By

Dr.Rania El-Tatawy
Prof. of Dermatology and Venereology
Faculty of Medicine Tanta University
Viral Skin Diseases With Oral Lesions

1. Herpes simplex
2. Chickenpox
3. Herpes zoster
4. Herpangina
5. Hand, foot and mouth disease
6. Kaposi’s sarcoma
7. Warts
 Herpes simplex

 It is a very common, acute, self-limiting, highly contagious,

vesicular eruption due to infection with Herpes virus hominis

Etiology:
- Herpes virus hominis
 Type I disease is usually facial.

 Type II lesion are commonly genital.

 Herpes simplex

Spread:
- Direct contact, droplets from infected

secretions.

- Trauma facilitates transfer of virus.

- Immunological abnormalities.

Initial lesion:
- Groups of vesicles on erythematous base

near body orifices.

 Herpes Simplex Type I

 Type I Herpes simplex

Incubation period: 2-5 days.
 Primary attack
They affect certain sites:
1. Herpetic Gingivostomatitis.
2. Herpetic Keratoconjunctivitis.
3. Herpetic Whitlow (fingers affection as in dentists).
Primary Infection of Herpes Simplex I
Herpetic Gingivostomatitis:

- Occur in children between 1 and 5 years.

Clinical features:

- Fever, malaise, excessive dribbling.

- Breath is foul, gums are swollen, inflamed and easy

bleed.

- Painful vesicles presenting as white plaques develop

into ulcers on the tongue, pharynx, palate, and buccal

mucosa & Local lymphadenopathy.

- They don't show a tendency to grouping as in recurrent
herpes simplex.
 Primary Infection of Herpes Simplex - I

Herpetic Keratoconjunctivitis
Viral infection of the eye caused by the herpes simplex virus (HSV).
- The symptoms of herpes keratitis may include:
• Pain , Redness, Blurred Vision, Tearing , Discharge , Sensitivity to light
• Rash : Vesicles on erythematous base.
 Primary Infection of Herpes Simplex-I

Herpetic Whitlow
 Appear anywhere on finger or thumb,
but it usually affects fingertip.
 Symptoms include:
- Swelling and pain in your finger
- Blisters or sores on your finger
- Skin becoming red or darker
- Skin tone feeling generally unwell
and having a high temperature
 Recurrent Herpes Simplex-I

 Recurrent Herpes simplex:

 Predisposing factors:
- Fever.
- Gastrointestinal tract disturbance.
- Psychological disturbance (e.g. in anxiety).
- Flu and upper respiratory tract infection.
- Exposure to sun.
- Mechanical trauma.
- Menstruation.
 Recurrent Herpes Simplex

 It is presented by group of vesicular

eruption on an erythematous base
usually around the mouth.
 Burning sensation may precede or
accompany the eruption.
 The vesicles are replaced by crusts in
few days.
 Healing occurs in 5-7 days with
normal skin.
 Herpes simplex Type II

Type II (Herpes progenitalis)

 It different from type I by the following:
-Mode of transmission: sexually transmitted.
-Site of affection: vulua, vagina and cervix in females. Glans,
shaft of the penis and scrotum in males.
 Clinical picture:
- Primary attack.
- Recurrent herpes progenitalis.
Herpes simplex
Herpes simplex
Herpetic gingivostomatitis
Herpetic gingivostomatitis
Herpetic gingivostomatitis
 Treatment of Herpes Simplex

 Mouth wash for oral lesions

 Analgesics

 Local antiseptic drying agents

 Local antiviral

 Systemic acyclovir: 400 mg 5 times/days/7-10 days.

 Varicella (Chicken Pox)

 It is the primary infection with varicella-zoster virus.

 Incubation period: 2-3 weeks.
 Mode of transmission:
 Droplet infection.
 Direct contact.
 The patient is infectious 4 days before the eruption until lesions
are crusted.
 Prodromal stage of approximately 1-2 days shows fever, malaise
headache… etc.
 Varicella (Chicken Pox)
Clinical features:
 The polymorphic eruption shows macules, papules, vesicles,
pustules and crusts.
 Centripetal in distribution ( mainly the trunk, face, scale and neck)
 Itching is common

• Mucous membrane affection : Vesicles are common in the

mouth (on the palate, tongue, inner cheeks and gum)
 Healing occurs within 10 days without sequels, sometimes leaves
post-inflammatory pigmentation and scarring especially in adults.
Chicken Pox (Varicella)
Chicken Pox (Varicella)
Chicken pox (Varicella)
Oral Chicken Pox (Varicella)
 Treatment of Varicella

Rest and light diet

Symptomatic treatment:
- Local antiseptics
- Mouth wash
- Systemic Antihistamines
- Systemic Antipyretics
- Systemic antiviral for severe cases: Acyclovir 800mg 5 times
per day for 7 days
- Prophylactic antibiotics
 Herpes zoster (shingles)

 It is an acute, self-limiting, vesicular eruption, occurring in a

dermatomal distribution.

