Art & science dermatology

Viral infections of the skin: clinical

features and treatment options
Newton H (2013) Viral infections of the skin: clinical features and treatment options.
Nursing Standard. 27, 52, 43-47. Date of submission: March 14 2013; date of acceptance: June 24 2013.

Abstract on the skin can be unpleasant and treatments are

often given to reduce the effects of the virus.
Viral infections of the skin can cause significant distress and this article explores common viral infections
embarrassment for people who are affected. This article explores four that affect the skin: herpes simplex, herpes zoster,
specific viral infections that manifest on the skin: herpes simplex, herpes viral warts and molluscum contagiosum.
zoster, viral warts and molluscum contagiosum. It describes the it describes how viruses affect the skin, the
presentation and appearance of the virus as it affects the skin and what effects on patients and available treatment options.
can be done to minimise the spread of the virus. Management options are
considered, although many of these conditions are self-limiting.
Definition of a virus
Author A virus is an infective parasitic microorganism
Heather Newton that can only replicate within a living host. viruses
Consultant nurse tissue viability, Dermatology Unit, Royal Cornwall invade living cells and use their energy and raw
Hospital Trust, Truro. materials to live and multiply. the core of the virus
Correspondence to: [email protected] contains either deoxyribonucleic acid (DnA) or
ribonucleic acid (rnA), and is surrounded by a
Keywords protective coat of antigenic protein. Although
viruses can be treated with antiviral agents, there
Dermatology, herpes simplex, herpes zoster, molluscum is a reliance on the body’s defence mechanisms to
contagiosum, viral infection, viral warts control the spread and subsequent effects of viruses.

Review
Herpes simplex
All articles are subject to external double-blind peer review and
checked for plagiarism using automated software. Herpes simplex virus (HSv) lives in a dormant
state within the sensory nerves of the skin. there
Online are two types of HSv: type 1 (HSv-1), which is
commonly known as the cold sore virus, and
Guidelines on writing for publication are available at type 2 (HSv-2), which is the usual cause of genital
www.nursing-standard.co.uk. For related articles visit the archive herpes (Buxton and Morris-Jones 2009).
and search using the keywords above. Primary infection with HSv-1 has been found
to be lower in higher socioeconomic groups. By
the age of 30, 50% of individuals with a higher
socioeconomic status and 80% of individuals with a
A virAl infection is an infection caused by lower socioeconomic status will test positive for the
the presence of a virus in the body. Depending on the virus (Salvaggio et al 2012). cevasco and tomecki
type of virus and a person’s state of health, viruses (2010) suggested that 85% of the global population
can infect almost any type of tissue and therefore can has antibody evidence of HSv-1 infection.
involve different parts of the body. Most viruses can the initial infection from HSv-1 usually occurs
be fought by the body’s immune system; however, in infants and young children through direct
in the most vulnerable groups, such as older people contact on mucosal surfaces or on sites of skin
and immunocompromised patients, the risk of damage following minor injury, when the virus is
contracting viral infections increases and they have inoculated into the skin. the source of the virus
the potential to be more severe. may be elsewhere on the body, and this occurs
Many viral infections are self-limiting and often especially in children who bite their nails or suck
require no specific treatments to aid recovery. their thumbs (Dermnet nZ 2013). once infected,
However, the signs and symptoms that present the virus stays in the body for life and there is no

©Downloaded
NURSING from
STANDARD / RCN PUBLISHING august 28 :: vol 27 no 52 :: 2013 43
RCNi.com by ${individualUser.displayName} on Jul 22, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
Art & science dermatology

