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400 Chapter 9: Dermatology and soft tissues

Table 9.8 Patterns of leprosy
Type Skin Lesions Nerve Involvement
Tuberculoid (TT) Single hypopigmented erythematous macule with a The nerve supplying the patch is thickened
well-defined, raised margin and central healing with loss of sensation and muscle atrophy
Borderline Skin lesions as for tuberculoid but multiple, smaller Peripheral nerves are thickened causing
tuberculoid (BT) lesions deformity of hands and feet.
Borderline (BB) Skin lesions are numerous, vary in size characteristic Widespread nerve involvement causing
annular rimmed, punched out lesion deformity of limbs
Borderline Large number of florid variable asymmetrical skin
lepromatous (BL) lesions
Lepromatous (LL) Erythematous macules, papules and/or nodules, or Glove and stocking neuropathy
occasionally diffuse disease without distinct lesions.
Infiltration at ear lobes and face results in typical
leonine facies

characterised by erythema and oedema of skin lesions, HSVtype1isusuallythecauseofperiorallesions,ocu-
accompanied by neuritis. lar infections, non-genital skin lesions and encephali-
Erythema nodosum leprosum (lepra type II) is a type tis. It spreads by direct contact with oral secretions

III hypersensitivity reaction seen in boderline and lep- and via droplet spread; infection is very common and
romatous leprosy. It is characterised by fever and mul- most individuals are seropositive by adult life. Genital
tiple erythematous tender nodules. infections may occur due to orogenital contact. Im-
munocompromised patients are at particular risk for
recurrent and disseminated infection.
Investigations
HSV type 2 is transmitted by direct contact; it usu-
The diagnosis is clinical but can be confirmed with
ally causes genital herpes and is therefore a sexually
demonstration of acid-fast bacilli in skin scrapings. PCR
transmitted disease.
can be used.
Afterprimary infection, the latent non-replicating virus
resides within the dorsal root ganglion, shielding the
Management
virus from the immune system. Reactivation may follow
Patients are treated with dapsone and rifampicin. Clo-
exposure to sunlight, fever, trauma or emotional stress.
fazimine is added in BB, BL and LL types. Patients may
require surgery and physiotherapy for deformities. Re-
versal reaction is treated with prednisolone. Erythema
nodosum leprosum is treated with analgesia, chloro- Clinical features
HSV type 1 primary infection usually occurs during
quine, clofazimine and antipyretics (thalidomide has
childhood and is often asymptomatic. Symptomatic
also been used).
infection usually manifests as acute gingivostomati-
tis with vesicles on the lips and painful ulcers within
Viral skin infections the mouth accompanied by fever and malaise. Local
herpes inoculation into a site of injury may present
Herpes simplex as a herpetic whitlow–a painful vesicle or pustule on
a digit. Ocular infections and encephalitis (see page
Definition
304) may occur with or without kin lesions.
Herpessimplexvirus(HSV)cancauseavarietyofclinical HSV type 2 primary infection is often asymptomatic,
presentations.
but may cause acute vulvovaginitis, penile or perianal
lesions.
Aetiology/pathophysiology Latent infection occurs and recurrence is often her-
There are two subtypes: alded by a burning or tingling sensation. It usually