Systems IV Derm Lecture 3

1. Systems IV Derm Lecture 3 Infectious skin dzs cont.

2. Viral Skin Issues • Very common • Usually • not life threatening • self limiting, but may be recurrent or chronic • a sign of immune status • Conventional treatment is either immunization or aimed at viral suppression (not eradication)

3. Childhood Exanthems • Chicken Pox aka Varicella • Roseolainfantum • Fifth’s Disease aka slapped cheek fever aka erythemainfectiosum • Hand, Foot and Mouth disease • Measles aka Rubeola • Rubella aka German measles

5. The Herpes Childhood Exanthems • Chicken Pox/Varicella-Zoster Virus (Herpesvirus Type 3) • Acute Phase is Chicken pox, usually experienced in childhood, Herpes zoster or shingles is the reactivation usually experienced in old age or with an immuno-compromised adult. • Extremely contagious, 48 hours before development of skin lesions. • Very itchy, start out as macules, turn into papules with little vesicles • Fever, fatigue, mild sore throat are common • Usually lasts 1-2 weeks

7. The Herpes Childhood Exanthems • Roseola Herpes virus type 6 • Usually seen in children 6-36 months • Starts suddenly with a high fever 102-104, and may have a runny nose and swollen glands • Characteristically, when the fever breaks, the rash begins, usually around day 4 • Lasts for 5- 10 days total, rash may only be around for a few hours or a few days. • Seizures occur sometime during fever-keep child hydrated-herbal teas and baths are great!

9. Erythemainfectiosum • Also known as “Fifth’s disease” or “slapped cheek fever” • A human parvovirus • Starts with a 2-3 day period of mild fever, sore throat, runny nose, tummy ache, or headache • Symptom free for about a week and then the redness appears on the cheeks which lasts for 2-4 days. • Then the rash gradually begins on the body, which can last for a week to a few weeks, fading away and then recurring for several weeks

11. Hand, Foot and Mouth Disease • Caused by a cocksackie virus, an enterovirus • Common and prevalent in warm weather months (late summer, early fall) in preschool and daycare • Spread by mouth to mouth contact or oral-fecal route • Mild self limiting illness usually seen in children younger than 10 years old. Fatigue, mild fever, loss of appetite • Mouth lesions can be painful, and inhibit child from drinking water and eating. Popsicles made from herbal teas can be helpful. • Fever, fatigue may accompany illness • Rare sequelae can include neurological issues-encephalitis/meningitis

13. Measles aka Rubeola • Rarely seen in children in US now due to vaccines • Starts out looking like a “cold” with runny nose, cough, conjunctivitis, and fever which breaks with appearance of morbiliform rash • Before rash breaks out “Koplick spot’s” can be seen in mouth • Now in US, most often seen in young adults, living in dorms or barracks • Very contagious. Virus can remain active for 2 hours in expelled respiratory droplets • Self limiting in most cases with 0.1% moving into an encephalitis. The most common serious sequelae is bronchpneumonia, in immunodeficient individuals • Vitamin A deficiency is related to serious cases and sequelae

14. Mobilliform Rash of Measles

15. K O P L I C K S S P O T S

16. Rubella aka German Measles • A mild, self limiting illness with rare sequelae • Rare now in US due to vaccinations. Was predominately seen in children, now young adults and immigrants • Congenitally acquired rubella has severe consequences to fetus-miscarriage, cataracts, deafness, heart malformations, organomegaly • Spread by respiratory droplets • Starts with runny nose, fever, and swollen lymph nodes esp. of head and neck. Rash appears in one to five days • People are most contagious when rash is erupting. • Forchheimer spots appear in mouth before rash erupts

18. Herpes virus • HSV-1 primarily affecting oral mucosa (cold sores, fever blisters) • 80% of US population has been exposed, 30% of these have had a clinically significant outbreak • Primary HSV-1 outbreak usually occurs in childhood • Generally present as a cluster of blisters on an erythematous base • HSV-2 Primarily affects genitalia

19. Herpes Simplex • “Primary infection: Symptoms of primary herpes labialis may include a prodrome of fever, followed by a sore throat and mouth and submandibular or cervical lymphadenopathy. In children, gingivostomatitis and odynophagia are also observed. Painful vesicles develop on the lips, the gingiva, the palate, or the tongue and are often associated with erythema and edema. The lesions ulcerate and heal within 2-3 weeks.” Medscape