cure. for many people the virus is never triggered itchy and painful (MedlinePlus 2013). they appear
and remains dormant; however, following seven to ten days after exposure and primary
initial presentation it can reappear at any time infection presents like an erosive dermatitis on the
throughout a person’s life. external genitalia. they can also appear on the tip
the initial entry of the HSv into a host cell or the shaft of the penis, on the foreskin and/or
involves the interaction of several glycoproteins, pubic area in men. in women, they are commonly
which contain oligosaccharide chains that are found on the genital area around the vagina and
present on the surface of the virus, with receptors the perineum. those affected may feel unwell with
on the surface of the host cell. complementary influenza-like symptoms, have swollen glands,
receptors bring the viral and the host cell especially in the groin, and experience pains in
membranes into close proximity so that the two cell the back of the legs a few days before the lesions
membranes can merge. An entry pore is then formed appear. in addition, they can experience many
through which the viral envelope contents are outbreaks during the year, with recurrence seen
introduced to the host cell. this is then transported in approximately 40% of those affected. As with
to the cell nucleus where the viral capsule ejects its HSv-1 there is no cure.
DnA contents (Subramanian and Geraghty 2007). treatment of HSv-1 usually consists of the
initially, the virus can be triggered by fatigue, application of topical aciclovir, which is a potent
injury to the affected area and menstruation inhibitor of herpes virus DnA and therefore
in women (ichihashi et al 2004). it can then be prevents replication of the virus. it reduces the
reactivated by colds and influenza, a flare in spread of the virus and works by preventing the
eczema, emotional and physical stress, gastric herpes virus from multiplying (Allen 2012). topical
upsets, fatigue, injury, menstruation and, in some treatments can be useful in primary infection if
cases, exposure to bright sunlight (ichihashi started at the first indication of symptoms such as
et al 2004). if a person’s immune system is tingling in the area; however, they will only shorten
compromised viral episodes can occur more the duration of illness by a day or so (Buxton
frequently (ichihashi et al 2004). and Morris-Jones 2009). in recurrent cases, oral
in both types of HSv, when the virus is activated it aciclovir may be considered, and the earlier the
spreads down the nerve pathways and on to the skin treatment commences the shorter the duration of
or mucous membranes. At this stage it multiplies, the symptoms (Brannon 2010). oral or intravenous
causing itchy painful blisters. HSv-1 appears as a treatment is also required for more severe cutaneous
single or cluster of fluid-filled blisters that eventually manifestations such as eczema herpeticum (British
form a crust and then scab over. occasionally, they Association of Dermatologists (BAD) 2011a).
can look like tiny red spots that do not blister but in HSv-2 infections, treatment is recommended
are itchy and painful. the lesions form mostly on at the first outbreak. oral antiviral tablets such as
the lips, however, they can be found on the nose, aciclovir are prescribed five times a day for at least
cheeks and chin (Knott 2011). it can take more than five days, or longer if the patient is still developing
14 days for the lesions to heal completely. When the new blisters (family Planning Association 2013).
virus is active, it is highly contagious and is spread for patients with recurrent infections, suppression
to other people through direct contact. After each therapy with antiviral agents taken daily for a
exacerbation the virus travels back up the nerve fibre longer period may be required (family Planning
and lies dormant again. Association 2013). the use of condoms should
Where a person is predisposed to an atopic be encouraged to protect partners against spread
eczematous condition, herpetic lesions can become of the virus, although they do not provide total
more widespread and severe. this condition is protection. People who have genital herpes are
known as eczema herpeticum and patients can deemed to be more at risk of infection with human
become systemically unwell, with some requiring immunodeficiency virus (Hiv) as the breaks in the
hospitalisation if the skin becomes severely affected. skin can increase the risk of Hiv entering the body
HSv-2 is usually sexually transmitted, especially during sexual contact.
in young adults, and is spread by direct contact
with an infected person through broken skin
or intact mucous membranes. cevasco and Herpes zoster
tomecki (2010) suggested that HSv-2 infection Herpes zoster is predominantly a skin and
is responsible for 20-50% of genital ulceration in neurological disorder that is caused by the varicella
sexually active people. Mothers can also infect zoster virus. Herpes zoster is also known as shingles,
their infants during childbirth. whereas the varicella virus is commonly known
HSv-2 can produce blisters on the genital or as chickenpox and is identical in its morphology
rectal area, buttocks and thighs, which can be to the varicella zoster virus. Herpes zoster is an

