1. COMMON Viral SkiN
DiSeaSeS
Ali M. Gargoom
MB,ChB. MSc. MD
Assistant Professor of Dermatology
Department of Dermatology
.Faculty of Medicine
Benghazi University

2. Viral SkiN
DiSeaSeS
1. Herpes Simplex Virus Infections.
2. Varicella Zoster Virus Infections.
3. Human Papilloma Virus Infections.
4. Molluscum Contagiosum.

3. HerpeS SiMplex ViruS
.iNfeCtiONS
 HSV is a double stand DNA virus
 There are two types of HSV.
 HSV type 1, associated with facial
and oral infection.
 HSV type 2, affecting the genitalia.

4. epiDeMiOlOgy
 HSV infection is one of the commonest
infections throughout the world.
 HSV1 infection commonly affecting children.
 HVS2 infection mainly occur after puberty

5. patHOpHySiOlOgy
 Close contact is required for HSV infection.
 Contact must involve mm or abraded skin.
 After an I.P (2-20days) , the primary attack will
occur which is asymptomatic in 90% of cases.
 Following the 1ry attack there will be a latency
period where the virus remain dormant in on of
sensory ganglion.
 Reactivation of the virus will lead to recurrence of
the infection.

6. preCipitatiNg faCtOrS
1. Ultraviolet rays.
2. Menstruation.
3. Febrile illness.
4. Common cold.
5. Stress.
6. GIT disturbances.
7. Immunosuppressions.

7. Clinical Picture
Erythematous patch
Grouped umbilicated vesicles
Pustules
Crusting
Weeks 2-3
Post-inflammatory hyper or hypo-pigmentations

8. CliNiCal preSeNtatiONS Of
HSV
1. Herpetic Gingivostomatitis.
2. Herpes Labialis.
3. Herpetic Whitlow.
4. Herpetic Keratoconjuctivitis.
5. Neonatal Herpes Simplex.
6. Herpes Genitalis.
7. Eczema Herpeticum.
8. Disseminated Herpes Simplex.

9. )Herpetic Gingivostomstitis (1ry herpes
 Most cases occur between 1-5 years.
 After constitutional symptoms which
may be sever the stomatitis began.
 The gums swollen, red and bleed easily.
 Vesicles presents as white plaques which seen
on tongue, pharynx, palate and buccal mucosa.
 Regional L.N may be enlarged and tender.
 Fever subside after 3-5 days and recovery is
completed in 2 weeks.

12. )Herpes Labialis (cold sores, fever blisteres
 The most common variety .
 Often occurred in childhood.
 Affecting the lips, but nose and cheeks
 Commonly caused by HSV type 1.
 1/3 of patients will experience a recurrence.
 Of these 50% will experience at least 2
recurrence annually.
 Post herpetic E.M may occur.

13. Herpes Labialis Grouped and confluent vesicles on an
erythematous base on the lips, 24 h after onset of symptoms.

15. Herpetic whitlow
Occur as a direct inoculation of the
. virus from oral or genital lesions
Painful, grouped, confluent vesicles
on an erythematous & edematous
base
The disease is a common
occupational hazard for medical and
dental personnel, who work in and
.around the mouth

17. .Herpes Genitalis
 Most commonly caused by HSV type II.
 Age of onset: Young (sexually active adult).
 Risk increases with multiple sex partners.
 1ry infections mostly asymptomatic but mild
fever, headache, and local pain is noted.
 Distribution:
Male: glans, shaft or sulcus of penis, scrotum
and buttocks.
Female: both labia, perinum and thigh.

18. Herpes Genitalis
18

19. Eczema Herpeticum
 Also known as Kaposi varicelliform eruption.
 It is a HSV infection occurring in atopic dermatitis
patient.
 Characterized by systemic symptoms e.g. fever,
malaise, irritability and lymphadenopathy.
 Clinical examination reveals generalized vesicles
which often becomes heamorrhagic and crusting.
 Commonly affecting the face, neck and trunk.
 The primary attack is sever but the recurrence tend
to be milder.

