12 - Viral Infections Flashcards
What are warts?
Benign epidermal neoplasms caused by HPV (small DNA viruses)
Causes/pathophys of warts
HPV (>100 types)
HPV infects keratinocytes and induces hyperplasia and hyperkeratosis
Infection can be
- latent
- subclinical
- clinical
Which warts are associated w SCC?
38
41
48
How are warts spread?
Touch
- adjacent toes
Moist surfaces (pools)
Sites of trauma
Course that warts follow?
May resolve spontaneously in
- weeks - months
- Years - lifetime
Regression involves a multifactorial immune response
Wart removal?
May take several sessions
Minimal scarring
If normal skin lines return, removal was successful
Morphology of warts?
Verrucous papule 1-5mm in size
Cylindrical projections
Thromboseses vessels become trapped in projections and seen as black dots on surface of warts
Diagnostic sign
Warts may become fused and produce mosaic pattern on surface
Comon warts are aka?
Verruca vulgaris
Describe a verruca vulgaris
Dome shaped Gray-brown Hyperkeratotic Papule Black dots on surface
Tx or verruca vulgaris?
Liquid nitrogen Q 2-4 weeks Light electrocautery Salicylic acid (topical) Imiquimod (topical) Blunt dissection
Describe filiform warts
Finger like
Flesh-colored projections
Very superficial
- easiest to treat
MC site of filiform warts?
MC on face
Tx for filiform warts?
Curettage Apply bilat traction Use 1 firm stroke Light electrocautery Light cryosurgery
Flat warts are aka?
Verruca plana
Describe verruca plana
Flat (lol)
Flat-topped papules Grouped Pink, light brown, yellow Sites - Forehead - around mouth - back of hands - shaved areas (beard, legs)
Tx for veruca plana
Imiquimod 5% cream (aldara)
Cryosurgery/electrosurgery
5-fluorouracel cream (efudex)
Tretinoin cream (retin-a)
Where are plantar warts found?
Soles of feet
points of max pressure
- metarasal heads or heels
How to differentiate plantar warts from corns?
Shave and look for black dots and lack of skin lines
- corns have skin lines
Plantar wart treatment?
Not required if painless
- will regress over time
But if youre feeling froggy:
Debride (pare) and warm water soak prior to tx - salicyclic acid w occlusion - 40% salicylic acid plaster - imiquimod (aldara) w occlusion - cantharidin w occlusion Blunt dissection
Alternate plantar wart tx?
Laser
E D and C
Chemotherapy (bichloracetic acid)
Intralesional bleomycin sulfate ($$)
When treating plantar warts you should avoid?
Cryo
- blister on sole can be painful
What are subungual and periungual warts?
Wart next to nail
- maybe the tip of the iceburg
- painful
May be spread by cuticle biting
Subungual and periungual wart tx?
Resistant to chemical and surgical methods
Cryosurgery Cantharidin (paint wait for blister, repaint, occlude x 48hrs) Salicyclic acid Duct tape Blunt dissection
Genital warts are aka?
Condyloma acuminata or veneral warts
Condyloma acuminata or veneral warts are associated w?
HPV 6, 11, 16, 18
MC viral STD
Describe genital warts
Pale pink w numerous discrete narrow-to-wide projections on a broad base
Surface is smooth, velvety, moist and lacks hyperkeratosis of warts found elsewhere
May coalesce to form large, cauliflower-like mass
Self inoculation of genital warts?
Spread rapidly over moist areas
Kissing lesions on labia or rectum
Genital wart treatment success?
Frequently recur
- latent virus extends beyond txt ares in clinically normal skin
Flat and inconspicuous warts may escape txt
High risk and low risk HPV subtypes?
high: 16,18
Low: 6, 11
Genital warts txt considerations?
HPV cannot completely be eliminated
- surrounding subclinical infection
HPV infx may persist -> pts lifetime
- intermittent infection
Contagious spread from subclinical HPV pts vs exophytic wart is unclear
Check partner
Genital warts provider administered tx?
TCA - trichloracetic acid Podophyllum resin Cryosurgery Scissor excision Curettage Electrosurgary Carbon dioxide laser
Genital warts Pt applied tx
Podofilox gel (condylox) Imiquimod 5% (aldara)
If all else fails
- 5-fluorouracil (efudex)
Warts DDX?
Genital
- bowenoid papules
- pearly penile papule (NOT WARTS)
Bowenoid papules morphology?
Small Brown or pink Flat/slightly irregular Discrete Grouped papules
Resemble flat or genital wart
Bowenoid papules distribution?