44 august 28 :: vol 27 no 52 :: 2013 © NURSING STANDARD / RCN PUBLISHING

Downloaded from RCNi.com by ${individualUser.displayName} on Jul 22, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
acute infection caused by reactivation of the latent Although difficult, it is important not to scratch
varicella zoster virus. if a person has had no previous the affected areas because this increases the risk
exposure to varicella, for example as frequently of developing a secondary infection.
occurs with children, they will develop chickenpox.
those who have had exposure and subsequently
developed circulating varicella antibodies can Viral warts
develop a localised reaction known as shingles Many years ago, when people knew very little
if their immune system is compromised. During about viruses, many folk beliefs arose to try to
systemic chickenpox infections, the virus is seeded explain the appearance of warts in healthy people,
to nerve cells and, like herpes simplex, can remain especially children. it was claimed that warty
dormant for many years. lesions would appear if you handled a toad or
Herpes zoster presents as a rash containing washed your hands in water that had been used to
macules and papules. they then progress into boil an egg. cures for warts were even stranger.
vesicles that erupt, release their contents, ulcerate it was claimed that rubbing warts with bean
and eventually form a crust. Herpes zoster is pods or the bark of an elder tree had curative
characterised by its distribution as it often follows properties. Another suggested cure was to rub a
a single nerve pathway, commonly affecting the piece of beef over the wart and then bury it in the
trunk, although the face, neck and lumbosacral garden. this was linked to the notion that as the
areas can also be affected. Some people experience meat rotted in the ground so the wart would rot
unusual skin sensations along the nerve pathway away (Pickering 2012).
days or weeks before onset of the rash (centers Warts are now known to be caused by localised
for Disease control and Prevention (cDc) infections with the human papilloma virus
2012). During the acute phase, those affected are (HPv), and there are more than 100 different
infective to others and therefore should avoid any types of HPv (national institute for Health
contact with vulnerable people, including older and care excellence 2009). Most people will be
people, those who are immunocompromised, infected with HPv at some stage in their life, and
pregnant women and people who have not prevalence figures in the UK range from 3.9-4.9%
previously had chickenpox. (Sterling et al 2001). there are marked regional
Herpes zoster can occur at any age, but it differences in wart prevalence, with higher rates
is more common in older people. A person’s in the north than in the south of england (Sterling
risk increases sharply after 50 years of age and et al 2001).
approximately 50% of people who live to 85 years Warts are most common in children and are
will have experienced an episode of herpes zoster spread by direct and indirect contact. Damage to
(cDc 2012). the rash can last for seven to ten days the epithelial skin layer greatly increases the risk of
but complete healing can take up to four weeks. inoculation with HPv. Skin abrasions from rough
in younger people herpes zoster can resolve surfaces in swimming pools can also increase the
without problems. However, it can cause risk of acquiring plantar warts (verrucas). in people
significant localised pain, general malaise, who bite their nails periungual warts can develop,
headache, myalgia and fever (tidy 2013). and warts can be spread across the beard area when
Secondary bacterial infection of the area can shaving. they are contagious and close skin to skin
occur, as can episodes of pain in the affected contact can pass on infection (nHS choices 2012).
area after clearance of the rash. this is known as the incubation period can range from a few weeks
postherpetic neuralgia (Buxton and Morris-Jones up to 12 months.
2009). Pain lasting more than 12 months has been Warts can present in different ways depending
described in nearly 50% of patients older than on the site of infection. Plantar warts occur on
70 years (Kost and Straus 1996). pressure-bearing areas such as the soles of the
treatment with oral aciclovir is best feet and have a flattened appearance. they can be
started within 72 hours of the rash appearing confused with callous formation or corns. common
(tidy 2013), especially in those who are warts are mostly found on the hands and can have a
immunocompromised, are older, or have a raised firm appearance with a rough surface. they
widespread rash and have moderate-to-severe can also appear as brown coloured papules with
pain. it is important to ensure that the skin is black pinpoint dots on the surface. this appearance
kept clean and dry because this reduces the risk is caused by thrombosed capillary blood vessels.
of secondary infection. the area should be kept Warts can disappear spontaneously after weeks,
covered where possible but if not, contact with especially in children. even without treatment
others should be avoided until the lesions are dry 50% of warts disappear within six months,
and crusty to avoid the small risk of infection. with 65-78% disappearing within two years

©Downloaded
NURSING from
STANDARD / RCN PUBLISHING august 28 :: vol 27 no 52 :: 2013 45
RCNi.com by ${individualUser.displayName} on Jul 22, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
Art & science dermatology

