Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

Disclosures

•There are no financial relationships with commercial interests to disclose Viral Rashes: New and Old •Any unlabeled/unapproved uses of drugs or products referenced will be disclosed Peggy Vernon, RN, MA, CPNP, DCNP, FAANP

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Restrictions Objectives

• Permission granted to the 2021 National Nurse • Identify a potential sequelae from hand, foot and Practitioner Symposium and its attendees mouth disease • Describe the pattern of distribution and lesion • All rights reserved. No part of this presentation may description of varicella be reproduced, stored, or transmitted in any form or • Identify a precursor of Henoch Schonlein Purpura by any means without written permission of the author •Contact Peggy Vernon at [email protected]

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Viral Exanthems Morbilliform Exanthems

•Morbilliform • Measles (rubeola) •Papular-nodular • Rubella •Vesiculobullous • Roseola •Petechial • Erythema Infectiosum •Purpuric • Pityriasis Rosea • Infectious Mono

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1 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

Measles (Rubeola) MEASLES (RUBEOLA) • Prodrome: fever, malaise, cough, DIFFERENTIAL DIAGNOSIS conjunctivitis. Patient appears quite ill •Other morbilliform eruptions: Rubella, • Koplik’s spots: bluish-white erythema infectiosum, pityriasis rosea, elevations on buccal mucosa infectious mono • Exanthem: erythematous •DRUG maculopapular eruption, from scalp to forehead, posterior ears, face, •Papulosquamous disorders: psoriasis, guttate neck, to trunk and extremities. psoriasis Fades in same progression • Incubation: 10-12 days • Contagious 4 days before and 4 days after rash appears

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Measles Diagnosis

• Throat or nasal swab Measles: Treatment and Prevention • Labs to detect antibodies • Symptomatic and • Report to Health Department • Who should get the vaccine? supportive • Those who received vaccine between 1963 and 1967 • Appropriate but don’t know which version received treatment of • International travelers who don’t have evidence of immunity secondary bacterial • Who is exempt from vaccine? infections: otitis • Those born before 1957 media, • Those who received live vaccine between 1963 and bronchopneumonia 1967 • Those who received 2 live measles vaccines • IMMUNIZE!

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Measles Cases and Outbreaks CDC • Measles cases in 2021 Rubella • As of June 4, 2021, there have been 2 cases of measles confirmed in 1 jurisdiction.* • Measles cases in 2020 • Mild illness • From January 1 to December 31, 2020, 13 individual cases of measles were confirmed in 8 jurisdictions.* • Suboccipital and posterior • * Jurisdictions refer to any of the 50 states, New York City, and the District of Columbia. auricular adenopathy • Measles cases in 2019 • From January 1 to December 31, 2019, 1,282* individual cases precedes cutaneous of measles were confirmed in 31 states. • This is the greatest number of cases reported in the U.S. since eruption by several days 1992. The majority of cases were among people who were not vaccinated against measles. Measles is more likely to spread and • Pink macular eruption first cause outbreaks in U.S. communities where groups of people are unvaccinated. on face to trunk and • For more information please see the following reports: • Increase in Measles Cases – United States, January 1-April 26, 2019 MMWR. May 3, 2019 proximal extremities Photo Courtesy Visual DX • National Update on Measles Cases and Outbreaks – United States, January 1-October 1, 2019. MMWR. October 11, 2019 ©Pvernon2021 ©Pvernon2021

2 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

Rubella STAR Complex • Prodrome: headache, •Sore malaise, anorexia, •Throat conjunctivitis, sore throat, cough, low-grade fever in •Arthritis adolescents and adults. Mild •Rash disease in children •Most common in adolescent girls. • Forchheimer’s sign: petechiae Arthritis may persist for several months Photo Courtesy Visual DX on soft palate • Incubation: 16-18 days ©Pvernon2021 ©Pvernon2021

