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D30 Dermatology
Infections Toronto Notes 2019
Differential Diagnosis
• beforethoracicskinlesionsoccur,mustconsiderothercausesofchestpain
• contactdermatitis,localizedbacterialinfection,zosteriformHSV(morepathogenicfortheeyesthan
VZV)
Investigations
• nonerequired,butcandoTzancktest,directfluorescenceantibodytest,orviralculturetoruleoutHSV
Prevention
• routine vaccination in 50+ yr old with Shingrix® (recombinant zoster vaccine) preferred to in 60+ yr old with Zostavax® (live zoster vaccine)
Management
• compresswithnormalsaline,Burow’sorbetadinesolution
• oralantivirals:famciclovir,valacyclovir,oracyclovirfor7d;mustinitiatewithin72htobeofbenefit • analgesia:NSAIDs,acetaminophenformild-moderatepain;opioidsifsevere
• post-herpeticneuralgia:TCAs,anticonvulsants(gabapentin,pregabalin)
MOLLUSCUM CONTAGIOSUM
Clinical Presentation
• discretedome-shapedandumbilicatedpearly,whitepapulescausedbyDNAPoxvirus(Molluscum contagiosum virus)
• commonsites:eyelids,beard(likelyspreadbyshaving),neck,axillae,trunk,perineum,buttocks
Etiology
• virusisspreadviadirectcontact,auto-inoculation,sexualcontact
• commoninchildrenandsexuallyactiveyoungadults(giantmolluscumandseverecasescanbeseenin
the setting of HIV)
• virusisself-limitedandcantake1-2yrtoresolve
Investigations
• nonerequired,howevercanbiopsytoconfirmdiagnosis
Management
• topicalcantharidin(avesicant) • cryotherapy
• curettage
• topicalretinoids
• Aldara®(imiquimod):immunemodulatorthatproducesacytokineinflammation
WARTS (VERRUCA VULGARIS) (HUMAN PAPILLOMAVIRUS INFECTIONS)
Table 19. Different Manifestations of HPV Infection
Verruca Vulgaris
(Common Warts)
Verruca Plantaris
(Plantar Warts) and
Verruca Palmaris
(Palmar Warts)
Verruca Planae
(Flat Warts)
Condyloma Acuminata
(Genital Warts)
Definition and Clinical Features
Hyperkeratotic, elevated discrete epithelial growths with papillated surface caused by HPV
Paring of surface reveals punctate, red-brown specks (thrombosed capillaries)
Hyperkeratotic, shiny, sharply marginated growths
Paring of surface reveals red-brown specks (capillaries), interruption of epidermal ridges
Multiple discrete, skin coloured, flat topped papules grouped or in linear configuration
Common in children
Skin-coloured pinhead papules to soft cauliflower like masses in clusters
Can be asymptomatic, lasting months to years
Highly contagious, transmitted sexually and non-sexually (e.g. Koebner phenomenon via scratching, shaving), and can spread without clinically apparent lesions
Investigations: acetowhitening (subclinical lesions seen with 5% acetic acid x 5 min and hand lens)
Complications: fairy-ring warts (satellite warts at periphery of treated area of original warts)
Differential Diagnosis
Molluscum contagiosum, seborrheic keratosis
May need to scrape (“pare”) lesions to differentiate wart from callus and corn
Syringoma, seborrheic keratosis, molluscum contagiosum, lichen planus
Condyloma lata (secondary syphilitic lesion, dark field strongly +ve), molluscum contagiosum
Distribution
Located at trauma sites: fingers, hands, knees of children and teens
Located at pressure sites: metatarsal heads, heels, toes
Sites: face, dorsa of hands, shins, knees
Sites: genitalia and perianal areas
HPV Type
At least 80 types are known
Commonly HPV 1, 2, 4, 10
Commonly HPV 3, 10
Commonly HPV 6 and 11
HPV 16, 18, 31,
33 cause cervical dysplasia, SCC, and invasive cancer