Copy of Derm Viral Infections

How is HPV transmitted?

Transmitted by direct contact of skin or mucous membranes with an infected lesion.

Genital lesions can be passed through sexual contact, oral-genital, manual-genital and autoinoculation.

Why are 15 of the genital types of HPV considered high risk?

bc of association with high-grade squamous intraepithelial lesions, cervical cancers and other genital tract cancers.

How does a HPV infection typically present

Warts

Cutaneous warts (verrucae) come in a variety of types and include:

Common wart

Plantar wart

Flat wart

More aggressive treatment may be needed for what type of warts

plantar warts

When should you use a less agressive treatment for warts

children (because of pain) and on parts of body where scarring is a serious concern

Spontaneous regression occurs how often when it comes to warts

two-thirds of warts within two years

Observation for warts is an option for all patients, but what is the downside of this

it is far easier to treat smaller, fewer warts early than to wait until lesions enlarge or multiply.

What are some important considerations to know when treating cutaneous warts

Therapy may take several weeks or even months; patience and perseverance are essential.

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Although the skin may look normal after treatment, there often is virus still present in the remaining tissue.

What kind of tools used for paring down warts should not be used

nail file, pumice stone, etc.

Initial treatment for __cutaneous__ warts that __patients__ can do on __smaller__ lesions

Salicylic acid in collodion

Initial treatment for __cutaneous__ warts that __patients__ can do on __larger__ lesions

Salicylic acid plaster

Initial treatment for __cutaneous__ warts that a __clinician__ can do

• Cryosurgery using liquid nitrogen.

• Electrosurgery is painful and greater chance of scarring

• CO2 laser surgery for recalcitrant warts

• Cantharidin liquid.

How to treat a __flat__ wart in __light skinned__ patients

liquid nitrogen

Tretinoin

5-fluorouracil

How to treat a __flat__ wart in __dark skinned__ patients

5-fluorouracil

imiquimod

In light-skinned adults with common, plantar, or palmar warts treat patients who want a rapid response to therapy with:

liquid nitrogen

In children old enough to comply with the therapy, treat common, plantar, and palmar warts with:

salicylic acid or cantharidin topically.

Potent preparations, such as 40 percent plasters (Mediplast or Duofilm patch), usually are reserved for:

Thicker Areas; they are particularly useful for plantar warts. Pare down and repeat

Treat filiform warts with

Snip incision

In patients with (cutaneous manifestations) facial lesions or other areas where scarring is a concern

treat with topical imiquimod or intralesional immunotherapy

Common warts (verruca vulgaris) description

\-Well-demarcated

\-hyperkeratotic papules

\-rough

\-hard nodules with an irregular surface

\-Quickly grow small to large

\-cauliflower-like papules

\-Firm papules 1-10mm

\-Red or brown dots on hand lens are thrombosed capillary loops

Common warts are usually asymptomatic

Are common warts usually symptomatic or asymptomatic

asymptomatic

Common anatomic sites for cutaneous warts verruca vulgaris include

Dorsum of the hand

Between the fingers

Adjacent to the nails (periungual)

Knees

Treatment for common warts

Salicylic acid, Cantharidin, Cryotherapy

Plantar warts usually affect what population

adolescents and young adults

Presentation of plantar warts

thick painful endophytic plaques located on the soles, heels, toes, head of metatarsal

Plantar warts tend to have what over them

a thick callous and shaving reveals punctate bleeding blood vessels.

Plantar warts treatment

Often resistant to treatment.

Liquid nitrogen, salicylic acid, bichloracetic acid

Surgical excision can be done

Another name for a flat wart

Juvenile Verruca Plana

Description of the appearance of a flat wart

Sharply defined, flat papules (1-5mm) about 1-2mm thickness. Round, oval, polygonal.

Where are the most common place flat warts are found

face, neck, beard, shins and dorsa of hand.

Flat warts treatment

Cryotherapy can be beneficial, but pigment changes can occur.

