Infectious Dermatology Part 2 Flashcards
MCC/types of Condyloma Acuminatum
HPV 6 & 11
HPV types ___, ___, ___, and ___ are the major etiologic factors for in situ and invasive SCC
16, 18, 31, and 33
how are Condyloma Acuminatum transmitted (incubation, development, etc)
- Invasion of basal cells of epidermal layer via microabrasion
- Active lesions are not required for transmission
- Incubation 3w-8m
- skin lesions develop 2-3 mos after exposure
RF for Condyloma Acuminatum
- Number of sexual partners
- Frequency of sexual intercourse
- Partner with HPV
- Other STI’s
transmission of condyloma acuminatum via how?
- sexual contact
- Oral - genital
- Genital - anal - Delivery
- mothers with infection transmit to baby
pathogenesis of condyloma acuminatum
- Low Risk – cause warts
- High Risk – cause warts
- HPV may persist for years in a dormant state and becomes infectious intermittently
- Immunosuppression high risk for warts if infected
clinical manifestations of condyloma acuminatum
- Usually asymptomatic
- Anxiety
- Obstruction if large mass - Mucocutaneous lesions (4 types)
4 types of mucocutaneous lesions
- Small papular
- Cauliflower-floret
- Keratotic warts
- Flat topped papules/plaques (MC on cervix)
presentation of condyoma acuminatum
- Skin colored/pink/red/tan/brown
- Solitary or scattered or isolated or mass
- Immunocompromised patients may have many lesions and may be large
MC sites for condyloma acuminatum
- Male = frenulum, corona, glans penis, prepuce, shaft, and scrotum
- Female = labia, clitorius, periurethral, perineum, vagina, and cervix
- BOTH = perineal, perianal, anal canal, rectal, urethral meatus, urethra, and bladder
what are Laryngeal Papillomas
- Uncommon HPV 6 and 11
- MC on vocal cords
- Age <5 years old or >20 years old
laryngeal papillomas are at - risk of ____ and ____
- SCCis
- invasive SCC
DDx condyllomas acuminatum
- PPP
- Sebaceous glands
- SCCis
- Skin tags
- Pilar cysts
- Molluscum
- Folliculitis
- Scabetic nodules
dx/tests for condyloma acuminatum
- Pap smear
- Dermatopathology
- typically clinical dx
- Dermoscopy = papillomatosis (hallmark)
- Finger like knob projections - Shave Biopsy – if refractory to tx
tx condyloma acuminatum
- Pt - Imiquimod, podofilox, trichloroacetic acid
- Provider - cryotherapy, electrosurgery, surgical removal, laser
*may resolve on their own
disposition/management for condyloma
Recommend follow up monthly until lesions gone then q3months
- Recurrence MC within 3 months of first treatment
- Routine PAP in females
- PREVENTION
— Gardasil vaccine– (6,11, 16,18) prior to sexual activity
— Condoms
gardasil dosing
- 9-14 y/o: 2-dose 0, 6-12 mo; 3-dose 0, 2, 6 mo
- 15-45 y/o: 3-dose 0, 2, 6 mo
Cervical, vulvar, vaginal, anal, oropharyngeal and other head and neck cancers caused by what type of HPV
16, 18
provider tx of condylomas
- Cryo - q2-4 wks x 3 mo (sometimes longer)
- CO2 laser - Recurrent or resistant to tx
- Surgical - Best option for >1cm; shave (same technique as shave biopsy)
- Curettage (pairing) - Can be done before LN or SA application
- Electrosurgery - Used alone or with curettage
MOA of Imiquimod 5%
Immunomodulator
induces immune system response to recognize and destroy lesions
application of imiquimod 5%
Application - (vehicle: cream)
- Apply small amount at bedtime 3x/wk - rub cream in until no longer visible
- Wash off upon awakening with mild soap (after 6-10 h)
- Cont Tx until complete clearance - maximum of 16 wks
SE imiquimod 5%
Localized inflammatory reaction (redness, irritation, induration, ulceration, erosions, and vesicles)
- Holiday of several days may be needed if SE are too severe for pt comfort
Pt ed for imiquimod 5%
Avoid sexual contact during application times (weakening of barrier contraception)
MOA of podofilox 0.5%
Antimitotic
prevents cell division and causes tissue necrosis
Vehicle: solution or gel
application of podofilox 0.5%
- Cotton tipped applicator (sol)/ finger (gel)
- Apply q12h x 3 days, off 4 days, repeat therapy weekly until resolution (max 5 consecutive wks of therapy)
- Apply to normal skin between lesions (if applicable)
- avoid open wounds
- Wash medication off after 1-4 hours - tx area ≤ 10 cm₂ AND Total volume should be no more than 0.5 ml/d
SE Podofilox 0.5%
- MC - Local mild-severe skin irritation
- MC systemic SE - HA (only 7% per EBM)
- Flammable (avoid flames or lit cigarette)
CI podofilox 0.5%
preg (cat C)
pt ed podofilox 0.5%
- Apply initial tx if possible in office to educate on proper application
- Avoid sexual activity during rx application times
MOA of Trichloroacetic Acid (TCA)
- burns, cauterizes and erodes skin lesions
- Strength = 80-90%
- Apply vaseline around lesion to create barrier apply TCA to area with cotton tip applicator x 6-10 weeks
- VERY effective
which type of infection of molluscum contagiosum is benign and self limiting
Viral infection - poxvirus
transmission of molluscum contagiosum
Direct skin – skin contact
- Bathing together
- Sexual encounter (Adults)
- 2-6 weeks incubation - MC in young children but can be adults
RF Molluscum Contagiosum
- Childcare/daycare
- School
- Sports
- Risky sexual behavior
- Small, smooth, dome shaped papules with umbilicated center
- In adults commonly in groin area or lower abdomen.