20. Eczema Herpeticum 20

22. Disseminated Herpes Simplex
 It’s potentially fatal systemic HSV infection.
 Characterized by generalize mucocutaneous
vesicles, pustules and erosions along with
widespread visceral involvement (lung, liver, GIT & CNS)
 Risk Factors Includes:
1. Immunodeficiency.e.g. AIDS, drugs, malignancy etc..
2. Malnutrition
3. Eczema herpeticum

23. Disseminated HSV in immuncompromized patient note the heamorrhagic and
.necrotic skin lesions also this patient has infection of liver, lung and brain

24. 1. Direct Microscopy Examination:
Tzanck smear.
smear
2. Viral culture:
It’s the most reliable way to make the diagnosis.
3. Serology:
Polymerase Chain Reaction (PCR).
Useful in the diagnosis of culture –ve. or atypical lesion.

25. : Tzanck's Test

26. Most HSV infections are self-limited. However antiviral therapy
shorten the course of the disease, prevent dissemination, and
recurrence.
Treatment of 1ry attack
.Acyclovir (Zovirax) 200mg orally 5 times for 7 days
Treatment of recurrence
Acyclovir 400mg twice daily for one year suppresses
recurrence by 75%

28. It’s acute localized viral infection caused by
reactivation of varicella-zoster virus and
characterized by unilateral pain and
vesicular eruption limited to a dermatome
innervated by a corresponding sensory
ganglion.

29. EtiopathogEnEsis
 The causative virus is VZV ( varicella-zoster virus)
 The same virus causes varicella (chickenpox).
 During varicella the virus travel the sensory
nerves to the sensory ganglion where it remain
dormant and establish the latency.
 When immunity to the virus decreased the virus
replicate within the ganglion then travel back the
sensory nerve to skin resulting in dermatomal pain
and skin lesion.

31. EpiDEMioLogY
AGE AND SEX:
 There is no racial or sex predilection.
 Most cases are older than 50 years .
RISK FACTORS:
1. Diminished immunity with ageing.
2. Immunosuppresions.
3. HIV-infection.

32. CLiniCaL piCtURE
PRODROMAL STAGE DAYS 3-5
ACUTE VESICULATION DAYS 3-5
CRUST FORMATION WEEKS 2-3
?
POST HERPETIC NEURALGIA MONTHS-YEAR

33. sKin LEsions
Closelygrouped vesicles & pustules.
On an erythematous base.
They may appear umbilicated.
Segmental ( dermatoml ) distribution.
New lesions continue to appear for a week.

34. sitEs of pREDiLECtions
 Thoracicregion ( >50% of cases )
 Trigeminal region ( 10 - 20%)
 Lumbosacral and cervical ( 10 - 20%)

35. Typical grouped vesicles and pustules on an erythematous base
involving thoracic dermatomes on the chest wall.

38. Ophthalmic herpes zoster due to involvement of ophthalmic branch
.of the trigeminal nerve with secondary dissemination

39. DiffEREntiaL Diagnosis
Prodromal Stage (Localized Pain)
Migraine, cardiac or pleural disease, an acute abdomen.
Cutaneous Eruption
Herpes simplex virus infection,
Contact dermatitis,
Erysipelas,
Bullous impetigo.

40. Diagnosis
Clinical picture usually diagnostic.
Confirmed by Tzanck test.
Viral culture to rule out HSV infection.

41. : Tzanck's Test

42. tREatMEnt
 The disease is self limited.
 The goals of treatment are.
1. Minimize the pain.
(Analgesic)
2. Speeding the healing.
(Topical & systemic antibiotic if 2ry bacterial infection)
3. Prevention of dissemination.
(Acyclovir 800mg / 6 hourly for 7-10 days)

43. CoMpLiCations
1. Post-herpetic neuralgia.
2. Ophthalmic zoster.
3. Ramsay Hunt syndrome.
4. Disseminated zoster.
5. Zoster encephalomyleitis.

