viral rash



OVERVIEW

Definition

Viral rash is the skin manifestation of viral infection of the organism, caused by viral skin diseases. There are 3 types of viral rashes: blisters, eruptions, and neoplasm, which are characterized by blisters, erythematous rashes, and wart-like growths.

Viral skin diseases are self-limiting to a certain extent, and active treatment can alleviate the symptoms and shorten the course of the disease.

Typing

According to the clinical skin manifestations caused by viral infection, it is mainly categorized into the following 3 types.

Blister type

The rash is characterized by blisters, either single scattered blisters or clustered blisters, some of which can be unilaterally distributed, as seen in herpes simplex virus, varicella zoster virus and other herpesviridae infections.

Neoplastic

The rash manifests as a proliferative rash on the skin and mucous membranes, which is seen in papilloma multiforme vacuolar virus family infections such as human papilloma virus and polyomavirus.

Rash

The rash presents as a symmetrical generalized cutaneous maculopapular or maculopapular rash, which develops rapidly, and is seen in parvovirus infections such as measles and rubella, and also in human herpesvirus type 6 and 7 infections.

Morbidity

Herpes simplex virus infection is one of the most prevalent infections in the world.

Chickenpox occurs in temperate regions in 90% of cases in children under 10 years of age, with peak incidence in unvaccinated children between the ages of 1 and 4 years.

The mortality rate of chickenpox in healthy children is 1.4/100,000, which can result in the death of 1 healthy child out of 100,000; the mortality rate of chickenpox in adults is 30.9/100,000, which can result in the death of approximately 31 adults out of 100,000, with pregnant women being at a 5-fold higher risk of adverse outcomes [1].

Measles can occur throughout the year, with winter and spring being the high incidence seasons. The incidence in our country is on a decreasing trend. Measles in young children occurs in spring and fall, mostly in infants and young children aged 6 to 18 months, and is rare above the age of 3 years. People in close contact with the patient in the family, child care institutions and schools are easily infected.

Causes

Causes

Viral rashes are skin lesions caused by a variety of viral infections, including herpes virus, paramyxovirus, poxvirus and others.

Blistering viral rash

Mostly caused by herpes virus infection.

Herpes simplex: caused by herpes simplex virus (HSV) infections, which are categorized as HSV-1 (cause of most oral and labial herpes simplex) and HSV-2 infections (cause of most genital herpes) [2].

Varicella: caused by the first infection of varicella-zoster (VZV).

Herpes zoster: latent varicella-zoster virus in the ganglia is reactivated by varicella-zoster to develop herpes zoster.

Patients in incubation and early stages of disease.

Respiratory transmission, less frequently by direct contact with skin lesions. hsv-2 virus can be transmitted by sexual contact.

Susceptibility: generalized susceptibility in the population.

Neoplastic viral rash

Caused by human papillomavirus (HPV) infection, manifesting as neoplastic skin lesions. there are currently more than 150 types of HPV, most of which are not pathogenic.

Common warts: often associated with HPV-1, HPV-2, HPV-4, HPV-27, HPV-57, HPV-63 infections. They appear as keratinized papules on the skin, preferably on the hands, feet, and exposed areas.

Flat warts: often associated with HPV-3, HPV-10, HPV-28, HPV-41 infection. They appear as brown flat papules on the face and upper limbs.

Plantar warts: often associated with HPV-3, HPV-10, HPV-28, HPV-41 infection. The manifestation of foot-plantar keratinized papules, the surface can be seen black spots.

Condyloma acuminatum: External genitalia often due to HPV6/11 infection. Abnormal development of anogenital skin structures is associated with HPV16/18. They present as exophytic growths in the genital area, ranging from small papules to papillary and cauliflower-like in growth.

HPV present in symptomatic patients or in the environment.

Skin warts can be transmitted by environmental infection or direct contact, and genital warts can be transmitted by sexual contact or indirect contact with objects.

People with broken skin and mucous membranes, close contact with patients, or immunocompromised.

Rash-type viral rash

Paramyxovirus infection is characterized by a rash. Human herpesvirus 6 and 7 can also cause rash.