- range in size from 3-6mm
- White, curd-like material can be expressed from the depression of the lesion.
- Pink/pearly/flesh colored
- Grouped or linear
-
Palms and soles are spared
- ID reaction = “dermatitis” - High risk = immunocompromised and atopic patients
Molluscum Contagiosum
DDx Molluscum Contagiosum
Warts
Condyloma
BCC
management for Molluscum Contagiosum? Why tx?
- Typically regress - 6 months to 2 years
- Why do we treat? Parents commonly want molluscum treated
- Helps with spreading
- Cosmetic
- Recurrent dermatitis
- Stress
tx for Molluscum Contagiosum
- Cryotherapy / curettage
- Podofilox 0.5%
- SA (compound W)
- DON’T PICK…PICK = SPREAD
cause of verrucae
HPV
Direct skin contact
Incubation = 2-6 months
3 types of verrucae
- Verruca vulgaris - common wart
- Verruca plantaris - plantar wart
- Verruca plana - flat warts
- 1-10 mm papules or >
- Isolated or multiple
- Red and brown spots - Seen under dermatoscope - thrombosed papilla capillary loops (patient’s common call them seeds)
- Isolated or multiple
- MC: Trauma, Hands/fingers, Knees
which type of verruca?
Verruca Vulgaris
- Shiny papules plaque with rough hyperkeratotic surface
- Thrombosed capillaries
- Skin lines decrease
- Usually uncomfortable
- tender
which type of verruca?
Verruca Plantaris
- Sharply defined
- 1-5 mm
- Flat surface
- Skin colored or light brown
- Round, oval, polygonal or linear
- MC on face, beard area, dorsa of hands and shins
which type of verruca?
Verruca Plana
dx verruca
Clinical
Biopsy can assist (SCC)
DDx verruca vulgaris/planus
- Molluscum
- SK
- AK
- SCC
- Skin tag
DDx verruca plantaris
Corn/callus
management + when to tx for verruca
- Resolve without treatment months years
- Should you treat?
- Painful /discomfort
- Impairment of function
- Cosmetic
- Immunosuppresion - SA
- Cryo
- Imiquimod
- Cantharidin
- Electrosurgery (use caution-aerosolized virus)
goal of salicyclic acid
Keratoylic agent
desquamation of hyperkeratotic epithelium
what % SA to use for smaller and larger lesions?
10 -30% = smaller lesions
40% = larger
DAILY / SAND OR FILE
Liquid, ointment, pad or patch
CI and SE of SA
- Contraindicated – hypersensitivity
- Side Effects – local irritation
- Apply after soaking foot/file before application
a substance derived from the blister beetle
Cantharidin
MOA canthrone
causes a blister to form on the wart or viral lesion
leave on for 4-6 hours then rinse off.
how to perform cryotherapy with verrucas
- Debride thick surface
- Repeat every 4 weeks (I usually do every 2-3 weeks x 3 months
Acute dermatomal infection infection associated with reactivation of VZV
Herpes Zoster
pathogenesis of herpes zoster
- Pathogenesis passes from lesions in the skin and mucosa via sensory fibers to sensory ganglia = lifelong latent infection
- Virus multiples and spreads down the nerve fibers to the skin and mucosa produces vesicles
triggers for herpes zoster
immunosuppression, trauma, tumor, or irradiation
phases for HZ
- Prodrome
- Active infection
- PHN
4 Dermatomal Lesions (active infection) and when do these start forming?
- Papules - 24 hours
- Vesicles/bullae - 48 hours
- Pustules - 96 hours
- Crusts - 7-10 days
prodomes of HZ
- Pain - Can mimic angina or acute abdomen
- Tenderness
- Paraesthesia - Flu like constitutional symptoms can occur
HZ - New lesions appear for up to ? wk
how do they look?
1 week
Erythematous, edematous base, clear vesicles, and sometime hemorrhagic
Vesicles erode forming crusted erosions
Dermatome crusting usually resolves in 2-4 weeks - Unilateral, Dermatomal
other involvement in HZ
- Mucous membrane can be involved
- LAD
- Sensory or motor changes
- Ophthalmic zoster
- 1/3rd of cases – trigeminal nerve (V1) - (+) Hutchinson sign
- Delayed contralateral hemiparesis
- Headache
- Constitutional symptoms
- PHN - Months to years
- Scars
HZ DDx of Prodrome Phase
- Migraine
- Cardiac or pleural disease
- Acute abdomen
- Vertebral disease
HZ DDx of Dermatomal Eruption
- HSV
- Photoallergic (poison ivy, poison oak)
- Contact dermatitis
- Erysipelas
- Necrotizing Fasciitis
how to dx HZ
- Prodromal
- Unilateral pain - young and immunocompromised - Active
- Clinical
- Tzanck test
- DFA
- Viral culture
- PCR (Most Sensitive) - Post-herpatic Pain
- History and clinical
tx/management HZ
f/u, prevention, meds
- Close follow up and ophthalmology referral if eye involvement
- Prevention
- Vaccination reduces burden by >60% and incidence by 51% - Antiviral therapy
- Valcyclovir 1000mg TID x 7 days
- Famciclovir 500mg q 8 hours x 7 days
- Acyclovir 800mg 5x daily x 7 days
— Immunocomp = extend to 10 d course
supportives for HZ
- Bed rest
- Sedation
- Pain management
- Moist dressings
pain management for HZ
- NSAIDS
- Gabapentin
- Pregablin
- TCA’s
- Nerve block (SEVERE)
