Many viruses like herpes simplex, chicken pox, measles, and now COVID-19, have prominent cutaneous physical findings.
Measles is a virus that is on the rise again in the United States because of decreased adherence to vaccination programs. Measles is spread by respiratory droplets and has a long incubation period of 10-12 days. Fever, conjunctivitis and malaise begin before the rash. The skin manifestations are red blotchy patches that typically start on the face around the ears, cheeks and neck then spread to involve the body. One key feature is called Koplik’s spots — tiny blue white dots inside the mouth.
Erythema infectiosum (Fifth disease)
One of the easiest viral rashes to identify is Erythema Infectiosum (Fifth Disease). It is caused by human parvovirus B19. After about the 10th day of asymptomatic infection, there is a mild fever, malaise and headache. The rash begins a few days later with a strikingly red raised patches over the cheeks (likened to slapped cheeks). It is followed by red patches over the buttocks, arms and legs. Adults have more symptoms like fever and not feeling well. When in doubt, antibody testing is very reliable. IgM, the initial antibodies, help me to confirm the case and last only a few months. Long term antibodies are the IgG and can last a lifetime.
Chicken Pox (Varicella) is caused by the same virus as Shingles (Herpes Zoster), a herpes virus (DNA virus) also spread by respiratory droplets. Interestingly the incubation period can be as long as 23 days for chicken pox. Again fever and malaise for a few days followed by crops of blisters predominately on the face and scalp. The rash is very itchy. Chicken pox can cause lots of complications like encephalitis and varicella pneumonia.
The second stage of chicken pox typically presents in adulthood, although children can get it also. There is no convincing evidence that shingles can be contracted from another individual. The virus is an opportunist and reactivates when an individual is immunosuppressed, or when a purely personal event allows the virus to resurrect. Most of you are aware that shingles follows one side of the body and corresponds to a dermatome (skin surface along a nerve branch). Shingles can be mild or extremely painful with complications like facial palsy, involvement of the eye and postherpetic long-lasting pain.
Herpes simplex, warts and molluscum contagiosum are other viral diseases of the skin. There are numerous others.
The most recent health care crisis with COVID-19 has brought us a variety of skin presentations. Reports are now storming the medical journals with skin rashes from COVID-19. Early reports suggest about 20% of patients have skin findings including generalized hives, small bruise-like rashes, frostbite-like changes in the fingers and toes and a red lacelike rash known by dermatologists as “livedo reticularis.”
Rashes start at the onset of COVID-19 symptoms or shortly thereafter. The rashes most commonly affect the trunk with itch that was mild or absent and resolved after a few days. The earliest reports of frostbite or purple fingers and toes were most commonly seen in those who were critically ill. Now, the dermatologic registry is expanding and most COVID toes are reported in younger patients, 20-30, who are recovering.
I have not encountered skin findings of COVID-19 as of yet with any of my patients.
I hope and pray that one of the good things that comes out of this crisis is that more and more people will realize the necessity of vaccination to prevent the spread of disease in the community. More than ever, I have encountered parents who refuse to vaccinate their children because they believed propaganda that vaccines are pushed on us for big pharma to make profits. Now there are concerns that vaccination rates are dropping further as more kids are missing vaccines due to the pandemic.
One of my earliest childhood memories is receiving the polio vaccine as a child with all of my family. A heartfelt thanks to Jonas Salk, the physician that ended the terror of polio by developing the polio vaccine released on April 12, 1955. He was a viral expert recruited by my undergraduate alma mater, the University of Pittsburgh. I attended pharmacy school classes in Salk Hall.
I have a very strong feeling about the importance of vaccination and I hope that this latest pandemic will help more people realize we need to vaccinate to prevent disease.