Macule Congenital white macule of nevus depigmentosus on thigh Papules n the trun! of a patient with lichen nitidus Plaques "ith silver# scale in severe psoriasis Nodules $odules on the forehead of a woman with l#mphoma Vesicles and bullae %n a child with severe chic!enpo& Pustules %n a patient with inflammator# acne Poiilode!"a %n a patient with m#cosis fungoides ' a form of s!in cancer #lac esc$a! %n a patient with invasive Rhi(opus infection APPROACH TO THE %ERMATOLO&' PRO#LEM PATIENT %s the diagnosis correct) %s the histor# correct) Prescription or over-the-counter drugs, or herbal therapies) *Drug eruptions+ Re-evaluate ph#sical findings Review the biops# slide #ourself Repeat laborator# tests, biopsies, or consider new tests Consider sending tests or biopsies to a different laborator# or dermatopathologist Did the patient actuall# receive the prescribed therap#) %s the patient compliant with the therap#) %s the dose ade,uate, or is absorption suboptimal) %s there a drug interaction that interferes with efficac#) %s the patient re-infected) *Scabies, S-D, etc+ Do other close contacts have the same problem) *%nfectious agents+ %s contact with antigen continuing) *Contact dermatitis+ %s the patient irritated b# or allergic to the prescribed therap#) *Contact dermatitis+ Reinvestigate travel, previous doctor visits and other therapies prescribed b# others Repeat ,uestioning about other organ s#stem s#mptoms *Review of s#stems+ btain records from previous treating doctors to loo! for hidden information Relati(e Si)e and S$ape o* Vi!uses In*ectin+ Hu"ans DNA viruses RNA viruses Po&virus *biggest+ Param#&ovirus *biggest+ .erpesvirus rthom#&ovirus Adenovirus Rhabdovirus Papovavirus Reovirus Parvovirus *smallest+ /nterovirus *smallest+ Papillo"a(i!us Li*e C,cle Des,uamation of virus-invaded dead cells *s,uamous+ 0-gene e&pression1 virion assembl# 2egetative viral D$A amplification 3444 genomes5cell /pisomal viral D$A *nucleus+ 634 copies5cell %nfection of basal cells following minor abrasion /&tensive and chronic verrucosis of the sole causing pain when wal!ing. .P2-7a was isolated from the lesions of this otherwise immunocompetent and health# patient Ve!!ucae planae or flat warts. -he warts are s!in colored to pin!, smooth surfaced, falt papules *.P2-34 was detected+ Cond,lo"ata acu"inata o! +enital -a!ts. -he warts are located on the prepuce and penis shaft 8iant cond#lmata acuminta *9usch!e- 0owenstein tumor+ Cauliflower-li!e deepl# infiltrating giant cond#lomata acuminate 0owenstein tumor+ in an older woman #asic Pat$o+enesis o* Hu"an He!pes(i!us In*ectios Primar# mucocutanoeus infection %nfection of the ganglia /stablishment of latenc# Recurrent infection Reactivations THE EI&HT H/MAN HERPESVIR/SES0 THEIR CLASSIFICATION AN% %IFFERENTIAL %/A&NOSES Human herpesvirus Classification Differential Diagnosis ..erpes simple& virus *.S2-3+ *..2-3+ .erpes simple& virus *.S2-:+ *..2-7+ Alpha herpesvirinae rolabial herpes; herpangina, aphthous stomatitis, Stevens-<ohnson s#ndrome, phar#ngitis *e.g. due to /92+, oral candidiasis, mucositis secondar# to chemotherap# 8enital trauma chancre *primar# s#philis+, aphthae, chancroid, granuloma inguinale 2aricella (oster virus *2:2+ *..2-=+ Alpha herpesvirinae 2aricella1 vesicular viral e&anthema */C., Co&sac!ie+, P0/2A, ric!ettsial po&, .S2, insect bites, drug eruption, scabies, contact dermatitis, smallpo& .erpes (oster1 (osteriform .S2, locali(ed contact dermatitis, ph#tophotodermatitis, bullous impetigo /pstein-9arr virus *..2->+ 8amma herpesvirinae 8roup-A streptococcal infection, acute viral hepatitis, anti-convulsant h#persensitivit# s#ndromes, to&oplasmosis, l#mphoma, and primar# CM2, ..2-?, .%2 infection C#tomegalovirus *..2-@+ 9eta herpesvirinae /92-induced infectious mononucleosis, to&oplasmosis, viral hepatitis, l#mphoma .uman herpesvirus ? *..2-?+ 8amma herpesvirinae 2iral e&anthems *measles, enterovirus infections, adenovirus, /pstein-9arr virus, rubella, parvovirus+, scarlet fever, Roc!