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
Viral infections of the skin can cause significant distress and
embarrassment for people who are affected. This article explores four
specific viral infections that manifest on the skin: herpes simplex, herpes
zoster, viral warts and molluscum contagiosum. It describes the
presentation and appearance of the virus as it affects the skin and what
can be done to minimise the spread of the virus. Management options are
considered, although many of these conditions are self-limiting.

Author
Heather Newton
Consultant nurse tissue viability, Dermatology Unit, Royal Cornwall
Hospital Trust, Truro.
Correspondence to: heather.newton@rcht.cornwall.nhs.uk

Keywords
Dermatology, herpes simplex, herpes zoster, molluscum
contagiosum, viral infection, viral warts

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A viral infection is an infection caused by

the presence of a virus in the body. Depending on the
type of virus and a persons state of health, viruses
can infect almost any type of tissue and therefore can
involve different parts of the body. Most viruses can
be fought by the bodys immune system; however,
in the most vulnerable groups, such as older people
and immunocompromised patients, the risk of
contracting viral infections increases and they have
the potential to be more severe.
Many viral infections are self-limiting and often
require no specific treatments to aid recovery.
However, the signs and symptoms that present

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on the skin can be unpleasant and treatments are

often given to reduce the effects of the virus.
This article explores common viral infections
that affect the skin: herpes simplex, herpes zoster,
viral warts and molluscum contagiosum.
It describes how viruses affect the skin, the
effects on patients and available treatment options.

Definition of a virus
A virus is an infective parasitic microorganism
that can only replicate within a living host. Viruses
invade living cells and use their energy and raw
materials to live and multiply. The core of the virus
contains either deoxyribonucleic acid (DNA) or
ribonucleic acid (RNA), and is surrounded by a
protective coat of antigenic protein. Although
viruses can be treated with antiviral agents, there
is a reliance on the bodys defence mechanisms to
control the spread and subsequent effects of viruses.

Herpes simplex
Herpes simplex virus (HSV) lives in a dormant
state within the sensory nerves of the skin. There
are two types of HSV: type 1 (HSV-1), which is
commonly known as the cold sore virus, and
type 2 (HSV-2), which is the usual cause of genital
herpes (Buxton and Morris-Jones 2009).
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
lower socioeconomic status will test positive for the
virus (Salvaggio et al 2012). Cevasco and Tomecki
(2010) suggested that 85% of the global population
has antibody evidence of HSV-1 infection.
The initial infection from HSV-1 usually occurs
in infants and young children through direct
contact on mucosal surfaces or on sites of skin
damage following minor injury, when the virus is
inoculated into the skin. The source of the virus
may be elsewhere on the body, and this occurs
especially in children who bite their nails or suck
their thumbs (DermNet NZ 2013). Once infected,
the virus stays in the body for life and there is no
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cure. For many people the virus is never triggered
and remains dormant; however, following
initial presentation it can reappear at any time
throughout a persons life.
The initial entry of the HSV into a host cell
involves the interaction of several glycoproteins,
which contain oligosaccharide chains that are
present on the surface of the virus, with receptors
on the surface of the host cell. Complementary
receptors bring the viral and the host cell
membranes into close proximity so that the two cell
membranes can merge. An entry pore is then formed
through which the viral envelope contents are
introduced to the host cell. This is then transported
to the cell nucleus where the viral capsule ejects its
DNA contents (Subramanian and Geraghty 2007).
Initially, the virus can be triggered by fatigue,
injury to the affected area and menstruation
in women (Ichihashi et al 2004). It can then be
reactivated by colds and influenza, a flare in
eczema, emotional and physical stress, gastric
upsets, fatigue, injury, menstruation and, in some
cases, exposure to bright sunlight (Ichihashi
et al 2004). If a persons immune system is
compromised viral episodes can occur more
frequently (Ichihashi et al 2004).
In both types of HSV, when the virus is activated it
spreads down the nerve pathways and on to the skin
or mucous membranes. At this stage it multiplies,
causing itchy painful blisters. HSV-1 appears as a
single or cluster of fluid-filled blisters that eventually
form a crust and then scab over. Occasionally, they
can look like tiny red spots that do not blister but
are itchy and painful. The lesions form mostly on
the lips, however, they can be found on the nose,
cheeks and chin (Knott 2011). It can take more than
14 days for the lesions to heal completely. When the
virus is active, it is highly contagious and is spread
to other people through direct contact. After each
exacerbation the virus travels back up the nerve fibre
and lies dormant again.
Where a person is predisposed to an atopic
eczematous condition, herpetic lesions can become
more widespread and severe. This condition is
known as eczema herpeticum and patients can
become systemically unwell, with some requiring
hospitalisation if the skin becomes severely affected.
HSV-2 is usually sexually transmitted, especially
in young adults, and is spread by direct contact
with an infected person through broken skin
or intact mucous membranes. Cevasco and
Tomecki (2010) suggested that HSV-2 infection
is responsible for 20-50% of genital ulceration in
sexually active people. Mothers can also infect
their infants during childbirth.
HSV-2 can produce blisters on the genital or
rectal area, buttocks and thighs, which can be
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itchy and painful (MedlinePlus 2013). They appear