20. Herpes Simplex • “Recurrences: The disease remains dormant for a variable amount of time. HSV-1 reactivation in the trigeminal sensory gaglialeads to recurrences in the face and the oral, labial, and ocular mucosae. Pain, burning, itching, or paresthesia usually precedes recurrent vesicular lesions that eventually ulcerate or form a crust. The lesions most commonly occur in the vermillion border, and symptoms of untreated recurrences last approximately 1 week. A recent study reported that HSV-1 viral shedding had a median duration of 48-60 hours from the onset of herpes labialis symptoms. They did not detect any virus beyond 96 hours of symptom onset.” Medscape

22. Genital Herpes and HSV-1 • “Genital herpes: HSV-2 is identified as the most common cause of herpes genitalis. However, HSV-1 has been increasingly identified as the causative agent in as many as 30% of cases of primary genital herpes infections likely secondary to orogenital contact. Recurrent genital herpes infections are almost exclusively caused by HSV-2.” Medscape • “Although HSV infections may occur anywhere on the body, 70-90% of HSV-1 infections occur above the waist. In contrast, 70-90% of HSV-2 infections occur below the waist.” Medscape

23. Diagnosis and Treatment • Often, oral herpes is diagnosed by clinical presentation • A viral culture may be obtained by swabbing an open lesion. A DNA-PCR test is most commonly used now rather than the Tzank smear. • Disease is self-limiting. Course may be shortened with antiviral drugs. Oral acyclovir, valacyclovir, and famciclovir are most commonly used. • A topical acyclovir with hydrocortisone may also be used.

24. Alternative and Complementary Tx • Herbs seen to affect herpes viruses: Licorice root (Gan Cao), Lemon Balm (Melissa officinalis), St. John’swort (Hypericumperforatum)- used as teas, tinctures or topicals • Avoidance of chocolate, nuts and other arginine containing foods • Use of L-lysine. HSV-1 replication is suppressed in a high lysine/low arginine environment • Northern pacific algaes topically-”AlgalAid” • Hot and/or cold compresses

25. Warts aka Verrucae • Human papillomavirus • 100s of strains of papillomaviruses • Papillomavirusescan infect all parts of the skin and mucus membranes • “Common, benign viral infection of the skin and adjacent mucus membranes”. PGD p766 • Generally, difficult to treat effectively • Viral replication occurs in the upper layers of epidermis, although viral particles can be found in the basal layer. The virus is not thought to spread systemically.

26. Warts • School aged children, immunosuppressed folks and meat handlers (?) have the highest prevelance. • Warts are common worldwide, estimated to affect 12-17% of the population. Whites seem to be affected at 2x the frequency than non-whites • Most common age is 12-16 years of age • Nongenital warts rarely become cancerous. • Warts are rarely painful, except plantar warts (on the plantar surface, i.e. sole, of the foot) • Spread by direct or indirect contact. The virus is viable outside of the body for up to 3 years or more!

27. Warts • A few different types • Common-Verrucavulgaris-hyperkeratotic papules with a rough, irregular surface often seen on the hands and knees • Plantar-Starts as flat shiny papules, and progress to deep, sharply defined, round lesions with a rough keratotic surface, surrounded by a smooth collar of calloused skin. They are often painful lesions found on the sole of the foot often where weight is carried. • Flat-Verrucaplana- flesh-colored, smooth or only slightly hyperkeratotic, that can be anywhere • Filiform-long, slender flesh colored, on neck, face, eyelids or nose.

28. Common F L A T

29. Plantar Warts

30. Filiform Warts

31. Treatment of Warts • Wow-you name it-it’s been tried for warts!! • Conventional Med-Salicylic acid is probably the most common, also, burning them off, freezing them off, using anti-cancer drugs like 5 –Flourauracil (5-FU), injecting Trichophyton or Candida antigens into the wart, various high grade antivirals • “Providing no treatment at all is certainly safe and cost effective. Consider this as an option, since 65% of warts may regress spontaneously within 2 years. Without treatment, however, patients risk warts that may enlarge or spread to other areas. Treatment is recommended for patients with extensive, spreading, or symptomatic warts or warts that have been present for more than 2 years.” Medscape