Measles is caused by measles virus, rubella is caused by rubella virus infection, and infantile rash is caused by human herpesvirus 6 and 7 infection.

Patients in the incubation period and early stages of illness. The source of infection of rubella in young children is mostly asymptomatic adults.

It is transmitted by droplets through the respiratory tract and conjunctiva.

The population is generally susceptible.

Predisposing Factors

The following conditions may predispose to the development of viral disease and viral rash.

Immunosuppression due to external factors such as fever and cold.

Lifestyle factors such as emotional excitement, stress, exertion, alcohol consumption, etc. lead to decreased immunity.

Stress factors such as surgery and trauma.

Skin mucous membrane breakage and decreased skin barrier function are the triggers of HPV infection.

High risk factors

People with the following high-risk factors are prone to viral rashes.

Close contact with patients with viral rash.

Patients with malignant tumors, patients receiving radiotherapy or chemotherapy, patients taking oral immunosuppressive drugs, AIDS patients and other immunocompromised people.

Pathogenesis

Herpes simplex

After HSV infects the organism, the virus invades the skin and mucous membranes and first proliferates locally to form the primary infection. The primary infection activates the immune system to clear the virus, and the infection heals spontaneously, but the virus is not completely cleared, but lurks in the local sensory ganglion cells.

Under certain triggering factors (such as fever, cold, emotional excitement, stress, exertion, sun exposure, etc.), the virus in the latent state can be activated and reach the skin along the nerves, causing the destruction of epidermal cells at the skin-mucous membrane junction, which is manifested as a recurrence of herpes [3].

Chickenpox.

Caused by the first infection of varicella-zoster (VZV). The virus initially replicates at the site of infection and after a few days viremia develops with characteristic skin lesions distributed throughout the body. Chickenpox can develop in susceptible individuals after contact with lesions of herpes zoster

Herpes zoster.

Caused by reactivation of VZV, which remains latent in the spinal ganglion cells of the sensory posterior root after initial infection or immunization. The virus reactivates when the organism is subjected to immunosuppression or triggering factors such as overwork, surgical trauma, or malignant tumors, and replication occurs, moving to the skin through the sensory nerves, resulting in a characteristic rash distributed in bands and accompanied by neuralgia.

Human papillomavirus infection

HPV is a DNA virus for which humans are the only host. After contact infection, the virus multiplies in the epithelial cells of the skin and mucous membranes, resulting in a characteristic rash.

Measles

Measles virus is an RNA virus with a vesicle membrane outside the viral capsid with hemagglutinin, which is hemolytic. Measles virus is mainly transmitted by droplets through the respiratory tract and conjunctiva. 2 weeks after the disease, circulating antibodies are produced in the body and there is lasting immunity.

Rubella

The pathogen is RNA virus – rubella virus, mainly transmitted by droplet. After entering the body, it begins to grow and multiply in the upper respiratory tract and cervical lymph nodes, and later spreads to other parts of the body through the bloodstream. The rash may be an inflammatory reaction due to the formation of antibody-virus complexes after the body produces antibodies to the virus.

Acute Childhood Rash

The pathogenesis is unknown and may be related to localized cutaneous manifestations due to viremia or may involve an immune response.

Symptoms

Main Symptoms

Herpes simplex viral rash

Site of occurrence: Herpes simplex occurs at the skin-mucosal junction of the perioral, perinasal and periocular areas. Genital herpes in men occurs on the foreskin, glans or coronal sulcus. In women, it occurs on the labia, pubic mound, clitoris or cervix.

Lesion characteristics: erythema on the basis of clustered papules and blisters, a few days after the blisters burst to form vesicles, followed by scabbing and healing. The duration of the disease is 1 to 2 weeks. At the time of initial infection, the lesions are extensive and self-conscious symptoms are obvious. Certain triggers cause the rash to recur with milder symptoms, occurring in the same place and recurring.

Mostly seen in children, there is a certain incubation period, the course of the disease is usually 14 to 16 days [4].

Prodromal phase: manifested by chills, low-grade fever, sore throat, loss of appetite, etc., lasting 1 to 2 days.

Rash stage: the rash is more frequent on the trunk, head and face, and less frequent on the limbs, with a centripetal distribution. Rash occurs in batches, the same part can be seen in different periods of erythema, blisters, papules or scabs and other rashes.

