Herpes Simplex Virus (HSV)

• Viral infections can manifest in several forms

Herpes Simplex (HS)

• It is a common viral infection caused by herpes simplex virus (HSV)
• HSV is a DNA virus with two types:
  • HSV type I leads to herpes labialis and other non-genital infections
  • HSV type II leads to herpes progenitalis
• It is transmitted through skin-to-skin or skin-to-mucous membrane contact

Primary Infection (HSV Type I)

• The patient is infected for the first time
• Causes primary herpetic gingivostomatitis
• Infection is usually subclinical, going unnoticed in around 90% of cases
• Characterized by superficial vesicles on the oropharynx that quickly rupture and leave behind denuded areas that are painful
• Accompanied by symptoms such as swollen gums, fever, sore throat, malaise, loss of appetite, and lymphadenopathy.
• Lesions typically heal within 2 weeks

Recurrent Attacks (HSV)

• After the primary infection, the virus remains in the body
• HSV has a predisposition for neural tissue
• It migrates to dorsal root ganglia and remains dormant
• When reactivated, viral particles travel along peripheral nerves, leading to recurrent HS near the initial site

Predisposing Factors for Reactivation (HSV)

• Fever
• Fatigue
• Trauma
• Ultraviolet light
• Radiation
• Stress
• Menstruation
• GIT disturbances
• Altered immune status
• Immunosuppression

Sites of Recurrent Attacks (HSV)

• Lips (Herpes Labialis): Bilateral grouped vesicles on an erythematous base, often preceded by burning or tingling that usually heal without scarring
• Face (Herpes Facialis): Occurs around orifices such as the nose, eyes, ears, and cheeks

Special Variants of HSV Type I

• Ocular Mucosa: Requires immediate ophthalmologic consultation due to the risk of corneal opacity
• Finger or Hand (Herpetic Whitlow): Occurs on the finger due to direct inoculation of HSV into broken skin; is is characterized by intense pain, vesicles, edema, and redness

HSV Type II: (Herpes Progenitalis)

• Primary Infection:
  • Transmitted by sexual contact
  • It involves the genitalia of both males and females
  • Characterized by painful, grouped superficial vesicles on an erythematous base, followed by erosion or genital ulceration
  • Herpes progenitalis in pregnant women is a strong indication for cesarean section due to the risk of neonatal infection
• Recurrent Attacks: Less severe compared to the primary infection

Complications of HSV Infection

• Secondary infection
• Eye complications such as keratitis and corneal ulcers
• CNS complications such as encephalitis and meningitis especially in infants
• Erythema multiforme by recurrent HSV-I
• Cancer cervix due to recurrent cervical HSV-II

Diagnosis of HS

• Clinical picture
• Tzanck smear using Giemsa stain
• Viral culture
• Serological tests; HSV antibody titers against types I and II
• Polymerase chain reaction (PCR)

Treatment of HS

• Avoid precipitating factors to prevent recurrence
• Avoid direct sexual contact during attacks of genital herpes
• Topical Therapy
• Systemic Therapy (Antiviral)

Topical Therapy (HS)

• Drying antiseptic lotions with K+ permanganate 1/8000-1/10,000 or 10% aluminum acetate
• Antiviral: acyclovir cream applied 5 times daily (every 4 hours) for 5 days, effective in the early stages of the disease. It reduces the duration of the attack and viral shedding
• Topical idoxuridine (IDU) is given for eye lesions

Systemic Therapy (Antiviral)

• Acyclovir 200 mg 5 times daily (every 4 hours) for 5 days, administered for severe episodes or in immunocompromised patients
• Should be given early, within 48-72 hours of eruption appearance.