(Kaintz et al 1996). However, in adults it can Products containing salicylic acid work by
take longer for the body to develop cell-mediated slowly destroying the virus-infected epidermis
immunity and for the warts to disappear. (Sterling et al 2001) but can take many weeks
there is a range of measures that can be to clear. the warty area should be softened first
implemented to limit the spread of viral warts. and the dry skin surface rubbed to remove any
Where possible the wart should be covered, loose skin. the paint is applied topically and then
especially when swimming or sharing communal covered with a plaster. this should be repeated on
areas where skin is exposed. A personal towel a daily basis.
should be used for the duration of the wart and cryotherapy, where the wart is frozen
shoes and socks should not be shared. Socks repeatedly with liquid nitrogen, is another option
should be changed daily and feet kept dry as much for more severe cases; however, this treatment can
as possible. it is advisable to wear waterproof shoes cause discomfort, swelling, redness and blistering
when in a swimming pool. (BAD 2011b).
if the warts are on the hands, then patients
should be advised to avoid sucking, nail biting and
scratching the affected areas. if the warts are not Molluscum contagiosum
causing a problem, then no specific treatments are Molluscum contagiosum is an infectious viral
advised as the majority will resolve spontaneously. disease of the skin that is caused by the pox virus
However, for some people they are seen as unsightly and, like many of the viruses, it is common in
and embarrassing and topical treatment is often children. Pox viruses are large DnA viruses that
considered. occlusion with duct tape is a simple favour the epidermis.
option. the affected area should be covered with Molluscum contagiosum presents as small
the tape for six days and then on removal of the clusters of papules that appear in moist places such
tape the area should be soaked in warm water for as in the groin, armpits and behind the knees. they
five minutes and pared down. the wart should are smooth and dome-shaped and can be pale
then be left uncovered overnight and a new piece pink, white or brown in colour. they range in size
of duct tape applied the following morning. it is from 1mm to 5mm in diameter (cDc 2011). the
recommended that this process is repeated until virus is spread by direct contact, especially in moist
the wart disappears (Primary care Dermatology areas such as communal showers and swimming
Society 2013). pools. However, despite its name it is not highly

TABLE 1
Overview of viral skin conditions
Viral condition Clinical features Treatment options
Herpes simplex Single or cluster of fluid-filled blisters often found on Topical aciclovir application. Best applied when the
virus (HSV)-1 the lips but can occur on the nose, chin and cheeks. area starts to tingle.
(cold sores) Often characterised by tingling in the area before the
blisters appear. The blisters eventually crust over and
can take up to two weeks to disappear.
HSV-2 Blisters appear in the genital area of men and women, Oral aciclovir administered five times a day for at
(genital herpes) usually around the surface of the vagina or perineum least five days. For recurrent infections of more than
in women and the shaft and tip of the penis in men. six in any one year, suppression therapy taken daily is
Influenza-like symptoms and swollen glands may also required for 6-12 months.
accompany the blistering.
Herpes zoster A macular, papular rash that often follows a single In younger people the condition resolves itself;
nerve distribution. Vesicles form that ulcerate and however, oral aciclovir is recommended for those who
present as dry crusty lesions. The affected area is are immunocompromised, are older, have a widespread
often very painful. rash and have moderate-to-severe pain.
Viral warts Common warts are found on the hands and have a Most common warts disappear spontaneously over
raised firm appearance with a rough surface. Plantar time. Products containing salicylic acid can be useful
warts found on the soles of the feet have a flattened in removing dead skin cells but this can take weeks.
appearance. They can also present as brown papules Cryotherapy where the wart is frozen is an option for
with small black dots. treating more severe cases.
Molluscum Small clusters of papules appear in moist places such No specific treatment. Avoid close contact with the
contagiosum as armpits and the groin. These smooth, dome-shaped infected person unless areas are covered. Avoid
lesions could be pale pink, white or brown. sharing towels and clothing.

46 august 28 :: vol 27 no 52 :: 2013 © NURSING STANDARD / RCN PUBLISHING

Downloaded from RCNi.com by ${individualUser.displayName} on Jul 22, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
contagious. Unlike the herpes virus, the virus does and symptoms at an early stage to prevent the
not lay dormant. once the papules are gone, the virus spreading, even though early identification
virus is also gone and it can no longer be spread may not prevent the virus from taking its course.
(cDc 2011). treatments can be useful in controlling the
like many of the other viruses, molluscum symptoms and reducing the spread, but they
contagiosum is best managed by letting it run its do not necessarily reduce the risk of re-infection
course, although this may take several months. in the long term. education for healthcare
A cochrane review by van der Wouden et al professionals and the public is important to
(2009) did not endorse any specific treatments. understand how these viruses are transmitted
it is important to make sure that all affected areas and how best to prevent their spread NS
are covered when in close contact with other
people, and the area can be uncovered when the
risk of spread is reduced. Sharing of towels and GLOSSARY
clothing should be avoided. An overview of the
Blister A localised swelling of the skin beneath the epidermis that
conditions is provided in table 1. contains watery fluid. It can be caused by friction, burns and
diseases of the skin.