 It is caused by reactivation of latent varicella-zoster virus

present in dorsal root or cranial nerve ganglion that travels to

the skin through cutaneous nerve.

 Herpes zoster (shingles)

 Clinical picture:
1. Pain varies from mild to severe. It may accompany or usually it
precede the attack.
2. It is strictly unilateral, if bilateral or generalized it indicates that the
patient is immunocompromized (e.g. internal malignancy, lymphoma,
systemic corticosteroids).
3. A group of vesicular eruption on an erythematous base appearing
along the pathway of cutaneous nerve (dermatome).
 Herpes zoster (shingles)
 Common sites:
- Thoracic affection.
- Cervical affection (usually c 2, 3, 4).
- Trigeminal affection (including ophthalmic division).
- Lumbosacral affection.
 Complications of Herpes zoster:
1-Post-herpetic neuralgia (persistence of pain after healing of
cutaneous lesions).
2-Secondary infection.
3-Gangrene of the skin.
4-Affection of the eye (herpes zosterophthalmicus).
Herpes zoster (shingles)
Herpes zoster (shingles)
Herpes zoster (shingles)
 Oral lesions of herpes zoster
 Affects the maxillary or mandibular division of trigeminal
nerve, pain and burning are the main complaint.
 Zoster of maxillary division:
- Vesicles and ulceration on one side of the palate, upper
gingival, and buccal sulcus
 Zoster of mandibular division:
- Vesicles and ulceration of one side of the tongue, floor of
mouth, lower labial and buccal mucosa
Oral Herpes zoster (shingles)
Oral Herpes zoster (shingles)
Treatment of herpes zoster
Symptomatic treatment:
Analgesics
Anti-inflammatory
Short course of corticosteroids
Antiseptics
Topical acyclovir
Systemic Acyclovir 800mg / 5times/ 7days
 Hand, foot and mouth disease
Etiology: - Coxsackie viruses

Clinical features:

- General constitutional symptoms

- Enlarged and tender anterior cervical lymph nodes

- Mouth ulcers: round or ovoid, sparse, affect any site

- Painful and deep seated vesicles on hands and foot

Treatment:

- Mouth wash, local antibiotic and healing agents

Analgesics, antihistamine
Hand, foot and mouth disease
Hand foot and mouth disease
Hand foot and mouth disease
Hand, foot and mouth disease
 Herpangina
Etiology:
- Coxsackie viruses
Clinical features:
- Constitutional symptoms
- Tender cervical lymph nodes
- Mouth ulcers on soft palate
D.D:
- Herpetic Gingvostomatitis
Treatment:
- Analgesics, antipyretics, mouth wash
Herpangina
Herpangina
 Warts (Verrucae)
Etiology:
- Human papilloma virus
Types:
- Verruca vulgaris
- Verruca plana
- Verruca plantaris
- Verruca filliformis
- Verruca digitiformis
- Genital warts
- Warts of mucous membranes
 Warts (Verrucae)

- Verrcua vulgaris (Ordinary warts):

 They appear as asymptomatic grayish papules which are few mm
in diameters with verrucous (irregular) rough surface.

- Plane warts:
 Usually affect children.
 Multiple skin colored small papules with flat smooch surface.

 Affect the face or extensor surface of hands.

 Warts (Verrucae)
Treatment of warts:
1- Chemical cautery:
Trichloro- acetic acid.
Salicylic acid 10%-60% in planter warts.
Salicylic acid + lactic acid in flexible collodion.
2- Electric cautery
3 - Cryotherapy with liquid nitrogen (-196°C)
4 - CO2 laser
5- Topical keratolytics e.g. retinoic acid preparation in plane warts.
6 - Genital warts are treated by 25% podophyllin in tincture benzoin
(contraindicated in pregnancy).
Verruca vulgaris
Verruca plana
Tongue warts
Lip warts
Warts of mucous membranes
Acquired Immune Deficiency Syndrome

 It is a striking disease complex characterized by severe and

apparently irreversible acquired defect in the cell mediated
immunity.

 AIDS leaves those affected susceptible to multiple severe

opportunistic infections and uncommon malignancies such as
Kaposi Sarcoma

 The mortality rate in this syndrome is high.

 Acquired Immune Deficiency Syndrome

 Causative Organism
Retrovirus known as human immune deficiency virus (HIV)
 Mode of Transmission
- Virus has been detected in some body fluids as blood, semen,
cervical, and vaginal secretions.
- Saliva and tears do not represent a likely source since the
virus is present in them in small proportion of infected
individuals
Acquired Immune Deficiency Syndrome

Common Route of Transmission are

 Sexual intercourse : homosexuals ,heterosexuals

 Blood and blood products.

 Contaminated syringes and needles.

 Infected mothers to fetus in utero or newborn during post

natal.
 Acquired Immune Deficiency Syndrome

Cutaneous manifestations Of AIDS

 Generalized pruritic dermatitis
 Recurrent and disseminated Herpes Zoster
 Seborrheic dermatitis
 Generalized fungal infection
 Disseminated candidal infections especially oro-pharyngeal candidiasis
 Extensive Psoriasis
 Condyloma Accuminata
 Kaposi Sarcoma
 Acquired Immune Deficiency Syndrome

Laboratory Diagnosis
 ELISA
- Screen test , easy to perform, very sensitive .
- False positive especially with pregnant female and liver diseases.

