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VIRAL SKIN INFECTIONS

PRACTICE PATTERNS (7B and 7C)


Pattern 7B: Impaired Integumentary Integrity Associated With Superficial Skin
Involvement

Inclusion - The following examples of examination findings may support the inclusion of
clients in this pattern: Risk Factors or Consequences of Pathology/Pathophysiology
(Disease, Disorder, or Condition)

• Amputation 

• Burns (superficial/first degree) 

• Cellulitis 

• Contusion 

• Dermopathy 

• Dermatitis 

• Malnutrition 

• Neuropathic ulcers (grade 0) and Pressure ulcers (stage 2) 

• Vascular disease 


Impairments of Body Functions and Structures, Activity Limitations, or Participation


Restrictions

• Edema 

• Impaired sensation 

• Impairments associated with abnormal fluid distribution 

• Impaired skin 

• Ischemia 


Pattern 7C: Impaired Integumentary Integrity Associated With Partial-Thickness Skin


Involvement and Scar Formation

Inclusion: The following examples of examination findings may support the inclusion of

clients in this pattern: Risk Factors or Consequences of Pathology/Pathophysiology

(Disease, Disorder, or Condition)

• Amputation 


• Burns (partial thickness/second degree) 


• Dermatologic disorders 

• Epidermolysis bullosa 


Impairments of Body Functions and Structures, Activity Limitations, or Participation


Restrictions

• Impairments associated with abnormal fluid distribution 


• Impaired sensation 


• Impaired skin 


• Muscle weakness 


DEFINITION, PATHOPHYSIO, S/SX AND TREATMENT


1. Molluscum contagiosum is a viral skin infection that causes either single or multiple
raised, pearl-like bumps (papules) on the skin. It is a chronic infection, so lesions may
persist from a few months to a few years. However, most cases resolve in six to nine
months.

Causes of Molluscum Contagiosum


Molluscum contagiosum is caused by a virus (the molluscum contagiosum virus) that is
part of the pox virus family. The virus is contagious through direct contact and is more
common in children. However, the virus also can be spread by sexual contact and can
occur in people with compromised immune systems. Molluscum contagiosum can
spread on a single individual through scratching and rubbing.

S/Sx of Molluscum Contagiosum?


Common locations for the molluscum contagiosum papules are on the face, trunk, and
limbs of children and on the genitals, abdomens, and inner thighs of adults. The
condition usually results in papules that:
• Are generally painless, but can itch
• Are small (2 to 5 millimeter diameter)
• Have a dimple in the center
• Are initially firm, dome-shaped, and flesh-colored
• Become softer with time
• May turn red and drain over time
• Have a central core of white, waxy material

Molluscum contagiosum usually disappears spontaneously over a period of months to


years in people who have normal immune systems. In people who have AIDS or other
conditions that affect the immune system, the lesions associated with molluscum
contagiosum can be extensive and especially chronic.
Therapeutic options for molluscum contagiosum can be divided into broad categories, including
the following:
• Benign neglect - Leaving mollusca to spontaneously resolve is often reasonable,
especially in young children for whom freezing or curettage may be painful and
frightening. The dictum primum non nocere (first do no harm) has a special significance
in children with minor, self-limited conditions.

• Direct lesional trauma- minor trauma to molluscum lesions frequently produces an


inflammatory response and resolution of the lesion. Various caustic agents have been
shown to be effective in treating molluscum contagiosum. Tretinoin, salicylic acid, and
potassium hydroxide may be used

• Antiviral therapy- In immunocompromised patients, improvement of lesions has been


observed in individual patients treated with ritonavir, cidofovir (intravenous and topical)
and zidovudine. Not surprisingly, patients with AIDS and severe molluscum contagiosum
improve with effective antiretroviral therapy.

• Immune response stimulation- Intralesional interferon-alfa and topical injections of


streptococcal antigen have been shown to be effective in treating patients with resistant
molluscum contagiosum.

• Podophyllotoxin cream (0.5%) is reliable as a home therapy for men but is not
recommended for pregnant women because of presumed toxicity to the fetus. Each lesion
must be treated individually as the therapeutic effect is localized. Other options for topical
therapy include iodine and salicylic acid, potassium hydroxide, tretinoin, cantharidin (a
blistering agent usually applied in an office setting), and imiquimod (T cell modifier).

2. Herpes simplex virus-1 (HSV-1) is the common virus that causes cold sores. It's
transmitted through saliva by kissing or sharing food or drink with an infected individual.
Sometimes, HSV-1 causes genital herpes.

What Causes Herpes Infections and Outbreaks?


Herpes simplex type 1, which is transmitted through oral secretions or sores on the skin,
kissing and sharing objects such as toothbrushes or eating utensils. In general, a person can
only get herpes type 2 infections during sexual contact with someone who has a genital
HSV-2 infection. It is important to know that both HSV-1 and HSV-2 can be spread even if
sores are not present.

What Are the Symptoms of Herpes Simplex?


