Roles & Responsibilities of the Advanced Nurse Practitioners

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Chapter 13:

Viral Infections of the Skin

Three Groups of Viruses Producing Skin Lesions

Herpes viruses: replicate their own polymerase, along with several of their own enzymes

Papilloma viruses: contribute to the initiation of DNA replication

Pox viruses: replicate entirely in the cytoplasm

Viruses

Viruses are obligate intracellular parasites consisting of a nucleic acid core surrounded by one or more proteins.

A host cell is required for viral replication.

Several mechanisms exist for viral replication, and different DNA viruses replicate by their own specific mechanism.

Seven Types of Herpes Virus Infections

Herpes simplex type 1 (HSV-1): involves the face and skin above the waist

Herpes simplex type 2 (HSV-2): involves genitals and skin below the waist

Varicella-zoster virus (VZV): causes varicella (chickenpox) and herpes zoster (shingles)

Epstein-Barr virus: associated with infectious mononucleosis

Seven Types of Herpes Virus Infections (cont.)

Cytomegalovirus: causes mononucleosis and pneumonia

Human herpesvirus type 6 (HHV-6): associated with roseola

Human herpesvirus type 8 (HHV-8): associated with Kaposi sarcoma, especially in patients with HIV infections

Question

A patient presents with painful vesicular eruptions located on his genitals. What herpes infection would the practitioner suspect?

Herpes simplex type 1 (HSV-1)

Herpes simplex type 2 (HSV-2)

Varicella-zoster virus (VZV)

Epstein-Barr virus

Answer

B. Herpes simplex type 2 (HSV-2)

Rationale: Herpes simplex type 2 (HSV-2) involves genitals and skin below the waist. Herpes simplex type 1 (HSV-1) involves the face and skin above the waist. Varicella-zoster virus (VZV) causes varicella (chickenpox) and herpes zoster (shingles). Epstein-Barr virus is associated with infectious mononucleosis.

Herpes Viruses

Action:

Herpes viruses replicate their own polymerase along with several of their own enzymes.

After primary infection, the virus becomes dormant until reactivated by triggers.

The virus is highly contagious and spread by direct contact with skin or mucous membrane.

Diagnostic criteria: vesicular eruptions that are painful and often recurrent.

Drug Therapy for Herpes Virus

Primarily treated with topical agents

Soaks with Burow solution

Viscous lidocaine (Xylocaine) 2%

Diphenhydramine (Benadryl) elixir and aluminum hydroxide/magnesium hydroxide (Maalox)

Systemic drug therapy in case of severe infection in immunocompromised patient

Antiviral treatment for herpes zoster

Topical Antiviral Agents

Types: acyclovir 5%, penciclovir (Denavir)

Action: inhibiting viral DNA synthesis; decrease healing time

Dosage: apply topical acyclovir every 3 hours, six times per day, for 7 days; apply penciclovir every 2 hours, during waking hours, for 4 days

Adverse effects: mild skin irritation and pruritus

Systemic Antiviral Agents

Types: acyclovir (Zovirax), famciclovir (Famvir), valacyclovir (Valtrex)

Contraindications: patients with renal disease

Adverse events: headache vertigo depression, tremors

Interactions: effect increase in patients taking probenecid; patients taking zidovudine (Retrovir) may experience drowsiness

Dosing Acylovir

Immunocompetent host: initial episode: 200 mg orally five times per day for 7 to 10 days; recurrent episodes: 200 mg five times per day for 5 days

Immunocompromised host: 400 mg five times per day for 7 to 10 days: suppression therapy, 400 mg twice a day is the dosage

Children: 5 mg/kg/d in five divided doses for 7 days

VZV infections: children 20 mg/kg four times per day for 5 days; adults: 800 mg five times per day for 7 to 10 days

Famciclovir

Action: diacetyl ester prodrug of penciclovir that is an acyclic guanosine analog; oral bioavailability ranges from 5% to 75%

Dosage: initial episode: 250 mg three times per day for 7 to 10 days; recurrent episodes: 1,000 mg twice daily for 1 day and 250 mg twice a day for suppression therapy

Valacyclovir

Action: prodrug of acyclovir that is converted rapidly with 50% bioavailability

Dosage: initial infection: 1,000 mg three times a day for 7 to 10 days; recurrent infection: 2,000 mg two times a day for 1 day; suppression therapy: 1,000 mg daily

Recommended Order of Treatment for HSV-1 Infection

First line

Topical therapy with acyclovir 5% (Zovirax) or penciclovir 1% (Denavir); treating at earliest signs of outbreak

Second line

Systemic therapy with acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex)

First-Line Therapy: Varicella-Zoster Virus

First-Line Therapy: Herpes Zoster

Question

An adolescent patient who is taking steroids is diagnosed with varicella-zoster virus and is manifesting fever and vesicular lesions on an erythematous base. What is an appropriate first-line therapy for this patient?

Treat symptomatically

Begin systemic therapy with acyclovir for 7 days

Topical acyclovir 5% every 3 hours six times a day for 7 days

Oral analgesics only

Answer

B. Begin systemic therapy with acyclovir for 7 days

Rationale: The first line of therapy for an adolescent with varicella-zoster who is immunocompromised is systemic acyclovir at a dosage of 20 mg/kg four times a day for 5 days. If the patient was not taking steroids, the disease could be treated symptomatically. Topical acyclovir 5% every 3 hours six times a day for 7 days is appropriate for herpes virus infections, and analgesics are used to control pain associated with the virus.

Patient Education

Hygiene

Precipitating factors

Prevention methods

Zostavax vaccine for herpes zoster

Safe sex practices for patients with HSV-2 infection

Wearing gloves when applying medication and careful hand washing

Avoiding skin-to-skin contact

Types of Warts (Verrucae)

Verruca vulgaris—common warts: infection with HPV-2; occur on the fingers or toes at sites of trauma

Plantar warts—HPV-1: occur on the soles of the feet and the palms of the hands; flesh-colored to brown, hyperkeratotic papules

Flat warts—HPV-3: located on the face, neck, and chest or flexor regions of the forearms and legs

Factors Predisposing to HPV

Infection with HIV

Intake of drugs that decrease cell-mediated immunity (prednisone, cyclosporin)

Chemotherapeutic agents

Pregnancy (may cause proliferation)

Handling raw meat, fish, or other animal matter

Warts

Action: HPV proteins contribute to the initiation of DNA replication; incubation period is usually 4 to 6 months with transmission by direct contact or by fomite

Diagnostic criteria:

Papillomatous, corrugated, hyperkeratotic growths found only on the epidermis, especially in areas subjected to repeated trauma

Can be solitary, multiple, or clustered

Named for clinical appearance, location, or both

Initiating Drug Therapy for Warts

Choice of medication depends on age of the patient, whether pain is involved, and the location of the wart.

Filiform and flat warts are removed by a dermatologist.

Topical treatment with salicylic acid (DuoFilm) is usually the starting point for all other warts.

The goal of therapy is eradication of the virus and lesion, although there is no way to actually kill HPV.

First-Line Therapy for Warts

Summary

Viruses producing skin lesions may be categorized into three groups: herpes viruses, papilloma viruses, and pox viruses.

Viruses are further classified by family—either the ribonucleic acid family or the deoxyribonucleic acid (DNA) family.

To prevent the spread of these viruses, it is important to educate the patient about hygiene, precipitating factors, and prevention.