RUBELLA CONGENITAL RUBELLA DIFFERENTIAL DIAGNOSIS • First trimester may result in embryopathy: neonatal purpura and petechiae secondary to •Other morbilliform eruptions thrombocytopenia. •Scarlet fever • Jaundice due to rubella hepatitis • May include deafness, congenital heart •DRUG! defects, cataracts, glaucoma, growth retardation, and psychomotor retardation

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ERYTHEMA INFECTIOSUM Rubella: Treatment and Prevention (FIFTH DISEASE) •Symptomatic • Parvovirus B19 • Stage 1: day 1: intense macular •Avoid exposure to pregnant women blush, “slapped cheek appearance” • • Stage 2: day 2: erythematous IMMUNIZE! maculopapular eruption on extensor surfaces of extremities • Stage 3: Day 6: rash on proximal extremities with reticulated or lacy pattern: most characteristic; reappears several times with exposure to heat or friction, lasting

weeks to months Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021

3 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

ERYTHEMA INFECTIOSUM ERYTHEMA INFECTIOSUM RISKS DIFFERENTIAL DIAGNOSIS • • Aplastic crisis in those Other morbilliform exanthems with sickle cell disease •Phototoxic reaction • Chronic anemia in •Systemic lupus immunodeficient patients •DRUG!! • STAR complex and arthritis • Hydrops fetalis and fetal Photo Courtesy Visual DX death in first trimester Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021

Pityriasis Rosea

• Prodrome: Usually no prodrome. Occasional Pityriasis Rosea pharyngitis, lymphadenopathy, headache, malaise. • DIFFERENTIAL DIAGNOSIS • Annular, scaly, • Tinea corporis erythematous lesion • Drug (herald Patch) precedes rash by 1-30 days • Nummular eczema • • Multiple erythematous Morbilliform eruptions macules follow lines of • Guttate psoriasis skin markings in • DURATION: “Christmas Tree” • Lesions may last 4-8 weeks configuration ©Pvernon2021 ©Pvernon2021

ROSEOLA PITYRIASIS ROSEA • Most common • TREATMENT: exanthem in children younger than 3 years • Antipruritics • Fever in otherwise well child for 3-5 days • UVL • Discrete rose-pink maculopapular exanthem, usually on the trunk, as the fever subsides • Incubation 5-15 days Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021

4 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

Infectious Mononucleosis ROSEOLA DIFFERENTIAL DIAGNOSIS AND TREATMENT • Clinical triad: fever, pharyngitis, cervical adenopathy •Other morbilliform eruptions • Headache, malaise, fever, lymphadenopathy, sore throat •DRUG!!! with exudative tonsillitis, hepatosplenomegaly, periorbital •Treat symptomatically edema, photophobia • Macular, maculopapular, morbilliform eruption trunk, upper arms, occasionally on the face, forearms, thighs, legs Photo Courtesy Visual DX • Discrete bright red petechiae on the palate, fade to brownish hue in 2 days ©Pvernon2021 ©Pvernon2021

INFECTIOUS MONONUCLEOSIS Vesiculobullous Lesions • Epstein-Barr virus (EBV) •Hand-Foot-Mouth • DDX: Streptococcal infections, other morbilliform eruptions •Herpes Simplex • Treatment: Symptomatic, rest. •Varicella Prednisone 2-3 mg/kg for adolescents •Herpes Zoster • AVOID ANTIBIOTICS without confirmation of bacterial infection • Education: Avoid contact sports until hepatosplenomegaly resolves

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Hand-Foot-Mouth Disease Hand-Foot-Mouth Disease • Prodrome: occasional low- grade fever, anorexia, sore •Enterovirus infection mouth, malaise, abdominal that causes a vesicular pain eruption that is clinically • Scattered papules & vesicles characteristic in on palms, fingertips, soles of appearance and feet. Discreet oral lesions on distribution soft palate, hard palate, buccal •Seasonal Peak summer mucosa, gingivae, tongue. and fall Photo Courtesy Visual DX • Fever, malaise, diarrhea, occasionally joint pain •Incubation 3-6 days • Cervical or submandibular adenopathy Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021