45. Warts
(( verruca
It is a common, discrete benign
epidermal hyperplasia induced
by different types of human
papilloma virus (HPV)

46. epidemiology
 Warts are very common infection allover the world.
 Both sexes are equally affected.
 All ages but rare in infancy & common in school years.
 The highest incidence of common warts is between
the age of ( 9 – 16 years).
 While for genital warts between 20 - 40 years.
 Warts more common in immuncompromized patients.

47. mode of
transmission
 Major mode is skin-to-skin contact.
 Minor trauma with breaks in the skin facilitates
transmission.
 Habitual nail bitter or children who suck their hand
are at risk of auto-inoculation
 Shaving may spread warts over the beard.
 Genital wart is the commonest STD.

48. aetiology
 Warts caused by human papilloma vrius.
 There are over 80 subtypes of HPV.
 It is a double stand DNA virus belong to
papovavirus family.
 The incubation period range from 1-6 months.
 Different subtypes of HPV are more or less
causing specific clinical mainfestation.
 Some subtypes are oncogenic ( e.g cervical
carcinoma caused by HPV 16 &18 ).

49. clinical
presentation
1. Common wart ( Verruca vulgaris ).
2. Plane (flat) wart ( Verruca plana ).
3. Planter wart ( Verrruca plantaris ).
4. Genital wart ( Condyloma accuminata)
5. Filiform wart.
6. Priungual wart.
7. Mosiac wart.

50. common Warts (verruca
(vulgaris
 HPV subtypes 1, 2, 4, 26, 27
 Papules / nodules with rough surface.
 They may occur singly or in groups.
 Can occur any where but most commonly over
dorsal aspect of fingers & hands.
 Characteristic by black dots on the surface which
represents thrombosed capillaries.
 New warts may appear at sit of trauma (koebner
phenomenon).
 Periungual warts and filiform warts are variants of
common warts.

51. Common warts: Multiple papules and nodules with rough
.surface on the dorsum of both hand

52. Verruca vulgaris: Numerous nodules and papules with rough surface
on the dorsum of left hand.

53. Periungual warts: Nodules with rough surface distributed around
The nails of the right hand.

54. Filiform warts: Multiple elongated ( thread like( projections on
the face of child.

55. plane Warts (verruca
(plana
 HPV subtypes 3, 10, 27, 38.
 Slightly elevated papule with smooth surface.
 The number range from few to many hundreds.
 Skin-colored, light brown, pink, or hypopigmented.
 Shape may be round, oval, polygonal, or linear
lesions ( auto-inoculation by scratching ).
 Common sit is the face or beard area, but may be
seen on dorsa of hands

56. Verruca plana (flat warts( : Flat-topped, smooth surface, skin-color
. numerous papules on the face

57. Verruca plana (flat warts( : Flat-topped, smooth surface, and
.erythematous numerous papules on the dorsum of right hand

58. planter Warts ( verruca
plantaris )
 HPV subtypes 2, 4.
 Rough hyperkeratotic surface studded with black
dots ( thrombosed capillaries ).
 Usually single but may be multiple.
 Affecting the planter aspects of feet or hands.
 When multiple warts coalesce into large flat plaque
it is called mosiac wart.
 Paring using surgical scalpel will produces pinpoint
bleeding spots.
 D.D : Callosities and Corns.