Site of occurrence: it occurs in intercostal nerve, cervical nerve, trigeminal nerve and lumbosacral nerve.

Characteristics of lesions: clustered blisters on the basis of erythema, unilaterally distributed in a band along the nerve. Accompanied by neuralgia characteristics.

Neoplastic viral rash

Varying in number, presenting as hard-textured papules with a rough, markedly keratinized surface and papillary or cauliflower-like hyperplasia at the tip, with no inflammation around them.

Special areas such as the peri-nail warts, plantar warts.

The warts are common in adolescents and young people, the size of a pinhead to a grain of corn, flat and smooth papules, normal skin color or brown, preferably on the face, the back of the hands, forearms. Some patients have self-limiting.

Single or clustered red, grayish-white papules, plaques, can be cauliflower-like, papillary, preferably in the external genitalia or perianal.

Rash type viral rash

Occurs in young children.

Occurrence: from behind the ear, hairline, rapidly extended to the neck, trunk, limbs, palm and plantar, usually 2 to 5 days.

Characteristics of skin lesions: there is a prodromal period before the onset of rash, manifested by high fever and nasal congestion, runny nose and other upper respiratory tract symptoms and conjunctival congestion, increased secretion and so on. Two to three days after the onset of fever, blue-white or purple dots appear on the buccal mucosa, surrounded by a red halo, known as measles mucous membrane spots. Rash starts 4 days after fever, it is maculopapular rash, at first rose-colored, then dark red, and the color fades when pressed.

Site of occurrence: initially on the face, spreading rapidly to the neck, trunk, upper limbs and finally to the lower limbs within 24 hours.

Characteristics of skin lesions: usually fever first, heat withdraws from the rash. The rash is monomorphic, a pink spot or macule that may be mildly itchy and sparsely present. After fading, it leaves no trace or is slightly flaky. It may be accompanied by swelling of superficial lymph nodes in the neck.

Site of occurrence: tends to be widespread on the neck, upper trunk, sacrococcygeal rash is often fused. Rash may also be present on the face and extremities.

Characteristics of skin lesions: body temperature drops suddenly after a few days of fever, and the rash starts after the fever subsides, which is mostly rubella-like maculopapular rash and subsides in 2~3 days.

Other symptoms

Fatigue and lethargy may be present. Measles and rubella may have fever symptoms.

When chickenpox virus involves the lungs, cough, hemoptysis, dyspnea, cyanosis, etc. may appear.

When the reaction to measles virus is severe, there are symptoms of increased toxicity and hepatosplenomegaly.

Complications

Complications of chickenpox

Rash secondary bacterial infection, local redness, swelling, pain, and even soft tissue infections such as salpingitis, cellulitis or sepsis.

Pneumonia: asymptomatic in mild cases. Severe cases have cough, hemoptysis, chest pain, dyspnea, cyanosis, and respiratory failure in severe cases.

Encephalitis: manifested by high fever, impaired consciousness, convulsions or seizures, respiratory failure, circulatory failure.

Hepatitis: manifested as abnormal liver function: elevated glutamic aminotransferase, and in a few cases, fatty liver degeneration with hepatic encephalopathy.

, such as thrombocytopenic purpura, diffuse intravascular coagulation.

Complications of measles and rubella

Bronchopneumonia: cough and sputum, asthma and other manifestations.

Otitis media: present with earache, ear canal discharge, hearing loss, etc.

Consultation

Department of Medicine

Dermatology

When skin lesions such as blisters, erythema, and neoplasm appear, it is recommended to first consult a dermatologist.

Sexually Transmitted Diseases

When the rash is mainly on the genitals or perianal area, it is recommended to first consult the Department of Dermatology and Venereology.

Infectious diseases

If the skin lesions are accompanied by symptoms such as fever, it is recommended to consult the Department of Infectious Diseases or the Fever Clinic at the same time.

Preparation for medical treatment

Preparation for consultation: registration, preparation of documents, common problems

Tips

Take a picture of the rash with your cell phone to record the changes, so that you can provide reference for the doctor during the visit.