seven to ten days after exposure and primary
infection presents like an erosive dermatitis on the
external genitalia. They can also appear on the tip
or the shaft of the penis, on the foreskin and/or
pubic area in men. In women, they are commonly
found on the genital area around the vagina and
the perineum. Those affected may feel unwell with
influenza-like symptoms, have swollen glands,
especially in the groin, and experience pains in
the back of the legs a few days before the lesions
appear. In addition, they can experience many
outbreaks during the year, with recurrence seen
in approximately 40% of those affected. As with
HSV-1 there is no cure.
Treatment of HSV-1 usually consists of the
application of topical aciclovir, which is a potent
inhibitor of herpes virus DNA and therefore
prevents replication of the virus. It reduces the
spread of the virus and works by preventing the
herpes virus from multiplying (Allen 2012). Topical
treatments can be useful in primary infection if
started at the first indication of symptoms such as
tingling in the area; however, they will only shorten
the duration of illness by a day or so (Buxton
and Morris-Jones 2009). In recurrent cases, oral
aciclovir may be considered, and the earlier the
treatment commences the shorter the duration of
the symptoms (Brannon 2010). Oral or intravenous
treatment is also required for more severe cutaneous
manifestations such as eczema herpeticum (British
Association of Dermatologists (BAD) 2011a).
In HSV-2 infections, treatment is recommended
at the first outbreak. Oral antiviral tablets such as
aciclovir are prescribed five times a day for at least
five days, or longer if the patient is still developing
new blisters (Family Planning Association 2013).
For patients with recurrent infections, suppression
therapy with antiviral agents taken daily for a
longer period may be required (Family Planning
Association 2013). The use of condoms should
be encouraged to protect partners against spread
of the virus, although they do not provide total
protection. People who have genital herpes are
deemed to be more at risk of infection with human
immunodeficiency virus (HIV) as the breaks in the
skin can increase the risk of HIV entering the body
during sexual contact.

Herpes zoster
Herpes zoster is predominantly a skin and
neurological disorder that is caused by the varicella
zoster virus. Herpes zoster is also known as shingles,
whereas the varicella virus is commonly known
as chickenpox and is identical in its morphology
to the varicella zoster virus. Herpes zoster is an

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acute infection caused by reactivation of the latent