5 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

HAND-FOOT-MOUTH DISEASE DIFFERENTIAL DIAGNOSIS HFM Treatment • Other morbilliform eruptions • Varicella • Herpes simplex virus •Symptomatic: • Herpangina Analgesics • 1-2 mm papules/vesicles, red halo, to shallow grey ulcer on soft Anti-pyretics, palate, tonsillar pillars, pharynx, Fluids Buccal mucosa • Fever, sore throat • Aphthous ulcers • Shallow erosions gums, tongue, palate, lips, buccal mucosa, gray- yellow base, burning, tenderness, heal in 7-10 days ©Pvernon2021 ©Pvernon2021 Photo Courtesy Visual DX

Sequelae

•Onychomadesis • Painless spontaneous separation of proximal nail plate

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Herpes Simplex

• Grouped vesicles on Herpes Gladiatorum erythematous base • Tense vesicles •Skin-to-skin exposure • May be recurrent and through contact reactivated by fever, UVB, sports trauma (dental procedures) •>1/3 of wrestlers • Regional adenopathy infected after single • Prodrome tingling, itching, match with infected individual burning 12-24 hours before Photo Courtesy Visual DX

lesions appear Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021

6 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

Herpetic Whitlow Eczema Herpeticum

• Lesions on fingers •Herpetic lesions in and periungual area sites of recent or • Common in health- active atopic care workers, dental dermatitis workers •Painful, edematous, • Children crusted vesicles autoinnoculate by sucking thumbs and biting nails

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Herpes Simplex Differential Herpes Simplex Treatment Diagnosis • Acyclovir: oral, topical, IV. 400 mg TID x 5-10 •Impetigo • Famciclovir: 250 mg or 500 mg TID x 5-10 •Aphthous Ulcers • •Herpes zoster Valacyclovir: 500-1000 mg bid x 5-10 •Autoimmune • Acyclovir 5%/Hydrocortisone 1% (Xerese®) blistering diseases • Benzalkonium chloride (Viroxyn®) • Docosanol (Abreva®) • Prophylaxis for 6 or more infections in one year

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VARICELLA NCAA Return to play • Successive crops of pruritic •Oral antiviral medication at least 5 days vesicles, evolve to pustules, crusts, scars. •No new blisters or lesions for 72 hours • Frequently involve mucous Pvernon 2017 •Visible lesions covered with impermeable dressing membranes of oral cavity, nasal mucosa, conjunctiva, vaginal •Athletes in contact sports with confirmed history mucosa should be on antiviral suppression therapy to • Incubation: 14 days decrease risk of transmission to others • Contagious :1-2 days before onset of skin eruption • Duration: 7-10 days ©Pvernon2021 ©Pvernon2021

7 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

Varicella Varicella Complications

•Prodrome: nausea, anorexia, myalgias, headache •Secondary bacterial infections •Reyes’s Syndrome •PapulesVesiclesPustules •Acute cerebellar ataxia •Lesions at various stages of healing •Pneumonia •Encephalitis •Begins on head and trunk, spreads to extremities

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Varicella Treatment Herpes Zoster

•Acyclovir, Famvir, Zovirax • Acute vesicolobullous •Symptomatic treatment of fever and pruritis infection caused by varicella •Antibiotic treatment of secondary bacterial infections zoster virus, remains dormant in cells of dorsal root ganglia •VACCINATE! or cranial nerve ganglia after initial varicella infection • Unilateral pain, itching, burning • Papulovesicular eruption on erythematous base in linear distribution PVernon

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Herpes Zoster Return to Play Guidelines

•Prodrome: neuritis, paresthesia precedes •Free of fever, malaise, feeling ill, etc. cutaneous eruption 3 > •No new blisters in past 72 hyours (3 days). days Existing lesions must be covered in a dry •Headache, malaise, fever crust •Post-herpetic neuralgia •Completed minimum 120 hours (5 days) systemic antiviral therapy as prescribed by health care provider