59. Verruca plantaris (planter warts ): Hyperkeratotic surfaces involving the planter
aspects of right foot with coalesce forming mosaic warts

60. ) callositis (d.d of planter Wart
Callositis are circumscribed plaque of hyperkeratosis
induced by repeated friction or trauma.
Commonly seen over weight bearing area.
The surface is somewhat smooth and the epidermal
ridges continue without interruption.
Paring using surgical scalpel will not produces the
pinpoint bleeding spots

61. .Callosities : Hyperkeratotic plaque over weight bearing area
paring with surgical blade does not revels any bleeding spot

62. genital Warts (condyloma
(accuminata
 HPV subtypes 6, 11, 16, 18.
 Cauliflower papules, nodules or plaques.
 Can occur solitary, multiple or in large masses.
 It is the most common STD.
 Seen in external genitalia of both sexes , perianal
region and in anal canal .
 May affects the urethral meatus, urethra, vagina
or cervix.
 Huge warts at risk of malignant changes.
 Important D.D is condyloma lata (2 ry syphilis).

63. Condyloma accuminata (genital wart( : small cauliflower
.erythematous nodules on the shaft of penis

64. Condyloma accuminata: Multiple, soft skin-colored papules on the
.glanus penis and shaft

65. Condyloma accuminata perianal: Multiple fleshy papules becoming confluent
.cauliflower-like mass around the ananus

66. Condyloma accuminata uterine cervix : sharply demarcated, whitish flat
.plaques in cervix

67. COURSE AND
PROGNOSIS
Immuno-competent individuals, cutaneous HPV infections
usually resolve spontaneously.
- 50% of warts will resolve within 1 year.
- 70% of warts will resolve within 2 years.
Immuno-compromised patients, cutaneous HPV infections may
be very resistant to all modalities of therapy.

68. DIAGNOSIS
1. History and examination:
2. Acetowhitening test:
Acetic acid 3.5% causes some cubclinical
warts to develop shiny white surface color.
3. PCR.
4. Pap smear: For cervical and anal warts.

69. TREATmENT
Treatment depend on no. of lesions, site of wart and
cosmetic disability.
 Keratolytics.
 Chemical cautery.
 Retinoic acid.
 Cryotherapy.
 Electrocautery.
 Topical 5-flurouracil.
 Podophyllin 20%.
 Imiquimod 5%.
 Laser therapy.

70. CRyOThERAPy
 Using liquid nitrogen ( -196 Co ).
 Quite effective.
 The procedure is minimally painfull.
 Heals without scarring.
 Can be used for all warts.

71. Mark the lesion 2 mm. Start freezing
Maintain freezing for 10 sec. weeks later 3

75. PODOPhyllIN 20%
 It
is a cytotoxic agent that arrest mitosis.
 The treatment most commonly used for
ganital warts.
 Contarindicated during pregnancy.

77. mOllUSCUm
CONTAGIOSUm.
Molluscum contagiosum is a self-limited
viral skin infection, characterized
clinically by skin-colored papules that are
often umbilicated, occurring in children &
sexually active adults.

78. AETIOlOGy
 Molluscum contagiosum virus (MCV).
 It’s a large double strand DNA virus belong
to pox virus family. ( The largest virus known )

79. EPIDEmIOlOGy
 Skin-to-skin contact is essentials for
transmission of the infection.
 MC is a common disease in children and
adults.
 Both sexes are equally affected.
 In children occur on exposed skin.
 In adults may occur in genital skin (STD).

80. ClINICAl PICTURE
 Incubation period 4 - 8 weeks.
 The lesion is asymptomatic.
 The charactarestic skin lesion is a PAPULE :
1. Size : Ranging from 2 – 10 mm.
2. Number : Single to hundred. (no specific distribution)
3. Color: Pearly white, translucent or skin-colored.
4. Surface: Smooth surface with umbilicated center.
5. Squeezing of lesion will extruded milky - white material.

81. Molluscum Contagiosum : Discrete, solid, skin-colored papules, 1 to 2
.mm in diameter ,with central umbilication

83. Molluscum Contagiosum : Single pearly - white papule on the shaft
. of penis

84. TREATmENT
1. Prevention :
Avoid skin-to-skin contact with infected individuals.
2. Curettage.
3. Cyotherapy.
4. Electrodessiction.
5. Topical imiquimod (Aldara).