 Western Blot technique :

- Most specific test for detection of antibodies against HIV specific proteins
( P24,P41 antigens)

 Indirect Immunofluorescence assay:

- Very sensitive test but very expensive
 Herpes virus 8 (Kaposi’s Sarcoma)

Skin lesions:
- Pink macules, enlarge and become palpable, darken into purplish or brown
colored, becoming hemorrhagic and nodular.
Oral lesions common in AIDs.
- Purple macules, plaques or papules on the oral mucosa.
Treatment:
- Surgery for large lesions
- Cryotherapy
- Electrodessication
- Laser irradiation
- Infrared coagulator, radiotherapy,
chemotherapy
Kaposi’s sarcoma
Kaposi’s sarcoma
 By

Rania El-Tatawy
Prof. of Dermatology and Venereology
Faculty of Medicine Tanta University
 Impetigo

- Acute contagious pyogenic infection of the skin.

 Causative organism: Staph. aureus or Strept. pyogenes or both.

 Predisposing Factors:

1. Unhygienic conditions and overcrowding.

2. Malnutrition.

3. Presence of a septic focus or systemic disease.

4. Itchy skin conditions as pediculosis or scabies.

Clinical Varieties

1. Classical ( Non- Bullous) :

- This is the commonest from (70%). It is usually caused to
Staphylococcus aureus.
- Initial lesion: Erythematous macules-vesicle- Pustules
Honey comb crust healed with normal skin.
 Clinical Varieties

 Circinate impetigo: impetigo lesions extend peripherally,

with central healing forming annular, circinate patterns or
may result from multiple lesions arranged in circular fashion.
 Clinical Varieties

 Bockhart impetigo: superficial follicular pustular eruption in

volving the scalp or other hairy area.

 Bullous impetigo: causative organism is staphylococci It

mainly affects neonates & infants, whose kidney cannot
excrete this toxin.
Complications of impetigo contagiosum

1. Post-streptococcal acute glomerulonephritis

2. Scarlet fever, utricaria and erythema multiform may
follow streptococcal.
3. Wide spread of the disease may occur by auto-
inoculation.
4. Extension in depth of the lesion, manifested by cellulitis
5. Eczematization of the lesion.
 Treatment of Impetigo

 Treatment of predisposing factors (Pediculosis or scabies)

 Local treatment:
i. Gentle removal of the crust (hot foments).
ii. Antiseptic lotions as potassium permenganate (1/8000 - 1/10000).
iii. Topical antibiotic creams: fusidic acid
 Systemic Broad spectrum antibiotics in widespread lesions (for 5-7
days):
i. ß-lactamase resistant antibiotics e.g. amoxicillin/clavulonate,
ampifillin/cloxacillin, cephalexin.
ii. Erythromycin, azithromycin Systemic broad spectrum.
 By

Rania El-Tatawy
Prof. of Dermatology and Venereology
Faculty of Medicine Tanta University
 Candidiasis
Causitive organism:
 Yeast Candida albicans.

Precipitating Factors:
 Moisture and maceration.
 Diabetes other endocrinal disorders.
 pregnancy.
 Immunosuppresive drugs, corticosteroids and
broad spectrum antibiotics.
Types of candidiasis
I- Oral candidiasis:
1. Oral thrush.
2. Angular stomatitis.
II- Candidiasis of the skin and genital mucous membrane
1. Candidal intertrigo.
2. Eroso interdigitalis.
3. Napkin candidiasis
4. Perianal and scrotal candidiasis.
5. Vulvovaginitis
6. Candidal balanitis.
7. Candidal paronychia.
8. Candidal onychomycosis.
Candidiasis
Candidal Paronychia
- Common in those whose hands are
frequently immersed in water.
- Red swollen, tender nail fold with
occasional thick white discharge on
pressure.
Candidal onychomycosis.
 oral candidiasis
1- Acute pseudomembranous
candidiasis(oral thrush):

- Sharply defined patch(s) of creamy curd

like, white pseudomembrane.
- When removed reveals an underlying
erythematous base.
- In immunocompromised patients e g
AIDS.
2. Angular stomatitis:
 Soreness and fissuring at the angles of the
mouth.
 Precipitated by persistent salivation and
nutritional deficiencies.
Oral Candidiasis
Oral Thrush
 Treatment
1. General principles:

- Frequent oral hygienic measures

2. Local antifungals:
- Nystatin oral gel and suspension
- Amphotericin oral gel
- Miconazole oral gel
- Clotrimazole cream
- Econazole
- Povidone iodine paint
Local therapy is applied several times/day
3. Systemic therapy

- Amphotericin: I.V.
- Fluconazole: 150 - 300 mg/week for 2 weeks
- Itraconazole: 100-200 mg/day for 10-14 days
- Nystatin suspension for children
Thank you •