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8 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

ERYTHEMA MULITFORME ERYTHEMA MULTIFORME TREATMENT • Oval or round fixed symmetrical lesions • Lesions progress to form •Cool wet concentric zones: central zone becomes dusky, compresses occasionally develops blisters (target lesions) •Antihistamines • Dorsal surfaces of hands and feet, palms and soles; •Acyclovir for herpes flexor surfaces less often, mucous membranes associated EM • DDX: urticaria, apthous ulcers, epidermolysis bullosa, Kawasaki, Drug

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TARGET LESIONS PETECHIAL LESIONS

• Atypical Measles • Hepatitis A and E • EchoVirus 9 • Gloves and Socks Syndrome

ATYPICAL MEASLES HEPATITIS VIRUSES A and E • In patients who have • Waterborne, enterically received killed vaccine or transmitted in whom live vaccine has • Low-grade fever, irritability, URI • Morbilliform eruption, failed. precedes icteric stage by 1-10 • High fever days • Urticarial and scarletinaform • Abdominal pain eruptions are rare • Eventual development of • Vesicular, vesiculopustular, hepatic tenderness, icterus, or purpuric lesions, acral hepatic enlargement • Disease may last 3-4 weeks petechiae ©Pvernon2021 ©Pvernon2021

9 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

HEPATITIS A and E HEPATITIS A and E •DDX: Other viral exanthems, esp. Rubella • Treatment: Symptomatic. Rest, adequate. and Parvovirus B19 Human Serum Globulin.02mg/kg for exposed individuals • Education: Transmitted enterically, possibly •Serum aminotransferase levels markedly orally. Personal hygiene. Contaminated food elevated early and water should be sought.

GLOVES AND SOCKS PAPULONODULAR EXANTHEMS • April to September •Gianotti-Crosti Syndrome • Lasts longer than 1 week but resolves by 2 weeks • Swelling of hands and feet • Occasional lip and mouth involvement • Fever • Treatment: symptomatic

GIANOTTI-CROSTI SYNDROME Gianotti-Crosti (PAPULAR ACRODERMATITIS) • Symmetric, flat-topped 1-10mm papules in acral •Preschool aged areas of face, buttocks, children up to early extremities, especially prominent over hands, teen elbows, knees. •Children with atopic • Pink, coppery-red, or dermatitis or other flesh-colored atopy greater risk • Preceded by low-grade fever and URI, lymphadenopathy, hepatosplenomegaly Photo Courtesy Visual DX • Can last 2-8 weeks ©Pvernon2021 ©Pvernon2021

10 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

GIANOTTI-CROSTI SYNDROME Petechial/Purpuric Exanthem Cytomegalovirus, Coxsackie • viruses, Parainfluenza virus, RSV, Echovirus 9 Some types of live virus vaccines •Henoch Schonlein Purpura Hepatitis A, B, and C viruses EBV most common cause in U.S. •Meningitis Treatment: symptomatic. Unresponsive to topical steroids. DDX: Irritant dermatitis, atopic dermatitis, lichen planus Education: prolonged nature. Evaluate contacts if positive for Hepatitis B.

ECHOVIRUS 9 ECHOVIRUS 9 DIFFERENTIAL DIAGNOSIS • Rubelliform macules and • papules face and neck, Roseola spread rapidly to trunk and • Atypical Measles extremities • Rocky Mountain Spotted Fever • Acral petechiae • Meningococcemia • Fever, sore throat, abdominal • Coxsackievirus pain, vomiting • Streptococcal • Petechiae last 2-7 days infections • Aseptic meningitis is common • EBV • Complete recovery • Hepatitis Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021