Preparation Checklist

Pay special attention to the time of onset of symptoms, special manifestations, etc.

When did the skin erythema, blisters, and new organisms appear?

Where did these rashes first appear?

Were there any symptoms such as fever, sore throat, tiredness, or weakness before the rash started?

Are they accompanied by unpleasant symptoms such as paroxysmal pain, tingling, itching, etc.?

What is the relationship between the fever and the rash, e.g., how many days after the fever does the rash appear? Or does the rash appear after the fever subsides?

Do family members, friends, or partners have similar symptoms?

Did you use any medications before the rash appeared? What medications were used?

Was there a history of sexual intercourse prior to the onset of the rash?

Are there any flare-ups and how often do they occur?

What factors may cause the rash to recur? Alcohol consumption, exertion, emotional stress?

Have there been any previous medical consultations, what medications and treatments have been used, and what were the results?

Test results in the last six months, which can be brought to the doctor’s office

Routine blood test, C-reactive protein (CRP), blood sedimentation, etc.

Medications used in the last 3 months, if available, bring the box or package with you to the doctor’s office.

Oral medication: acyclovir, vasiclovir, antiviral granules, etc.

Topical medications: different rashes will be treated with different medications topically, e.g., glycerite lotion, imiquimod ointment, interferon gel, fusidic acid, etc.

Diagnosis

Diagnosis is based on

Medical history.

There may be exposure to patients with herpes simplex, herpes zoster, chickenpox, warts, measles, rubella, etc.

There may be an immunocompromised condition.

There may be a history of unclean sexual intercourse.

There may be triggers such as stress, emotional stress, and exertion.

Clinical manifestations

The diagnosis can be confirmed directly according to the typical manifestations of the rash.

Herpes simplex: recurrent erythema and clustered blisters at the junction of skin and mucous membranes.

Varicella: there are prodromal symptoms such as fever. The blisters appear 1 day after the prodromal symptoms. The rash is centripetally distributed with a red halo around the blisters and some crusting.

Herpes zoster: clustered blisters on the basis of erythema. Usually distributed unilaterally in bands along the nerves. Accompanied by neuralgia.

Various kinds of warts: the number of different, hard papules, surface rough, keratinization obvious, the tip of the papillary or cauliflower-like proliferation, special parts such as periungual warts for periungual warts, foot plantar part of the known as metatarsal warts. The most important thing to remember is the fact that they are the most common type of warts in the world, and they are the most common type of warts in the world. Warts can be found on the genitals or around the anus.

Measles: Mostly young children, there is a prodromal period, manifested by high fever, upper respiratory tract symptoms, etc.. Oral measles mucous membrane spots appear 2~3 days after the fever, 4 days after the fever skin rash, for maculopapular rash, the first rose red, then dark red, pressure of the fading color. From the back of the ear, hairline, rapidly extended to the neck, trunk, limbs, palm and plantar, generally 2~5 days out all.

Rubella: Mostly for young children, 1~2 days of fever in the prodromal period, and the rash appears when the fever subsides. The rash is monomorphic, mild, and itchy, and it subsides in 1~2 days. It is accompanied by swelling of superficial lymph nodes in the neck.

Childhood Acute Rash: Mostly infants and young children under 3 years of age, with sudden onset of high fever and rash, mostly maculopapular rash.

Laboratory Tests

Blood tests are routine. In herpes virus or paramyxovirus infection, there may be a decrease in white blood cell count, high lymphocytes, and elevated monocytes, all of which are indicative of viral infection.

C-reactive protein (CRP) and blood sedimentation tests are also performed, which are helpful in determining the severity of the disease.

Other ancillary diagnostic tests include viral antibody or antigen tests.

Differential Diagnosis

Fixed-type drug rash

It needs to be differentiated from herpes simplex.

Fixed-type drug rash: there is a history of drug taking before the onset of the disease, and the onset of the disease can be triggered after the application of the same kind of drug or the same class of drugs. There is a tendency for exacerbation after multiple applications. Manifestation of purplish-red spots at the junction of skin and mucous membranes, and even blisters.