varicella zoster virus. If a person has had no previous
exposure to varicella, for example as frequently
occurs with children, they will develop chickenpox.
Those who have had exposure and subsequently
developed circulating varicella antibodies can
develop a localised reaction known as shingles
if their immune system is compromised. During
systemic chickenpox infections, the virus is seeded
to nerve cells and, like herpes simplex, can remain
dormant for many years.
Herpes zoster presents as a rash containing
macules and papules. They then progress into
vesicles that erupt, release their contents, ulcerate
and eventually form a crust. Herpes zoster is
characterised by its distribution as it often follows
a single nerve pathway, commonly affecting the
trunk, although the face, neck and lumbosacral
areas can also be affected. Some people experience
unusual skin sensations along the nerve pathway
days or weeks before onset of the rash (Centers
for Disease Control and Prevention (CDC)
2012). During the acute phase, those affected are
infective to others and therefore should avoid any
contact with vulnerable people, including older
people, those who are immunocompromised,
pregnant women and people who have not
previously had chickenpox.
Herpes zoster can occur at any age, but it
is more common in older people. A persons
risk increases sharply after 50 years of age and
approximately 50% of people who live to 85 years
will have experienced an episode of herpes zoster
(CDC 2012). The rash can last for seven to ten days
but complete healing can take up to four weeks.
In younger people herpes zoster can resolve
without problems. However, it can cause
significant localised pain, general malaise,
headache, myalgia and fever (Tidy 2013).
Secondary bacterial infection of the area can
occur, as can episodes of pain in the affected
area after clearance of the rash. This is known as
postherpetic neuralgia (Buxton and Morris-Jones
2009). Pain lasting more than 12 months has been
described in nearly 50% of patients older than
70 years (Kost and Straus 1996).
Treatment with oral aciclovir is best
started within 72 hours of the rash appearing
(Tidy 2013), especially in those who are
immunocompromised, are older, or have a
widespread rash and have moderate-to-severe
pain. It is important to ensure that the skin is
kept clean and dry because this reduces the risk
of secondary infection. The area should be kept
covered where possible but if not, contact with
others should be avoided until the lesions are dry
and crusty to avoid the small risk of infection.

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Although difficult, it is important not to scratch

the affected areas because this increases the risk
of developing a secondary infection.

Viral warts
Many years ago, when people knew very little
about viruses, many folk beliefs arose to try to
explain the appearance of warts in healthy people,
especially children. It was claimed that warty
lesions would appear if you handled a toad or
washed your hands in water that had been used to
boil an egg. Cures for warts were even stranger.
It was claimed that rubbing warts with bean
pods or the bark of an elder tree had curative
properties. Another suggested cure was to rub a
piece of beef over the wart and then bury it in the
garden. This was linked to the notion that as the
meat rotted in the ground so the wart would rot
away (Pickering 2012).
Warts are now known to be caused by localised
infections with the human papilloma virus
(HPV), and there are more than 100 different
types of HPV (National Institute for Health
and Care Excellence 2009). Most people will be
infected with HPV at some stage in their life, and
prevalence figures in the UK range from 3.9-4.9%
(Sterling et al 2001). There are marked regional
differences in wart prevalence, with higher rates
in the north than in the south of England (Sterling
et al 2001).
Warts are most common in children and are
spread by direct and indirect contact. Damage to
the epithelial skin layer greatly increases the risk of
inoculation with HPV. Skin abrasions from rough
surfaces in swimming pools can also increase the
risk of acquiring plantar warts (verrucas). In people
who bite their nails periungual warts can develop,
and warts can be spread across the beard area when
shaving. They are contagious and close skin to skin
contact can pass on infection (NHS Choices 2012).
The incubation period can range from a few weeks
up to 12 months.
Warts can present in different ways depending
on the site of infection. Plantar warts occur on
pressure-bearing areas such as the soles of the
feet and have a flattened appearance. They can be
confused with callous formation or corns. Common
warts are mostly found on the hands and can have a
raised firm appearance with a rough surface. They
can also appear as brown coloured papules with
black pinpoint dots on the surface. This appearance
is caused by thrombosed capillary blood vessels.
Warts can disappear spontaneously after weeks,
especially in children. Even without treatment
50% of warts disappear within six months,
with 65-78% disappearing within two years
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(Kaintz et al 1996). However, in adults it can
take longer for the body to develop cell-mediated
immunity and for the warts to disappear.
There is a range of measures that can be
implemented to limit the spread of viral warts.
Where possible the wart should be covered,
especially when swimming or sharing communal
areas where skin is exposed. A personal towel
should be used for the duration of the wart and
shoes and socks should not be shared. Socks
should be changed daily and feet kept dry as much
as possible. It is advisable to wear waterproof shoes
when in a swimming pool.
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
causing a problem, then no specific treatments are
advised as the majority will resolve spontaneously.
However, for some people they are seen as unsightly
and embarrassing and topical treatment is often
considered. Occlusion with duct tape is a simple
option. The affected area should be covered with
the tape for six days and then on removal of the
tape the area should be soaked in warm water for
five minutes and pared down. The wart should
then be left uncovered overnight and a new piece
of duct tape applied the following morning. It is
recommended that this process is repeated until
the wart disappears (Primary Care Dermatology
Society 2013).