Symptoms of herpes simplex virus typically appear as a blister or as multiple blisters on or
around affected areas -- usually the mouth, genitals, or rectum. The blisters break, leaving
tender sores. Outbreaks are described as aches or pains in or around the genital area or
burning, pain, or difficulty urinating. Some people experience discharge from
the vagina/penis.
Treatment for Herpes Simplex: NO CURE. But, Medication can decrease the pain related to
an outbreak and can shorten healing time. They can also decrease the total number of
outbreaks. Drugs including Famvir, Zovirax, and Valtrex are among the drugs used to treat
the symptoms of herpes. Warm baths may relieve the pain associated with genital sores.

3. Varicella-zoster virus (VZV) causes itchy, oozing blisters, fatigue, and high fever
characteristic of chickenpox. The chickenpox vaccine is 98% effective at preventing
infection. People who have had chickenpox (or in extremely rare instances, people who
have received the chickenpox vaccine) are at risk for developing shingles, an illness
caused by the same virus. Shingles can occur at any age, but it occurs most often in
people age 60 or older.

Pathophysiology
The host immunologic mechanisms suppress replication of the virus. Reactivation can
occur if host immune mechanisms are compromised.
This may be caused by:
• medications
• illness
• malnutrition,
• natural decline in immune function with aging.

Upon reactivation, the virus migrates along sensory nerves and produces sensory loss,
pain, and other neurologic complications. If motor nerve roots are also involved,
weakness can develop in addition to sensory changes. Leptomeningeal involvement is
rare but may develop when the ophthalmic branch of the trigeminal nerve is involved.

S/SX
Herpes zoster (shingles)
The most common presentation is the shingles vesicular rash, which most commonly
affects a thoracic dermatome.

After a prodromal illness of pain and paresthesias, erythematous macules and papules
develop and progress to vesicles within 24 hours. The vesicles eventually crust and
resolve.
Pain and sensory loss are the usual symptoms, but motor weakness also occurs and is
frequently missed on examination. Motor weakness results when the viral activity
extends beyond the sensory root to involve the motor root.

TREATMENT

-Oral Acyclovir, others: valacyclovir, penciclovir, and famciclovir,


-Varicella zoster immune globulin (VariZIG) is indicated for administration to high-risk
individuals within 10 days (ideally within 4 days) of chickenpox (varicella zoster virus)
exposure.
- Shingles can be treated conservatively using nonsteroidal anti-inflammatory drugs
or wet dressings with 5% aluminum acetate. These dressings should be applied for
30-60 minutes and be done 4-6 times each day. Lotions such as calamine can also be
used to help relieve symptoms.

FOR PREVENTION

 Administer two doses of recombinant zoster vaccine (RZV) (Shingrix) 2-6 months apart to
adults aged 50 years or older regardless of past episodes of herpes zoster or receipt of
zoster vaccine live (ZVL) (Zostavax).
 Administer two doses of RZV 2-6 months apart to adults who previously received ZVL at
least 2 months after ZVL.
 For adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred)

FOR SURGICAL CARE


Surgical care may be required for complications of zoster, such as necrotizing fasciitis.

4. Warts are benign (not cancerous) skin growths that appear when a virus infects the
top layer of the skin. Viruses that cause warts are called human papillomavirus (HPV).
You are more likely to get one of these viruses if you cut or damage your skin in some
way. Wart viruses are contagious. Warts can spread by contact with the wart or
something that touched the wart. Warts are often skin-colored and feel rough, but they
can be dark (brown or gray-black), flat, and smooth.

Who gets warts?


Anyone can get warts. Some people are more prone to getting a wart virus (HPV) than
others. These people are:

• Children and teens.


• People who bite their nails or pick at hangnails.
• People with a weakened immune system (the body’s defense system).

In children, warts often go away without treatment. A dermatologist should treat warts
that hurt, bother the child, or quickly multiply.

What causes warts?


Viruses called human papillomavirus (HPV) cause warts. It is easier to catch a virus that
causes warts when you have a cut or scrape on your skin. This explains why so many
children get warts. Warts also are more common on parts of the body that people shave
such as the beard area in men and the legs in women. You can spread warts from one
place on your body to another.
Warts can spread from person to person. You can get warts from touching a wart on
someone’s body. Some people get a wart after touching something that another
person’s wart touched, such as a towel. It often takes a few months for warts to grow
large enough to see.

S/SX of WARTS

Common warts
(also called vurruca vulgaris)
If you see a wart on your child's face, check your child's hands for warts. The virus that
causes warts can spread from the hands to the face through touch or nail biting.
Common warts have these traits:
 Grow most often on the fingers, around the nails, and on the backs of the hands.
 Are more common where skin was broken, such as from biting fingernails or
picking at hangnails.
 Can have black dots that look like seeds (often called "seed" warts).
 Most often feel like rough bumps.

Foot warts-may be hard to treat


(also called plantar warts)
Plantar warts have these traits:
• Grow most often on the soles (plantar surface) of the feet.
• Can grow in clusters (mosaic warts).
• Often are flat or grow inward (walking creates pressure, which causes the warts
to grow inward).
• Can hurt, feels like you have pebbles in your shoe.
• Can have black dots.