Tretinoin

5-Fluorouracil

What is Epidermodysplasia Verruciformis

\-Autosomal recessive condition

\-rare, lifelong hereditary disorder characterized by chronic infection with HPV

Epidermodysplasia Verruciformis presentation

Flat topped papules that are skin-colored, light brown, pink, hypopigmented. May be numerous lesions

Where is Epidermodysplasia Verruciformis typically found

Face, dorsa of hands, arms, legs, anterior trunk

Premalignant and malignant lesions of Epidermodysplasia Verruciformis arise most commonly where

face

What kind of skin cancer is associated with the malignant lesions of Epidermodysplasia Verruciformis

SCC in situ and invasive

At what age do lesions of Epidermodysplasia Verruciformis typically arise

5-7 years of age

What is common with the lesions of Epidermodysplasia Verruciformis

progressive and widespread lesions that respond poorly to treatment

The HPV viruses that cause most genital warts are

low risk for cervical cancer

What HPV type is most common for cause of warts

HPV types 6 and 11

What HPV type is most common for cause of cervical cancer

types 16 and 18

The most common clinically apparent manifestation of genital HPV infection is

genital warts (condyloma acuminatum).

Other related anogenital hpv manifestations include

Buschke-Lowenstein tumor

External genital warts of HPV is spread by

direct skin-to-skin contact, including sexual intercourse, genital-genital, oral-genital, genital-anal.

Science explanation of how genital hpv is spread through skin to skin contact

Microabrasions on the epithelial surface allow virions to gain access to basal cell layer of noninfected partner

HPV dysplasia can range from mild to severe what

SCC

Four types of HPV mucocutaneous lesions are

Small Papular

Cauliflower-floret

Keratotic warts

Flat-topped papules/plaques

other name for Condyloma Acuminata

Genital Warts

Charecterisitic Look of Condyloma Acuminata

verrucous, pink or skin-colored, papilliform appearance

HPV is the major etiologic agent in pathogenesis for

cancer of the cervix.

Diagnosis of genital HPV is is made by

clinical inspection.

Cervical cytology (Pap smear)

Acetic acid application (accentuates the nuclear/cytoplasmic ratio)

Biopsy

Gardasil® Quadrivalent vaccine was developed to help prevent infection with what types of HPV

types 6, 11, 16, and 18 Not in US

Gardasil® Quadrivalent vaccine is recommended for:

all females and males between ages 9 and 26 years. Also recommended for males age 9-26 years.

How is the Gardasil® Quadrivalent vaccine administered

The vaccine is given by injection and requires two or three doses

Gardasil 9 protects against

HPV 6, 11, 16, 18, 31, 33, 45, 52, 58

\*Available in US.

Gardasil 9 is approved for what ages

9-45

What is Cevarix?

Not in US

prevent cervical cancer caused by HPV types 16 and 18

For females 15-25 years of age

Individuals younger than 15 years in the US getting their HPV vaccine should receive

two doses of HPV vaccine at least six months apart.

Individuals older than 15 years in the US getting their HPV vaccine should receive

three doses of HPV vaccine over a minimum of 24 weeks.

The minimum interval between the first two doses is four weeks

the minimum interval between the second and third doses is 12 weeks

The quadrivalent vaccine (Gardasil) and 9-valent vaccine (Gardasil 9) are typically administered what time span

three doses at time zero, and at two and six months of follow-up.

T/F

the bivalent (cevarix) vaccine is typically administered in three doses at time zero, and at one and six months of follow-up

True

HPV is the cause of what specific types of cancer

squamous cell carcinoma and adenocarcinoma of the cervix and is highly associated with other anogenital SCC.

How to reduce spread of HPV

Avoiding contact with infected individuals

Condoms do not provide complete protection (areas that aren't covered are still susceptible)

What is the goal when treating patients with HPV

to decrease warts. Unable to eradicate HPV or cure it

How to diagnose angiogenital warts

The use of dilute solutions of acetic acid (3 to 5 percent) is a valuable adjunct for delineation of disease before biopsy.

Biopsy may be needed if unsure of diagnosis.

Immunofluorescence

Pap testing through cytology.

HPV-associated lesions after the application of acetic acid develop what

a characteristic aceto-white appearance.

Immunofluorescence explanation

uses fluorescent dye and shows an antigen by exposing it to antibodies.