# Mountain spotted fever, Aawasa!i disease .uman herpesvirus B *..2-B+ 8amma herpesvirinae Similar to ..2-? .uman herpesvirus C *..2-C+ 8amma herpesvirinae Acroangiodermatitis *pseudo-AS+, bacillar# angiomatosis, ecch#mosis, hemangioma, angiosarcoma, p#ogenic granuloma, psuedol#mphoma5l#mphoma ANTIVIRAL THERAP' FOR HERPES SIMPLE1 VIR/S AN% VARICELLA 2OSTER VIR/S D%S/AS/ C$-/D- Drug and dosage Herpes simplex infections rolabial herpes *recurrence+ 8enital herpes *first episode+ 8enital herpes *recurrence+ Chronic suppression $eonatal %mmunocompromised Ac#clovir-resistant .S2 in immunocompromised patients Penciclovir1 3E cream applied ,7 hours & > da#s 2alac#clovir 7 g P bid & 3 da# Ac#clovir1 744 mg P @&5d & 34 da#s or >44 mg P tid & 34 da#s Famciclovir1 7@4 mg P tid & 34 da#s 2alac#clovir1 3 g P bid & 34 da#s Ac#clovir 1 744mg P @&5d & @ da#s or >44 mg P tid & @ da#s Famciclovir1 37@ mg P bid & @ da#s 2alac#clovir1 @44 mg P bid & =- @ da#s Ac#clovir1 >44 mg P bid Famciclovir1 7@4 mg P bid 2alac#clovir1 @44 mg P ,d for 634 outbrea!5#r or3 g P ,d for 34 or more outbrea!s5#r Ac#clovir1 34 mg5!g %2 ,C hours & 34-73 da#s Ac#clovir1 >44 mg P @&5d&B-3> da#s or @ mg5!g %2 ,C hours & B- 3> da#s Famciclovir1 @44 mg P bid Foscamet1 >4 mg5!g %2 ,C-37 hours & 7-= wee!s *or until all lesions are healed+ Cidofovir1 3E cream ,d & 7-= wee!s Varicella zoster virus infections 2aricella :oster Ac#clovir1 74 mg5!g *C44 mg ma&+ P ,id & @ da#s Ac#clovir1 C44 mg P @&5d & B- 34 da#s Famciclovir1 @44 mg P tid & B da#s Adult immunocompromised Pediatric immunocompromised Ac#clovir1 34 mg5!g *@44 mg5m 7 + %2 ,C hours & B-34 da#s Ac#clovir1 34 mg5!g *@44 mg5m 7 + %2 ,C hours & B-34 da#s %$-RDGC-%$ "hat are viruses) o %nfectious agent o Hobligate intracellular parasiteI o Composition PA-.8/$/S%S 3. Direct %noculations 7. S#stemic infection =. 0ocal Spread M/C.A$%SM F PA-.08J 3. Blister K necrosis /&1 .erpes and Po& 7. Growth K proliferation /&1 Papova and Molluscum =. xanthem ! blood vessel r&n x" R$A viruses "hat are the viruses that cause s!in diseases) D$A viruses K specific s!in lesions R$A viruses K non-specific s!in lesions RNA VIR/SES 3. M#&ovirus K Measles, Mumps 7. Rhabdovirus K 2esicular stomatitis =. -ogavirus K Rubella >. Picornavirus - Co&sac!ie A and 9 K .FMD, .erpangitis, /&anthem - /chovirus K /&anthem #easles HRubeolaI Caused b# a Param#&ovirus Gniversal, highl# contagious, acute Childhood Florid, generali(ed maculopapular rash Preceded b# high fever, cough, cor#(a, conLunctivitis M Aopli!Ns spots Ru$ella H8erman measlesI Caused b# a -ogavirus Children5#oung adults Pin!-red macules and papules spreads centrifugall#, lasts for 7-= da#s followed b# des,uamation Mild prodrome, l#mphadenopath# Hand%&oot%#outh Disease Caused b# Co&sac!ie A3? or /nterovirus B3 Characteristic vesicular lesion in mouth *hard palate, tongue, and buccal mucosa+ and e&tremities *handsOpalms, dorsumOpalms5soles+ %NA VIR/SES 3. Po& virus K 2ariola, 2accinia, Molluscum contagiosum, Mil!erNs $odules, Paravaccinia, /cth#ma contagiosum 7. .erpes virus K .erpes simple&, /92, CM2, 2aricella5.erpes (oster =. Papova virus K "arts *2erruca vulgaris, 2erruca plana, 2erruca plantaris, Cond#loma acuminate, 9owenoid papulosis, 9usch!e-0owenstein tumor, /pithelioma cuniculatum+ Po& 2irus #olluscum Contagiosum Common, benign 8enerall# affects children Person to person spread5fomites /tio1 Molluscum contagiosum virus o A po&virus o MC2 % and MC2 %% strains Resolve spontaneousl# K ?-P mos or t&1 e&traction #il'er(s Nodules 9enign viral disease -ransmitted to cattle handlers /tio1 paravaccinia po&virus *pseudocowpo& in infected cows+ Self-limited -&1 s#mptomatic .erpes 2irus Herpes )implex S#non#ms K Hcold soresI - Hfever blistersI - Hherpes labialisI /tiolog# .erpes virus hominis o -#pe 3 and -#pe 7 o Composed of1 - D$A genome - protein coat - lipid envelope Herpes *oster S#non#ms1 o HshinglesI o H(osterI A locali(ed disease limited to dermatome levels /lderl# people Result of reactivation of latent endogenous infection Pathogenesis o 2:2 from s!in *healed 2aricella+ sensor# ganglion *harmless, silent+ reactivation s!in o +rimar, Viremia1 virus respirator# tract blood R/S o )econdar, Viremia1 R/S blood *fever+ s!in *vesicles+ -reatment1 o S#mptomatic and supportive o Antivirals o %nterferon Papovavirus -arts S#non#ms o Hcommon wartI o Hflat wartI o Hplantar wartI o Hgenital wartsI -reatment1 o Reassurance *spontaneous resolution+ o Ph#sical and Chemical Destruction o Resistant wart treatment 3EN%3