32. Alt/Comp Treatment of Warts • Again everything has been tried! • Hypnosis, duct tape, fingernail polish, buying them, affirmations • Caustic substances: black salve, sanguinaria, chelidonium • Banana peel taped over wart with inner peel inside • Antifungals: Thuya essential oil or homeopathic, • Antivirals: Lemon Balm, Licorice (Gan Cao), St. John’swort • Urine therapy • For quiz/test be able to list 5

33. Insect Related Skin Issues • Scabies • Lice • Bedbugs • Fleas • Mosquitos • Spider bites • Ticks

35. Scabies • Very itchy mite infestation by Sarcoptesscabieivarhominis. • The mite lives only for 2-3 days without a human host. • Female mites burrow into the skin to lay eggs • They’ll often happen in mini “epidemics” in dorms, classrooms, girl scout troops, etc • Spread by casual or sexual contact • Mostly get itchier at night-usually between fingers , on wrists, elbows, skin folds, genitalia • Conventional treatment is with topical insecticides-lindane (Kwell), permethrin, sulfur, crotamiton • All clothing, bedding etc. must be washed in hot water

36. S C A B I E S

37. Lice • Pediculosishumaniscorporis (body lice) • Pediculosishumaniscapitis (head lice) • Phthirus pubis (pubic lice aka “crabs”) • Lice lay their eggs (nits) on human hair and clothing • They feed on human blood, biting the skin around hair causing an irritation that brings blood closer to the surface • All clothing and affected hair must be thoroughy washed often multiple times with special products • Conventional treatment is with topical insecticides-Lindane, permethrin, pyrethrin, malathion, ivermectin

38. LICE!!

39. BedBugs • Cimex species of arthropods, feed on the blood of human • “They are typically less than 1 cm in length and reddish brown in color. Bedbugs can be found in furniture, floorboards, peeling paint, or other small spaces, most commonly in areas of clutter. These insects come out at night in search of prey upon which to feed, with peak feeding times just before dawn. Bedbugs are typically attracted to body heat, carbon dioxide, vibration, sweat, and odor.” Medscape

40. Bedbugs • Becoming more common • Bites are most common on exposed areas, i.e those not covered by pajamas • Often , the first few days of bites aren’t as reactive as subsequent bites. They often in 3’s. • They are said to give off a characteristic odor detectable by pest control workers, and those that live with bedbugs • Treatment of bites are unnecessary unless there is infection. Bedbugs must be killed by pesticides or mechanical means (repeated vaccumingesp. of crevices).

41. Bed Bugs

42. Flea Bites

43. Western WA “Swimmer’s itch” • Something that you will see if you practice in Western WA. Similar things happen throughout the country. • Caused by Schistosomecercaria, which is a small parasite that happens upon the human skin quite by chance. • Lifecycle is infected water fowl poop (larvae) to snail (adult) back to water fowl. When larvae are released into the water they can end up on a swimmer’s skin. As the water evaporates from the skin, the “little wiggler” knows it must find moisture or die, so it burrows under the swimmer’s skin, where they die.

44. Western WA “swimmer’s itch” • Even though the creature will die, it sets off an immunologic response , causing inflammation, burning and itching. This occurs soon after leaving the water. • Papules will develop within 12 hours that are very itchy. Things will resolve on their own in a week. • To prevent it towel off well immediately upon leaving the water or get as much water off your skin • Treatment is for itch: calamine lotion, baking soda baths, or benadryl. • Secondary bacterial infection can be set up from scratching.

46. Ticks and Skin Manifestation of Lyme Disease • Lyme disease diagnosis and treatment is controversial in Western medicine, conventional and alternative. • Lyme disease is caused by a spirochete, Borreliaburgdorferi • Tick bites are common. Not every tick carries Borrelia. • The localized skin manifestation of lyme is called erythemamigrans. It is treated conventionally with antibiotics, most commonly doxycycline.

48. Classic “Target Lesions” of Erythemamigrans

49. Less “classic, but more common presentation

50. Other Resources • Quick online guide for info about childhood exanthems: http://blog.dermcareonline.com/tag/viral-exanthem/ • Good slideshow on viral skin issues: http://reference.medscape.com/features/slideshow/viral-skin • Slide show on differentiating lice, bedbugs and scabies: http://reference.medscape.com/features/slideshow/bedbugs-lice-mites • Western WA “swimmer’s itch” info pamphlet: http://www.co.thurston.wa.us/health/ehadm/swimming/pdf/swim_itch_info.pdf