Herpes simplex: no history of medication before the onset of recurrent episodes associated with fever, cold, stress, fatigue, etc., recurrent cases of rash fixed, manifested as a cluster of blisters on the basis of erythema at the skin-mucous membrane junction, symptoms are mild, a week of spontaneous healing, and will not aggravate the tendency of generalization.

Papular urticaria

It needs to be differentiated from chickenpox.

Papular urticaria: mostly caused by insect bites, the rash is red, fusiform, with blisters at the top. Itching is obvious, preferably on the limbs, waist and back, buttocks, etc., without the characteristics of centripetal distribution, without fever, lethargy and other prodromal symptoms. Non-contagious.

Chickenpox: history of contact with patients with chickenpox or herpes zoster, with prodromal symptoms such as fever, lethargy and sore throat before the onset of the disease. Rash centripetal distribution, mild itching, the same site can have erythema, blisters, scabs and other multi-period skin lesions exist, infectious.

Impetigo

It needs to be differentiated from herpes zoster.

Impetigo: lesions for scattered erythema, blisters, pustules quickly formed, pustules rupture to form pus scabs, can be self-inoculated spread, mostly in children, blister fluid smear or culture visible bacteria. No distribution along the nerves, neuralgia characteristics.

Herpes zoster: prevalent in children, the elderly, immunocompromised people, the rash is erythema based on clusters of blisters, usually distributed along the peripheral nerves in bands, accompanied by the characteristics of neuralgia.

Measles type or scarlet fever drug rash

Needs to be differentiated from measles.

Onset is sudden and may be accompanied by fever, but symptoms are mild compared to measles. There is mostly a clear history of drug use, such as penicillins, sulfonamides, antipyretics, and barbiturates. Skin lesions mostly appear within 3 weeks of the first dose.

Scarlet fever

Needs to be differentiated from measles.

Scarlet fever: caused by bacterial infection, in addition to fever and scarlet rash, there are red, swollen and pus-filled tonsils, pale circles around the mouth, “prune tongue”, obvious rash in the folds of the skin, and obvious desquamation of the hands and feet after the onset of the rash.

Measles: caused by viral infection, with fever for 2-4 days in the prodromal period, moderate to severe respiratory symptoms, but no obvious suppurative inflammation of tonsils, no perioral pale circle, “prune tongue”, skin folds where the rash is obviously linear, etc., and chaffy desquamation after healing.

Treatment

Treatment objectives: shorten the course of the disease, reduce symptoms, minimize the chance of recurrence and transmission, and prevent possible complications.

Treatment principle: symptomatic and supportive treatment, appropriate use of antiviral drugs can shorten the course of the disease. New biological viral skin disease, in addition to drug treatment can also be physical therapy or surgical treatment.

Drug treatment

Systemic medication

Used for blister-type diseases caused by herpes virus infection, e.g. herpes simplex, chickenpox, herpes zoster.

Nucleoside analogs are the most effective drugs for treating herpes viruses, such as acyclovir, valacyclovir, famciclovir, and ganciclovir.

For those with herpes simplex who are resistant to acyclovir, consider phosphonium and bromvudine therapy.

Analgesia: For herpes zoster neuralgia, oral nonsteroidal antipyretic and analgesic drugs and calcium channel modulators, such as ibuprofen, diclofenac sodium, gabapentin, and pregabalin, can be used.

Nutritional nerve: for herpes zoster, oral vitamin B1 or vitamin B12, methylcobalamin tablets.

Antibiotics should be applied to those with secondary bacterial infections, and dehydration treatment should be taken for those with varicella encephalitis with cerebral edema.

Topical medication

The main focus is on astringency, dryness and prevention of secondary infection.

3% Acyclovir ointment, 1% Penciclovir cream.

For secondary infection, 0.5% neomycin ointment, mupirocin ointment can be used.

Patients with oral infections can gargle with 1:1000 benzalkonium bromide solution.

Antiviral drugs or cytotoxic drugs, such as: fluorouracil ointment, vinpocetine ointment, imiquimod cream.

Physical therapy

Ultraviolet light, spectrum meter, helium-neon laser, etc. can relieve shingles pain.

Cryotherapy, laser therapy: can be used for neoplastic viral rashes caused by human papillomavirus infection to remove the growths.

