Intro I - Viral and Fungal Skin Infections

What is the etiologic agent for warts?

Human Papilloma Virus

What are the types of warts?

Common, periungual, flat, filiform, plantar, and genital

What strains of HPV cause 90% of genital warts?

6, 11

How many high-risk cancer strains of HPV are there and what strains cause 70%?

12 strains; 16, 18

What is the other name for common warts?

Verruca vulgaris

Where are common warts the most common?

Hands and knees, but can occur anywhere on the body

What do common warts look like?

Dome shaped with irregular surfaces

How are common warts spread?

Skin to skin contact, contact with contaminated surfaces, and autoinoculation

In what group of people are common warts most common?

Children

How do you treat a common wart?

Salicylic acid-First line treatment (Compound W)

Liquid nitrogen-2 freeze thaw cycles are administered every 2-4 weeks for several visits

Surgical removal or laser therapy only if recurrent

"Benign Neglect" is also an option

What is a plantar wart?

Occurs on the plantar surface of the feet

Why do plantar warts become calloused?

Because of the forces on the feet from walking the warts grow into the foot

In _________ patients, plantar warts may be widespread and intractable.

immunocompromised

How to treat plantar warts?

Cut duct tape size of lesion and leave in place for 6 days, remove, and wash skin, then gently debride

OTC topical salicylic acid preparations used for 8-12 weeks with cure rate of 75% (do not use in diabetics)

Cryotherapy ablation with liquid nitrogen with cure rate of 50%

Surgical removal/laser treatment (may still recur)

What are other types of warts?

Deep palmoplantar warts (myrmecia)

Flat warts

Heck disease

What is Heck Disease?

Painless, intraoral lesion; Secondary to HPV strains 13 and 32

What is the name for genital warts?

Condyloma Acuminata

What is Condyloma Acuminata?

Infection of the genital or anal skin by HPV

What strains are responsible for >90% of Condyloma Acuminata?

HPV Serotypes 6 and 11

Where do Condyloma Acuminata lesions spread rapidly?

Over moist areas as well as symmetric surfaces of the labia or rectum

What do Condyloma Acuminata lesions look like?

Pale pink to white, warty-like raised papules. May coalesce to form large cauliflower like masses

How can you tell if you have Condyloma Acuminata?

Use white vinegar to bathe the suspected lesion. If acuminata, lesion will turn white

What can be used to make the diagnosis of Condyloma Acuminata?

Pap smear, biopsy, or colonoscopy

How do you treat Condyloma Acuminata?

Podofilox (Condylox) is applied by the patient twice daily 3 consecutive days a week for cycles of 4-6 weeks

Imiquimod (Aldara) 5% cream once daily on 3 alternate days per week for 8-12 weeks

Surgical removal may be indicated in cases resistant to other treatments

What is the prevention of Condyloma Acuminata?

Vaccination against HPV

What is herpes simplex?

A viral infection, primary or recurrent, characterized by grouped vesicles on an erythematous base on skin or mucous membrane

How is herpes simplex spread?

Skin to skin, skin to mucosa, mucosa to mucosa with individuals shedding virus

What are the symptoms of herpes simplex primary infection?

Occurs with multiple, painful lesions, fever, lymphadenopathy, and general malaise

How long does herpes simplex primary infection last?

2-4 weeks

When does HSV1 most often occur?

Infancy or early childhood

What is herpes simplex secondary infection?

The lesions and symptoms are similar but less severe and shorter duration of 1-2 weeks

What is the treatment for herpes simplex?

Acyclovir 400 mg 1 tab po TID x 7-10 days (first line)

Valacyclovir

Famcyclovir

What is herpes zoster better known as?

Shingles

How does herpes zoster come about?

Decline in t cell mediated immunity to VSV

Reactivation of varicella virus due to cold, stress, age, medical conditions

What are symptoms of herpes zoster?

Unilateral pain, vesicular lesions limited to a dermatome

Pain/burning/itching will often precede rash (1-5 days)

How does herpes zoster present?