Flat warts
Flat warts have these traits:
• Can occur anywhere. Children usually get them on the face. Men get these most
often in the beard area, and women tend to get them on their legs.
• Are smaller and smoother than other warts.
• Tend to grow in large numbers — 20 to 100 at a time

Filiform warts
Filiform warts have these traits:
• Looks like long threads or thin fingers that stick out.
• Often grows on the face: around the mouth, eyes, and nose.
• Often grow quickly.

HIV weakens the immune system, so the body often cannot fight the virus that causes
the warts.
How do dermatologists treat warts?
Warts often go away without treatment. This is especially true when children get warts.
In adults, warts may not disappear as easily or as quickly as they do in children.
Although most warts are harmless, dermatologists do treat them.

A dermatologist may use one of the following treatments:


 Cantharidin: A dermatologist may treat a wart in the office by "painting" it with
cantharidin. Cantharidin causes a blister to form under the wart. In a week or so,
you can return to the office and the dermatologist will clip away the dead wart.
 Cryotherapy: For common warts in adults and older children, cryotherapy
(freezing) is the most common treatment. This treatment is not too painful. It
can cause dark spots in people who have dark skin. It is common to need repeat
treatments.
 Electrosurgery and curettage: Electrosurgery (burning) is a good treatment for
common warts, filiform warts, and foot warts. Curettage involves scraping off
(curetting) the wart with a sharp knife or small, spoon-shaped tool. These two
procedures often are used together. The dermatologist may remove the wart by
scraping it off before or after electrosurgery.
 Excision: The doctor may cut out the wart (excision).

If the warts are hard-to-treat, the dermatologist may use one of the following
treatments:
 Laser treatment: Laser treatment is an option, mainly for warts that have not
responded to other therapies. Before laser treatment, the dermatologist may
numb the wart with an anesthetic injection (shot).
 Chemical peels: When flat warts appear, there are usually many warts. Because
so many warts appear, dermatologists often prescribe "peeling" methods to
treat these warts. This means, you will apply a peeling medicine at home every
day. Peeling medicines include salicylic acid (stronger than you can buy at the
store), tretinoin, and glycolic acid.
 Bleomycin: The dermatologist may inject each wart with an anti-cancer
medicine, bleomycin. The shots may hurt. They can have other side effects, such
as nail loss if given in the fingers.
 Immunotherapy: This treatment uses the patient’s own immune system to fight
the warts. This treatment is used when the warts remain despite other
treatments. One type of immunotherapy involves applying a chemical, such as
diphencyprone (DCP), to the warts. A mild allergic reaction occurs around the
treated warts. This reaction may cause the warts to go away.

PT PROBLEM LIST
- Pruritus/Itching
- Pain
- Impaired sensation
- Motor weakness
- Poor cosmesis
- Spread of infection

PT ASSESSMENT AND POINTS OF EMPHASIS

Assessment
Use the ABCDE rule:
A-symmetry
B-orders
C-olor
D-iameter
E-volving (size, shape and color)

Sensory Assessment
- Check temperature of skin
- Test ability to feel touch and pressure
- Mobility and turgor

Motor Assessment
- ROM
- MMT

Points of Emphasis
- History of illnesses
- Take note of differential diagnosis
- Social History/Health Habits of patient
- Observe size, shape and characteristics
- For herpes zoster, motor weakness is often left out in the examination

PT TREATMENT PLAN

Patient Education
- Educate patient not to harm, rub or scratch as it can cause spread of infection.
- Avoid sharing towels and clothes with others.
- Cover exposed lesions with bandage.

FOR MOLLUSCUM CONTANGIOSUM

Goal:
- to remove the lesions without risking the spread of infection.
POC: Physical removal of lesions may include,
- Cryotherapy (freezing the lesion with liquid nitrogen)
- Curettage (the piercing of the core and scraping of caseous or cheesy material)
- Laser therapy

FOR HERPES ZOSTER

Goal:
-to reduce itching and pain
-to improve sensory and motor function

POC:
TENS may be used to treat acute pain and reduce the healing time of the rash
associated with herpes zoster. It can be used safely with antiretroviral tre atment or
as the only treatment. TENS therapy generally involves placing two electrodes on
the dermatome affected by herpes zoster for 30 minutes five times per weeks for
a period of time up to three weeks. Suggested electrical output was 1-5 mA with
frequencies ranging from 20 to 40 Hz.

If the facial nerve is affected by herpes zoster and peripheral facial palsy results,
facial exercises have been found to be effective. These exercises include exercises
to:
 stimulate functional movement in the face
 achieve symmetry
 improve motor control
 reduce synkinesis (the result from miswiring of nerves after trauma. This result
is manifested through involuntary muscular movements accompanying voluntary
movements. E.g., voluntary smiling will induce an involuntary contraction of the
eye muscles causing the eye to squint when smiling)
 improve perception of movement
 promote emotional expression.

FOR WARTS

Goal:
-to reduce spread of infection
-to improve cosmesis

POC:
-ultrasound
-topical agents: salicylic acid, cantharidin
-cryotherapy
-laser therapy