of hsv1
- primary infection: childhood, herpetic gingivostomatitis, pharyngitis
- reactivation: perioral facial area, outer 1/3 of lip, vermillion border
stages of hsv1 infection
- developmental stages: prodrome, erythema, papule
- disease stage: vesicle, ulcer, hard crust
- resolution stages: dry flaking and residual swelling
- resolve in 5-15 days
trigger factors for hsv1
anything that causes stress
most prevalent sexually transmitted disease, most common cause of ulcerative genital disease
hsv2 (genital herpes)
also important in acquisition and transmission of hiv
course of hsv2
- acute first episode
- extensive genital lesions in different stages of evolution
- pain, itching, dysuria, vaginal and urethral discharge, tender inguinal lymphadenopathy
- recurrence: first months to years
characteristic lesions of hsv2
- multiple small grouped vesicular lesions in genital area
- prodrome: itching, burning, tingling
- heal in 6-10 d
diagnosis of hsv
- viral culture (not that accurate)
- tzanck smear
- pcr!!!
- direct fluorescent antibody staining
- skin biopsy
complications of hsv
- ocular: recurrent keratoconjunctivitis, corneal opacification, visual loss
- neurologic: hsv meningitis, hsv encephalitis
treatment of hsv
acyclovir or valacyclovir
prevention of hsv
- patient education and safer sex practices
- outbreak: refrain from sex and 1-2 d after, use condoms
- vertical transmission low
- suppressive antiviral therapy