__Patient__ applied treatment for HPV

Imiquimod (Aldara® or Zyclara) (immune response modifier)

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Podofilox (Condylox®) (purified derivative of podophyllin resin) Not to be used in pregnancy

__Provider__ Applied Treatment of Genital Warts

Trichloroacetic acid or bichloracetic acid bicarbonate (OK during pregnancy)

Podophyllin resin (washed off 6 hours later)

Interferon alfa (injection)

Surgical removal: laser, and excision (cutting out)

Cryotherapy

Laser

How many human herpes viruses strains are there

Currently 8 identified (HSV1, HSV2, VZV, EBV, CMV, HHV6, HHV7, HHV8)

what are the most frequent clinical manifestations of first-episode HSV infection in children.

Gingivostomatitis and pharyngitis

Many primary infections of skin HSV are

asymptomatic or have trivial symptoms.

Majority of the cases of herpes labialis are caused by

Herpes simplex virus type 1 (HSV-1)

Hsv type 1 is often referred to as

cold sores

HSV-1 can also cause clinical disease in a wide variety of other anatomic locations:

the genitalia, liver, lung, eye, and central nervous system.

HSV-1 tends to occur how many times per year

twice

t/f HSV-1 can cause infection anywhere on the skin, especially if there is disruption of skin integrity.

true

How to clinically diagnosis HSV

viral culture medium

The Tzanck smear (activated lesions)

Polymerase Chain Reaction (PCR) testing.

t/f Primary ocular HSV infections are common

false-occur in less than 5 percent of patients, but can cause significant morbidity due to keratitis and acute retinal necrosis. Due to HSV-1

What strain of HSV is responsible for Gingivostomatosis

HSV-1

Elaborate on Herpes Simplex encephalitis

mostly due to HSV-1.

It involves the temporal lobe

Mortality is high

50% of survivors have moderate to severe neurologic impairment

Athletes should not participate in contact sports until all herpes lesions have

encrusted

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Antiviral therapy can expedite healing of lesions during primary and recurrent disease

How to diagnose HSV

Tzanck. Better test is detection of virus, viral antigen or viral DNA in scrapings from lesions detected by PCR.

HSV treatment

\-Topical Antiviral Therapy for herpes labialis is minimally effective. Acyclovir and Penciclovir

Ocular HSV Treatment

Topical idoxuridine, trifluorothymidine, vidarabine, cidofovir

Herpetic Encephalitis Treatment

immediate IV Acyclovir

Genital lesions, herpes gladiatorium, recurrences treatment

Oral Acyclovir, Valacylovir, Famciclovir

In most cases, genital herpes results from infection with the herpes simplex virus type:

Type 2 (HSV-2)

The herpes simplex virus is usually contracted when a person:

engages in unprotected oral, anal, or vaginal sex with an infected partner

Initial outbreak of Genital Herpes are typically:

\-The most severe

\-occur within a few weeks of infection

\-Symptoms tend to resolve within about three weeks

\-symptoms of genital herpes tend to be more severe in women than in men

\-The cervix is involved in 70%.

A very small percent of infected individuals with genital herpes may develop additional non-genital symptoms like:

Proctitis-(inflammation of the lining of the rectum**)**

meningitis

The period during which the virus is traveling to these nerves is called:

latent stage, and no symptoms are evident.

Recurrence of genital herpes

Recurrence occurs between 6-10 x a year for 20-30%. Becomes less frequent

Triggers for recurrences of HSV 2

Illness, Stress, Fatigue,

All may act as triggers for recurrent herpes outbreaks

Menstruation in women may also cause an outbreak to occur

Recurrence Treatment for HSV

Valacyclovir 500 mg BID for 3 days

OR Acyclovir 800 mg three times for two days • or 800 mg oral BID for five days

OR Famciclovir

Self-care measures for HSV that we should educate patients on

\-cool cloths applied to the affected area

\-Sitz baths can also alleviate pain (peeing at the end in bath)

\-keep the genital area clean and dry

\-avoid tight or irritating underwear and clothing

List some Complications of HSV

Herpetic WhitlowHerpes Gladiatorum (disseminated cutaneous infection common in wrestlers)

Disseminated neonatal infection.

CNS complications

Elaborate on Herpetic Whitlow:

\-Erythema, swelling, and pain, presence of vesicular or pustular herpetiform lesions.

\-occurs in medical personnel who have contact with oral secretions and can be recurrent.

\-may also experience fever, lymphadenitis, and epitrochlear or axillary lymphadenopathy.

Diagnosis of Herpetic Whitlow

suspected by an exposure history as well as the presence of vesicles