Penis
Vulva
Anus
Bowenoid papules etiology?
Sex
- HPV - oncogenic type
- quasi-premalignant
Bowenoid papules prognosis?
Resolve spontaneously in months-years
Direct progression to SCC has not been observed
Bowenoid papules txt?
Cryo Electrosurgery Excision CO2 laser Imiquimod 5% (aldara) 5-FU (efudex) Abstinence Condom use
Check sex partner
Bowenoid papules DDX
Genital warts
Bowen disease
Psoriasis
Lichen planus
Mulluscum contaginosum is MC found in?
Kids
How is molluscum contagiosum spread?
Kids
- Touching
- Self-inoculation
- arms and face
Adults
- sex
- groin, pubis, thighs
- wrestlers/wrasslers
- masseurs
Molluscum contagiosum morphology
Small discrete 2-5mm flesh colored
- central umbilicaiton
- large lesions (1cm) (inflamed and crusted)
Molluscum contagiosum etiology
DNA poxvirus
Virion colony encased in protective sac
- prevents triggering host immune response
Molluscum contagiosum management?
Self limiting
Pruritic
Problems of contagion
Molluscum contagiosum txt?
Babies/small kids
- apply tretinoin
- lesion irritated - rub off w cloth
- wash area to prevent spread
Older kids/adults few lesions — durette — LN2 multiple lesions — retinA or TCA
Herpes names?
Oral - herpes labialis
Genital - herpes genitalis
Serotypes
- HSV-1 - oral
- HSV-2 - genital
HSV-2 spread is often?
From undiagnosed pts
- mild or unrecognized sxs but still sheds virus
Asymptomatic viral shedding is primary mode of herpes virus transmission
Herpes simplex first presentation?
First time is the worst time
Vesicles appear 6 days after contact
Last 14 days
Shedding last 15-16 days
Why is herpes the gift that keeps on giving?
Ascends peripheral sensory nerves and establishes latency in nerve root ganglia
Recurrent HSV “flare-ups”
Less severe than primary Prodrome - Itching burning, pain Virus cultured x 5 days Shed virus between flareups
Tends to get less freq over time
HSV morphology?
Grouped vesicles on an erythematous base
Superficial lesion
Slight central umbilication in 2-3 days then erode
Crust form then heal w/o scarring in 2 weeks
Clinical presentation of HSV?
Discharge Dysuria Inguinal LAD Fever Myalgia Lethargy Photophobia
All more common in women
Types of Herpes simplex?
Herpes gladitorium Ocular herpes Herpetic whitlow HSV of buttock (women usually) HSV of trunk
Diagnosis of HSV?
PCR - gold standard Viral culture (during shedding) Tzanck prep - multinucleated giant cells Serology differentiates 1 and 2
HSV management
Acyclovir
Valcyclovir
Famciclovir
penciclovir or abrevia (labialis)
Which HSV med is the best?
- per ms booker
Valcyclovir (valtrex)
Presentation of varicella?
Prodrome
- fever
- malaise
- HA
Croups of lesion in various stages
- Trunk-> extremeties
- Puritic in vesicle phase
- Scarring
Stages of varicella?
Papule-vesicle-erosion-crust
Etiology of varicella?
DNA poxvirus Respiratory transmission Spring (more common) Lifelong immunity - except reactivation
Varicella txt?
Cool bathes (aveeno)
Antihistamine PRN
Tylenol (no ASA)
Acyclovir
Acyclovir indication (varicella)
Start w/in 24hrs
Non-pregnant over age 13
Chronic skin disease
Children on steroids or immunocompromised
What is herpes zoster?
Reactivated varicella virus
- dorsal root ganglion
Herpes zoster presentation?
Prodrome
- pain, itching, burning
- constitutional sxs
Red swollen papules/plaques of varying size
Vesicles appear as clusters on the erythematous base
Clear and change to cloudy and prulent then erode/ruptureto form cursts (2 weeks)
dx of herpes zoster?
Clinical
+ tzanck prep
Herpes zoster txt
Acyclovir
Valcyclovir
Famciclovir
Prednisone (over 50 yrs) Analgesics - opiate pain meds prn Capsaicin cream Soaks
If herpes zoster is on ophthalmic branch of trigeminal nerve
Ophthalmologist consult
Prevention of herpes zoster?
Zostavax
- Single dose
- Sub Q
- Live attenuated vaccine
Pts 60yrs +
Zostavax is not?
Substitute for varivax
Txt for zoster or PHN
Why do fish live in salt water?
Because pepper makes them sneeze
