Verrucous and papillary conditions

• Macules


  Small flat area of altered colour or texture
• Patch


  Large flat area of altered colour or texture
• Papule


  Solid and raised lesion smaller than 1 cm
• Plaque


  Solid and raised lesion larger than 1 cm (large papules)
• Fissure


  Linear cut in the epithelium
• Erosion


  Moist red lesion due to loss of the superficial epithelium
• Ulcer


  Circumscribed depressed lesion over which the epithelium is lost
• Nodule


  Lesion deep in submucosa, over-which the epithelium can be easily moved
• Exophytic


  Growing upwards
• Endophytic


  Growing downwards
• Vesicle


  Elevated blister containing clear fluid that is under 1 cm in diameter
• Bullous


  Elevated blister containing clear fluid that is greater than 1 cm in diameter
• Pustule


  Elevated lesion containing purulent material
• History elements


  • Onset of the lesion
  • Duration
  • Progression
  • Single or multiple
  • Acute or chronic
  • Pain
  • Other systems involved; skin, eye, genitalia
  • Family history
  • Drug history
  • Social history
• Vesciulo-bullous Diseases


  • Viral infection
  • Immune-mediated
  • Hereditary
• Viral infections


  • Herpes viruses
  • Coxsackie viruses
  • Paramyxoviruses
• Human Herpes Viruses (HHV)

  80 types of Herpes viruses, 8 types infect humans, six of those infect the head and neck area
• Human Herpes Viruses (HHV)


  • HSV-1
  • HSV-2
  • VZV
  • EBV
  • CMV
  • HHV-6
  • HHV-7
  • HHV-8
• Herpes Simplex Virus (HSV-1)

  Primary infection is self-limited, virus then migrates to the trigeminal ganglion where it remains latent, reactivation follows trauma, UV light, cold, stress, immune-suppression, and is usually localized
• Herpes Simplex Virus (HSV-1) primary infection

  • Eruption of small vesicles on any oral mucosal surface, including the gingivae (gingivostomatitis), wide spread and associated with clinical signs and symptoms, symptoms last for 7-10 days
• Herpes Simplex Virus (HSV-1) secondary (recurrent) infection


  • Also called Herpes Labialis (usually affect the vermillion zone), occurs when the immune system is altered unfavorably, occurs in 40% of sero-positive persons, prodromal symptoms followed by vesicles that rupture and coalesce leaving an irregular ulcer, which heals in 1-2 weeks
• Intra-oral Herpes Simplex

  • Usually affects the hard palate, does not cross the midline, follows the same phases as other HSV-1 infections, pain is variable
• Herpetic whitlow

  Direct contact to the skin, used to be seen in dental practitioners, prior to the use of examination gloves, causes severe pain, swelling and vesicular eruptions in the affected finger

  
• Herpes Simplex Virus (HSV-2)

  • Predilection to genital mucosa, but might also infect oral mucosa following oro-genital contact, latency occurs when HSV 2 travels to the lambo-sacral ganglion, clinically and histologically indistinguishable from HSV-1
• Histopathology of herpes infections
• Treatment of herpes infections

  Supportive therapy for primary infection, Acyclovir for treating severe systemic infections, or to reduce the duration of the recurrent infections, Acyclovir activated by thymidine kinase (produced by herpes viruses), therefore it inhibits DNA polymerase in infected cells and not in healthy cells, Topical: 5% Acyclovir 5 times/day, Systemic: 200-400 mg 5 times per day (immune compromised), should be used as early as possible
• Acyclovir

  Antiviral agent that is active against HSV 1 and 2, and to lesser extent VZV, needs to be phosphorylated in order to become active
• Acyclovir

  • It is well tolerated on the lips, but application to the mucosa causes irritation, adverse effects include; dryness, burning and stinging, pregnancy class B
• Varicella-Zoster virus (VZV)
• Varicella (chickenpox) infection

  • Childhood disease, associated with systemic signs and symptoms, rash progresses from vesicles to pustules to ulcers, self limiting, lasts for few weeks, pruritic
• Zoster (shingles) infection


  • Elderly disease, affects the trunk and head & neck (latency in sensory ganglion or trigeminal nerve), prodromal symptoms followed by maculopapular rash that progresses to vesicular and pustular lesions, consequences include scar, post-herpetic neuralgia, infection, hyperpigmentation, paralysis
• Ramsay Hunt syndrome

  Herpes zoster oticus, if latency at cranial nerves VII and VIII
• Treatment of varicella and zoster

  Varicella: self limiting, Zoster: Acyclovir (800 mg five times / day), Systemic Corticosteroids are used, with or without antiviral drugs, for the treatment of Ramsay Hunt syndrome
• Hand Foot and Mouth disease

  • Caused by Coxsackie virus (A16 mainly), highly contagious, by airborne and oro-fecal routes, affects children, prodromal symptoms followed by oral lesions (vesicles to ulcers) and skin lesions (maculopapular rash to vesicles to ulcers), symptomatic treatment with bland mouthwash
• Herpangina


  • Caused by Coxsackie virus, transmitted by saliva and possibly oro-fecal routes, affects children, endemic and seasonal (summer and early autumn), vesicles (soft palate faucial pillers, tonsiles) to ulcers plus pharyngitis and sore throat, dysphagia, mild and short infection, symptomatic treatment
• Measles


  • Caused by Measles virus (Paramyxovirus family), airborne infection, affects children, seasonal (winter and spring), prodromal symptoms followed by Koplik's spots and then maculopapular rash, symptomatic treatment
• Vesciulo-bullous Diseases


  • Viral infection
  • Immune-mediated
  • Hereditary
  • Epidermolysis Bullosa
  • HSV
  • VZV
  • HFM
  • Herpangina
  • Measles
  • Pemphigus
  • Pemphigoid
  • Dermatitis Herpetiformis
  • Linear IgA Disease
• Coxsackie virus (A16 mainly)

  Highly contagious, by airborne and oro-fecal routes
• Coxsackie virus infection


  • Affects children
  • Prodromal symptoms, followed by:
  • Oral lesions: oral vesicles (anywhere) --> ulcers
  • Skin lesions: maculopapular rash (hands and feet) --> vesicles --> ulcers
  • Symptomatic
• Herpangina


  • Caused by Coxsackie virus
  • Transmitted by saliva and possibly oro-fecal routes
  • Affects children
  • Endemic and seasonal (summer and early autumn)
  • Vesicles (soft palate faucial pillers, tonsiles) --> ulcers + pharyngitis + sore throat, dysphagia
  • Mild and short infection
  • Treatment is symptomatic