Products containing salicylic acid work by

slowly destroying the virus-infected epidermis
(Sterling et al 2001) but can take many weeks
to clear. The warty area should be softened first
and the dry skin surface rubbed to remove any
loose skin. The paint is applied topically and then
covered with a plaster. This should be repeated on
a daily basis.
Cryotherapy, where the wart is frozen
repeatedly with liquid nitrogen, is another option
for more severe cases; however, this treatment can
cause discomfort, swelling, redness and blistering
(BAD 2011b).

Molluscum contagiosum
Molluscum contagiosum is an infectious viral
disease of the skin that is caused by the pox virus
and, like many of the viruses, it is common in
children. Pox viruses are large DNA viruses that
favour the epidermis.
Molluscum contagiosum presents as small
clusters of papules that appear in moist places such
as in the groin, armpits and behind the knees. They
are smooth and dome-shaped and can be pale
pink, white or brown in colour. They range in size
from 1mm to 5mm in diameter (CDC 2011). The
virus is spread by direct contact, especially in moist
areas such as communal showers and swimming
pools. However, despite its name it is not highly

TABLE 1
Overview of viral skin conditions
Viral condition

Clinical features

Treatment options

Herpes simplex
virus (HSV)-1
(cold sores)

Single or cluster of fluid-filled blisters often found on

the lips but can occur on the nose, chin and cheeks.
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.

Topical aciclovir application. Best applied when the

area starts to tingle.

HSV-2
(genital herpes)

Blisters appear in the genital area of men and women,

usually around the surface of the vagina or perineum
in women and the shaft and tip of the penis in men.
Influenza-like symptoms and swollen glands may also
accompany the blistering.

Oral aciclovir administered five times a day for at

least five days. For recurrent infections of more than
six in any one year, suppression therapy taken daily is
required for 6-12 months.

Herpes zoster

A macular, papular rash that often follows a single

nerve distribution. Vesicles form that ulcerate and
present as dry crusty lesions. The affected area is
often very painful.

In younger people the condition resolves itself;

however, oral aciclovir is recommended for those who
are immunocompromised, are older, have a widespread
rash and have moderate-to-severe pain.

Viral warts

Common warts are found on the hands and have a

raised firm appearance with a rough surface. Plantar
warts found on the soles of the feet have a flattened
appearance. They can also present as brown papules
with small black dots.

Most common warts disappear spontaneously over

time. Products containing salicylic acid can be useful
in removing dead skin cells but this can take weeks.
Cryotherapy where the wart is frozen is an option for
treating more severe cases.

Molluscum
contagiosum

Small clusters of papules appear in moist places such

as armpits and the groin. These smooth, dome-shaped
lesions could be pale pink, white or brown.

No specific treatment. Avoid close contact with the

infected person unless areas are covered. Avoid
sharing towels and clothing.

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contagious. Unlike the herpes virus, the virus does

not lay dormant. Once the papules are gone, the
virus is also gone and it can no longer be spread
(CDC 2011).
Like many of the other viruses, molluscum
contagiosum is best managed by letting it run its
course, although this may take several months.
A Cochrane review by van der Wouden et al
(2009) did not endorse any specific treatments.
It is important to make sure that all affected areas
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
clothing should be avoided. An overview of the
conditions is provided in Table 1.

Conclusion
Viral infections of the skin can cause pain and
distress for those affected, and for many following
initial presentation, the virus can re-present
at any time when a persons immune system is
vulnerable. It is important to identify the signs

and symptoms at an early stage to prevent the

virus spreading, even though early identification
may not prevent the virus from taking its course.
Treatments can be useful in controlling the
symptoms and reducing the spread, but they
do not necessarily reduce the risk of re-infection
in the long term. Education for healthcare
professionals and the public is important to
understand how these viruses are transmitted
and how best to prevent their spread NS

GLOSSARY
Blister A
 localised swelling of the skin beneath the epidermis that
contains watery fluid. It can be caused by friction, burns and
diseases of the skin.
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
with no changes in skin texture.
Papule A
 solid, rounded, usually inflammatory elevation of the skin,
typically less than 1cm in diameter. It does not contain pus.
Vesicle A small elevated area of skin containing serous fluid.

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