Clustered vesicles of varying sizes

Herpes zoster lesions do not cross the _______ of the body.

midline

How do herpes zoster lesions develop?

Continue to develop for 3-5 days, scab over in approx 10 days

What is the treatment for herpes zoster?

Acyclovir 800 mg 5x per day

Valacyclovir (given x 7 days)

Famcyclovir (given x 7 days)

Give within 74 hours of symptoms to prevent post herpetic neuralia and shorten course

Pain management includes topical cream, Tylenol, Advil, narcotics

What is PHN relative to herpes zoster?

When patient has pain along dermatome after rash goes away

What are herpes zoster complications?

Herpes zoster opthalmicus

Ramsay-Hunt Syndrome - facial nerve affected

PHN-pain lasting > 3 months after lesions resolve (most common complication and risk increases with age)

Encephalitis

What is the herpes zoster prevention?

Shingris

Vaccination against Varicella

What is the recommendation for the shingles vaccine?

By the CDC for patients over 60 for routine immunization to help reduce the risk of developing shingles and PHN

What is the most common type of mucocutaneous infections?

Superficial fungal infections

What are the 2 common groups of fungal skin disease?

Dermatophytes and Candida

What are dermatophytes?

Unique fungi that infect nonviable keratinized cutaneous structures; "Tinea"

How are dermatophytes classified?

According to their site of infection

How does Tinea corporis present?

As irregularly shaped, scaly patches and plaques, often with a raised erythematous border and central clearing

Where does tinea corporis occur?

Trunk, arms, and legs

What is tinea corporis more commonly known as?

Ringworm

What is the treatment for tinea corporis?

Topical antifungals

What is tinea capitus?

Ringworm of the scalp

In what people does tinea capitis mainly affect?

Children from ages 2-10

What are some presentations of tinea capitis?

Scaling, broken hair, painful inflammation, and possible scarring alopecia

What is the treatment for tinea capitis?

Oral antifungals

Topical antifungals only if hair is short and only small areas affected

What is tinea pedis?

Dermatophyte infection of the feet

What is tinea pedis better known as?

"Athlete's foot"

What does tinea pedis look like?

Erythema, scaling, erosions, maceration, and/or bullae; often asymptomatic, but may be associated with itching

How do you prevent tinea pedis?

Use of shower shoes in public facilities, keep feet dry

How do you treat tinea pedis?

Topical antifungals

What is tinea cruris?

Dermatophytosis of the groin, pubic regions, and thigh

What is tinea cruris known as?

"Jock itch"

What does tinea cruris present as?

Lesions are large, scaling, well demarcated, dull red to brown plaques; asymptomatic or mild itching

What are some predisposing factors of tinea cruris?

Humidity, tight clothing, and obesity

How do you treat tinea cruris?

Topical antifungal

Information on Clotrimazole

Cream 1%: $19.90/15 g OTC

Solution 1%: $9.23/10mL

Twice daily

Available OTC

Information on Econazole (Spectazole)

Cream 1%: 17.50/15g

Once daily

Rx only

Information on Ketoconazole

Cream 2$: $16.43/15g

Once daily

Rx only

Information on Miconazole

Cream 2%: $3.30/30g OTC

Twice daily

Available OTC

When should you use oral antifungal treatment with Griseofulvin to treat?

When lesions are large, numerous, or resistant to topical antifungals

What is candida?

A fungal infection caused by yeast

What causes Candida?

Candida albicans

What structures can candidal infections affect?

Any anatomical structure

Who is at the greatest risk for candida?

Very young and very old, as well as those with comprised immune systems

What is intertrigo?

A candida infection in the intertriginous areas

How does intertrigo present?

A rash that begins with vesiculopustules which rupture, causing maceration; Lesions coalesce and satellite lesions are visible near the margins

What is the treatment for candida?

Topical - Nystatin, clotrimazole

Oral - fluconazole (Diflucan)