Conclusion Macule A discoloured spot that is not raised above the surface of the
skin. It is usually less than 1cm in diameter and has a flat surface
viral infections of the skin can cause pain and with no changes in skin texture.
distress for those affected, and for many following
Papule A solid, rounded, usually inflammatory elevation of the skin,
initial presentation, the virus can re-present typically less than 1cm in diameter. It does not contain pus.
at any time when a person’s immune system is
Vesicle A small elevated area of skin containing serous fluid.
vulnerable. it is important to identify the signs

References
Allen H (2012) Aciclovir. www. Prevention (2012) Shingles (Herpes Knott L (2011) Herpes Simplex Oral. Salvaggio MR, Lutwick LI,
patient.co.uk/medicine/Aciclovir.htm Zoster). www.cdc.gov/shingles/ tinyurl.com/lebrmpg (Last accessed: Seenivasan M, Kumar S (2012)
(Last accessed: August 9 2013.) hcp/clinical-overview.html (Last August 9 2013.) Herpes Simplex. tinyurl.com/lcx4lnn
accessed: August 9 2013.) (Last accessed: August 9 2013.)
Brannon H (2010) Cold Sores Kost RG, Straus SE (1996)
Information: Fever Blisters and Cold Cevasco NC, Tomecki KJ (2010) Postherpetic neuralgia: Sterling JC, Handfield-Jones S,
Sores. tinyurl.com/mn7swuq (Last Common Skin Infections. tinyurl. pathogenesis, treatment, and Hudson PM (2001) Guidelines for
accessed: August 9 2013.) com/kffczxo (Last accessed: prevention. New England Journal the management of cutaneous
August 9 2013.) of Medicine. 335, 1, 32-42. warts. British Journal of
British Association of Dermatologists Dermatology. 144, 1, 4-11.
(2011a) Eczema Herpeticum. www. DermNet NZ (2013) Herpes Simplex. MedlinePlus (2013) Genital Herpes.
bad.org.uk/site/1466/Default.aspx www.dermnet.org.nz/viral/ tinyurl.com/84hu7jl (Last accessed: Subramanian RP, Geraghty RJ
(Last accessed: August 9 2013.) herpes-simplex.html (Last accessed: August 9 2013.) (2007) Herpes simplex virus
August 9 2013.) type 1 mediates fusion through
British Association of Dermatologists National Institute for Health and a hemifusion intermediate by
(2011b) Cryotherapy. www.bad. Family Planning Association (2013) Care Excellence (2009) Warts and sequential activity of glycoproteins
org.uk/site/1192/default.aspx (Last Genital Herpes. tinyurl.com/ldewuj7 Verrucae. tinyurl.com/ku7d86k D, H, L and B. Proceedings of the
accessed: August 9 2013.) (Last accessed: August 9 2013.) (Last accessed: August 9 2013.) National Academy of Sciences of
the USA. 104, 8, 2903-2908.
Buxton PK, Morris-Jones R (Eds) Ichihashi M, Nagai H, Matsunaga K NHS Choices (2012) Warts and
(2009) ABC of Dermatology. Fifth (2004) Sunlight is an important Verrucas – Treatment. tinyurl. Tidy C (2013) Shingles (Herpes
edition. BMJ Publishing Group Ltd, causative factor of recurrent com/mxotyaz (Last accessed: Zoster). tinyurl.com/lp8qs5n
London. herpes simplex. Cutis. 74, August 9 2013.) (Last accessed: August 9 2013.)
Suppl 5, 14-18.
Centers for Disease Control and Pickering D (2012) Dictionary of van der Wouden JC, van der
Prevention (2011) Molluscum Kaintz JT, Kozel G, Haidvogl M, Superstitions. Cassell, London. Sande R, van Suijlekom-Smit LW,
(Molluscum Contagiosum). www. Smolle J (1996) Homoeopathic Berger M, Butler CC, Koning S
cdc.gov/ncidod/dvrd/molluscum versus placebo therapy of children Primary Care Dermatology (2009) Interventions for
(Last accessed: August 9 2013.) with warts on the hands: a Society (2013) Warts. tinyurl.com/ cutaneous molluscum contagiosum.
randomized, double-blind clinical mvb5ugl (Last accessed: Cochrane Database of Systematic
Centers for Disease Control and trial. Dermatology. 193, 4, 318-320. August 9 2013.) Reviews. Issue 4, CD004767.

©Downloaded
NURSING from
STANDARD / RCN PUBLISHING august 28 :: vol 27 no 52 :: 2013 47
RCNi.com by ${individualUser.displayName} on Jul 22, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.