Surgical excision

Surgical excision can be considered for refractory common warts and condyloma acuminatum, but they are prone to recurrence.

Other treatments

Measles, rubella treatment principle is symptomatic and supportive treatment. According to the routine treatment of respiratory infectious diseases, pay attention to isolation. At the same time to prevent and control possible complications.

The symptoms of infantile emergency rash are mild, usually do not need treatment, parents pay attention to care.

Prognosis

Cure

The prognosis of viral infectious diseases is good and most of them are self-limiting.

Herpes simplex: can be self-limiting and clinically cured. It is prone to recurrence when immunity is lowered.

Chickenpox: self-limiting disease, mildly ill patients heal spontaneously in 10-14 days, severely ill patients are treated aggressively and have a good prognosis.

Herpes zoster: most patients can obtain lifelong immunity after healing, and the recurrence rate is low. Recurrence suggests a decline in immune function or an underlying malignant disease. Recurrent cases have been reported in recent years.

Measles: with active treatment, lifelong immunity can be obtained after healing, and recurrence is rare.

Rubella: with active treatment, the prognosis is good.

Rubella: mild symptoms, short duration of illness, good prognosis.

Hazards

Immunocompromised, immunosuppressant treatment, patients treated with glucocorticoids are prone to hemorrhagic chickenpox when infected with chickenpox.

Malnutrition, lymphoma, leukemia and other disorders infected with the virus, prone to viral dissemination, more serious condition, complications well.

Pregnant women infected with chickenpox can lead to fetal malformation, preterm delivery or stillbirth.

Herpes zoster, especially in the elderly, immunocompromised people are prone to complications of postherpetic neuralgia [5], severe patients with anxiety, sleep disruption, so that the quality of life is reduced.

Pregnant women with rubella in the first four months of pregnancy may experience miscarriage, preterm delivery, fetal malformations, such fetal malformations are called congenital rubella syndrome.

Daily

Daily management

Dietary management

Balanced and nutritious diet, with more food rich in vitamins and proteins, such as fruits, vegetables, milk and lean meat.

During the period of illness, easy-to-digest food should be chosen and hydration should be taken care of.

Life management

Patients with chickenpox, measles, rubella and early childhood emergency rash need to be isolated.

Keep the skin clean and avoid scratching which may lead to secondary infection.

Take rest and ventilate the room.

Disease monitoring

Chickenpox: monitor blood routine, liver function, body temperature, number of blisters, skin for secondary infection, dyspnea, cyanosis, convulsions and seizures.

Herpes zoster: Follow-up on time. If pain persists after the rash subsides, treatment should be continued to reduce pain and improve the patient’s quality of life.

Rubella and measles: pay attention to monitor the mental state and general symptoms of the child, and consult the doctor promptly if there is any change in the condition.

Prevention

Patients with certain viral skin diseases are highly infectious during the incubation period or onset of the disease. Respiratory isolation or isolation of close contacts should be carried out according to different diseases to cut off the means of transmission.

Control of infectious agents

Chickenpox is highly contagious, 1~2 days before the onset of the rash until the rash is completely scabbed are contagious, need to be isolated.

Pollutants and utensils can be sterilized by boiling and sunlight.

Contacts of chickenpox patients should be isolated for at least 3 weeks.

Immunocompromised, using immunosuppressants or pregnant women with a history of exposure can use human gammaglobulin or herpes zoster immunoglobulin to alleviate the condition.

The incubation period is 10 to 15 days, and isolation is required from the incubation period until 5 to 7 days after the appearance of the rash, when the cicatricial symptoms subside and there is no discharge.

Contacts are recommended to be isolated for 2~3 weeks for observation, and normal human immunoglobulin can be injected intramuscularly if necessary.

Cut off the transmission pathway

Pay attention to wearing masks and avoid close contact with patients with chickenpox, measles and rubella.

Avoid staying in closed public places for too long for those who are physically weak.

Protecting susceptible people

Vaccination can play a large part in prevention. Children can be vaccinated with rubella vaccine, inactivated measles vaccine and chickenpox vaccine according to the vaccination schedule. Adults can be vaccinated against herpes zoster [7-10].