Herpes Zoster (HZ)

• Caused by varicella zoster virus (VZV)
• Chicken Pox (Varicella): Occurs in individuals exposed to the virus for the first time
• Chicken pox is a relatively with generalized but self-limiting vesicular eruption that leads to the formation of a brownish crust, and lesions heal within 10 days
• After the attack, the virus remains in posterior root ganglia

Reactivation of Infection (Herpes Zoster)

• Predisposed by:
  • Trauma
  • Fever
  • Decreased resistance
  • Drugs (corticosteroids and immunosuppressive agents)
  • Diseases of the spine
  • Malignant diseases

Clinical Picture (Herpes Zoster)

• Onset: Preceded by pain for one week
• Features include unilateral groups of vesicles on an erythematous, edematous base following the distribution of sensory nerves
• Local lymph nodes can be enlarged
• Vesicles dry up, resolving in 2-4 weeks, which may leave scars.
• Lesions may be hemorrhagic
• Types: Those that are abortive are typified by pain and some redness without any vesicular eruptions, but one attack of the disease gives permanent immunity

Complications of HZ

• Secondary infection
• Eye complications (HZ ophthalmicus)
• CNS complications, such as post-herpetic neuralgia. It occurs in 10-20% of patients, especially the elderly or due to delayed antiviral therapy
• Sign of internal malignancy: Very old age, gangrenous type, the affection is bilateral, it is recurrent

Treatment of HZ

• Topical Therapy: Used in vesicular stage
• Systemic Therapy

Topical Therapy (HZ)

• Drying antiseptic lotions
• Antiviral: Acyclovir cream in very early vesicular stage reduces the duration of the attack if administered 5 times daily

Systemic Therapy (HZ)

• Antiviral:
  • Acyclovir: 800 mg tablets, 5 times daily for 7 days
  • Valacyclovir: 1000 mg, 3 times daily for 7 days.
  • Famciclovir: 500 mg, 3 times daily for 7 days
• Analgesics, carbamazipine and gabapentin as relief for neuropathic pain

Warts (Verrucae)

• These are benign, common epithelial growths resulting from human papilloma virus (HPV)
• Affect skin and mucous membranes
• The mode of infection is either direct or indirect contact
• Incubation period is 1-6 months

Types of Warts

• Common warts (Verruca Vulgaris)
• Plane warts (Verruca Plana)
• Filiform warts (Verruca Filiformis)
• Digitiform warts (Verruca Digitata)
• Plantar warts (Verruca Plantaris)
• Genital warts (Condyloma Acuminata)

Specific Warts

• Common warts (Verruca Vulgaris): Asymptomatic, skin-colored, & verrucous papules
• Plane warts (Verruca Plana): Skin-colored and flat-topped papules, which are more common in children and are typified by the Koebner phenomenon
• Filiform warts (Verruca Filiformis): These are long, thin, pedunculated skin growths
• Digitiform warts (Verruca Digitata): These warts are typified by papillomatous thin projections with finger-like processes branching off of a common stem.
• Plantar warts (Verruca Plantaris): Located on the sole of the foot and growing inwards, they are typically tender and thick
• Genital warts (Condyloma Acuminata): referred to as venereal, anal and anogenital warts, and is typified to affect the skin of the genitals (both sexes), mucous membranes. They have a soft pinkish hue, have a foul smell, moist and are prone to bleed when touched

Complications of HPV Infection

• Has an oncogenicity that predispose an individual to cervical dysplasia or cancer cervix

Course of Infection (Verrucae)

• Spontaneous involution may occur within 2 years.
• Treatment of a few warts may induce regression of other warts.

Treatment of Warts

• Electrocautery
• Cryotherapy
• Chemical cautery like carbolic acid (phenol), glacial acetic acid, trichloroacetic acid 40%, salicylic acid 40 % or lactic acid 40%.
• Laser treatment is effective
• Apply podophyllin resin 25% in alcohol, liquid paraffin or tincture benzoin Co for treating venereal warts. It is painted twice weekly and washed after 6-8 hours, but contraindicated in pregnancy and bleeding warts.
• The application of imiquimod cream may stimulate local interferon production
• Radiotherapy works for plantar warts
• Autosuggestion (placebo effect): Warts disappear spontaneously after placebo application

Molluscum Contagiosum

• It is caused by poxvirus
• Mode of Infection: Direct or indirect contact
• Incubation Period: 2-6 weeks

Clinical Picture (Molluscum Contagiosum)

• Shiny, pearly white, dome-shaped papules with a smooth surface and characteristic central umbilication
• A white cheesy material can be expressed from the central punctum on squeezing the lesion
• Considered a sexually transmitted disease.

Treatment (Molluscum Contagiosum)

• Electrocautery
• Cryotherapy
• Chemical cautery with phenol after removal with curette.
• Laser treatment.