3 MARCH 2006
Viral Exanthems - Why are They Good Choices for Research by Family Physicians?
Dr. Antonio AT Chuh
MD(HK) FRCP(Irel) FHKCFP FHKAM(Fam Med)
Family physician in private practice, Part-time Associate Professor, Department of Community and Family Medicine, The Chinese University of Hong Kong Honorary Clinical Assistant Professor, Family Medicine Unit, Department of Medicine, The University of Hong Kong
Abstract
Family physicians are well placed to study viral exanthems because they see patients at an early stage of the eruption, and can obtain early virological evidence. Several exanthems are under-reported and underinvestigated in China and in Asia. Such provides good opportunities for clinical research. Epidemiological data are less biased in primary care than in secondary care settings. Family physicians are also interested in the entire illness instead of the disease only, and can thus evaluate impacts of management in a comprehensive and evidence-based manner. Contrary to common belief, several exanthems of multiple or unknown viral aetiologies such as Gianotti-Crosti syndrome and pityriasis rosea are common conditions. These rashes might appear to be uncommon merely because of under-diagnosis and under-reporting.
Background
Viral exanthems are skin eruptions occurring as symptoms of acute viral diseases.1 Exanthem comes from the Greek word exanthema, meaning breaking out, and anthos, denoting blossoming flowers. We shall discuss in this article why viral exanthems matter much to family physicians, and why family physicians are well placed to investigate them. We shall also describe future challenges in researching viral exanthems.
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Medical Bulletin
and Canada.18 It is likely to be endemic in parts of Europe (Taieb - personal communication). To our best knowledge, the occurrence of this exanthem in Asia has not been reported in indexed journals. We reported the first patient with asymmetric periflexural exanthem in Asia.19, 20 We shall also report the first patients with a novel variant of asymmetric periflexural exanthem in the world, which we term unilateral mediothoracic exanthem.21
demonstrated that the effects on the quality of life are independent of rash severity in adult patients with pityriasis rosea.33 The implication of this finding is that active intervention might be unnecessary even for some patients with diffuse eruptions. We also documented that effects on the quality of life are minimal for children with pityriasis rosea,34 and that active treatment is unnecessary for most children with this exanthem.
4. Family physicians care for the person, not only the disease
While some specialists might concentrate their efforts on the disease, family physicians have a heart for the patient and the illness as well. We are concerned about the impacts of exanthems on the quality life of patients, and whether schooling and work of patients are affected. We are therefore disheartened to find that major treatment trials on pityriasis rosea, for example, do not include quality of life as one of the outcome measures.29-32 Even pruritus, the major symptom in pityriasis rosea, was not investigated in some of the studies. 29, 30 These investigators only measured how the rash severity and extensiveness were modified by medications. Many of the patients could have no or little pruritus, and the face and distal aspects of extremities are uncommonly affected in this exanthem. These patients might not warrant active intervention in the first place. Recognising this gap in knowledge, we investigated and
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and further search for the roles of other viruses might shed light on the management strategies.42 The roles of atopy and hyperimmunoglobulinaemia E states in viral exanthems,43 and conversely, the role of early viral infections in atopic states44 warrant further investigations. Further studies should be performed to establish the validity and reliability of diagnostic criteria for several exanthems.45-47 The treatment of the exanthems are at present largely empirical. Clinical trials and systematic reviews48 would rationalise patient management. There lies rough water ahead, and we are acutely aware of our limitations such as constraints in time and resources. We also lack the clinical expertise possessed by our specialist colleagues. Dedication, commitment and perseverance might overcome some, but not all, of our hindrances. The rest will have to depend on support from specialist colleagues and the development of a sustainable infrastructure in family medicine research deliberated in the Editorial of this issue.
28. 29.
Acknowledgements
An article based on part of this manuscript was selected in the 14th Congress of the European Academy of Dermatology and Venereology, 2005, London, as "One of the Most Worth Reading Papers in Medical Dermatology of the Year". Part of this manuscript was presented in the Joint Research Meeting of Family Medicine Units of The Chinese University of Hong Kong and The University of Hong Kong, 2005.
30. 31.
32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.
References
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