ECHOVIRUS 9 HSP • • Preceded by fever, malaise, Treatment: Symptomatic arthralgia, and •Education: Contagious nature, photosensitivity gastrointestinal upset • Major presenting factor: is common palpable purpura • 2mm-7mm purpura surrounded by 2-3mm flat red halo or collar • Most common on lower legs • Mucous membranes not often involved • 50% have joint, peripheral nervous system, GI tract, and lung involvement ©Pvernon2021 ©Pvernon2021

11 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

HSP HSP Treatment

• Ages 2-10 • Symptomatic • Palpable purpura legs and buttocks, occasionally arms, • Identify causative factors: face, ears---spares trunk viral, bacterial, drug • Abdominal pain GI bleeding, arthralgia, hematuria, • Appropriate antibiotics leukocytoclastic vasculitis • Degree of renal involvement • Serial UA determines prognosis • Corticosteroids debatable: • Preceded by strep or viral URI infection 1-3 weeks helpful for short periods prior with GI complications or • Usually benign, long-term prognosis excellent Photo Courtesy Visual DX chronic glomerulonephritis Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021

Meningitis Meningitis Prevention •Caused by viruses, bacteria, or fungi •2 of 4 symptoms: • Standard hygiene: don’t share food, drinks, headache, fever, stiff utensils, or personal items neck, altered mentation • seen in 95% of patients Hand washing •Petechial rash occurs as • Stay home when ill disease progresses • Meningococcal Vaccine at age 11-12 and booster at •21% of all age 16 meningococcal disease occurs between 11 and • 5 vaccine-preventable groups of bacterial 24 years.. In infants, meningitis in the US are A,C,W,Y, and B. Vaccine highest rates younger for meningitis B wasn’t available until 2014 Photo Courtesy Visual DX than 12 months.

Covid 19 Covid 19

•Pernio-like lesions on • Faint urticarial plaques acral surfaces • Vesicular eruption • Erythema • All lesions same stage • Edema of development • Vesiculation • Vesicles may coalesce • Purpura • Urticaria

Photos Courtesy Visual DX Photos Courtesy Visual DX

12 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5

Covid 19 Covid Arm

•Urticarial eruption • Rash develops at site of • injection spreading 5-6 Transient livedo inches across arm • Develops more than 4 hours after receiving first injection • Resolves 24 hours to 1 week • Second vaccine SAFE

Photo Courtesy Visual DX

References • Bobonich, M, Nolen, M. Dermatology for Advanced Practice Clinicians. Wolters Kluwer, 2015. First Edition. • Foe, Donna Poma, Cutaneous Drug Eruption: A Case Study and Review; Journal of the Dermatology Covid 19 DDX Nurses’ Association, Nov/Dec 2009, Vol 1 Issue 6, p 345-409 • Goodhearts, Herbert P. Goodheart’s Photoguide to Common Skin Disorders, Third Edition, Lippincott Williams & Wilkins 2009 • Habif, Thomas. Clinical Dermatology. Fourth Edition, Mosby, 2004 • • Mina, Michael, et al: Science, 2/19/2019 Kawasaki disease • Schachner, Lawrence A. & Hansen, Rondal C. Pediatric Dermatology, Third Edition, Mosby, 2003 • Sulzberger and Zaidems: “Psychogenic factors in Dermatological Disorders”. Medical Clinics of North •Adenoviral infection America, 1948, Vol. 32, P. 669. • Wollf, Klaus et al. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, Sixth Edition, McGraw-Hill, •Enteroviral infection 200 • Internet Resources •Toxic shock • American Academy of Dermatology, www.aad.org • American Academy of Pediatrics, www.aap.org syndrome • American Lyme disease Foundation, www.aldf.com • Centers for Disease Control and Prevention, www.cddc.gov •Bacterial sepsis • DermNetNZ, www.dermnetnz.org Photo Courtesy Visual DX • Mayo Clinic: diseases and conditions, www.mayoclinic.com/health/DiseasesIndex •Juvenile idiopathic • Medscape:dermatology; http://emedicine.medscape.com • National Eczema Association, www.nationaleczema.org arthritis • UpToDate • VisualDx