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Microbiology and Immunology 59
DNA Viruses
Virus Disease DNA Envelope
Herpes- ds yes
Alpha
Simplex HSV-1 and 2
Varicella VZV (HSV-3)
Beta
CMV CMV (HSV-5)
Roseola HSV-6
Gamma
Lympho EBV (HSV-4)
Hepadna- HBV ds yes
Adeno- pharyngitis, ARD ds no
Papo- no
Papilloma- papilloma ds
Polyoma- BK, JC ss
Parvo- B-19 ss no
Pox- molluscum, orf ds yes
variola, vaccinia
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60 Pocket Guide for Cutaneous Medicine and Surgery
RNA Viruses
Virus Disease RNA Env
Toga- ss yes
Alpha- E/W/V encephalitis
Rubivi- rubella virus (German measles)
Corono- ss yes

Condyloma, flat 42
Epidermodysplasia verruciformis 5, 8–10, 12, 14, 15, 17,
19–29, 36, 47, 50
Genital papilloma 42
Giant condyloma accuminata of
Buschke and Lowenstein
6, 11
Laryngeal papilloma 6, 11, 16, 18
Laryngeal carcinoma 6, 11, 30, 40
Keratoacanthoma 36, 37
Malignant melanoma 38
Oral focal epithelial hyperplasia
(Heck’s disease)
13, 32
Stucco keratoses 9, 16, 23b
Verrucous carcinoma of the foot 2
Verruca, filiform 2
Verruca, mosaic (plantar) 2 (4, 60, 63, 65)
Verruca, palatal 2
Verruca, plana 3, 10, 28, 41, 49
Verruca, plantar/palmar/myrmecia 1
Verruca, vulgaris 2, 7
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62 Pocket Guide for Cutaneous Medicine and Surgery
Smallpox
Caused by variola (poxvirus)
Major Criteria:
r
Febrile prodrome 1–4 days before rash: fever ≥101

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Microbiology and Immunology 63
Complications of smallpox vaccination
r
eczema vaccinatum (seen with eczematous patients)
r
generalized vaccinia (children with IgM deficiency prone)
r
vaccinia necrosum (usually infants <6mowith immune
deficiency)
r
roseola vaccinia (symmetrical eruption macules, papules)
r
congenital vaccinia (following vaccination in pregnancy)
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64 Pocket Guide for Cutaneous Medicine and Surgery
Candida Antigen Therapy for Verrucae
r
0.1 ml Candida test Ag intradermal
r
assess reaction at 48 hour (positive >5 mm)
r
Candida antisera for injection (based on initial reaction):
induration (mm) injection (ml)
5–20 0.3
21–40 0.2
>40 0.1
Exclusion criteria:

area of normal skin on upper arm
overnight
r
patient may wash after 24 hour period
r
may re-sensitize in 7–10 days if needed
r
apply squaric acid to verruca after sensitized q 2 weeks
Exclusion criteria:
r
intolerance to squaric acid
r
pregnancy
r
chronic allergic contact dermatitis
r
systemic immunosuppression
Silverberg NB, Lim JK, Paller AS, Mancini AJ. Squaric acid immunotherapy
for warts in children. JAmAcad Dermatol 2000; 42: 803–808.
Lee AN, Mallory SB. Contact immunotherapy with squaric acid dibutylester
for the treatment of recalcitrant warts. JAmAcad Dermatol 1999; 41: 595–
599.
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66 Pocket Guide for Cutaneous Medicine and Surgery
Immunology
Naive T-cell
IL-12
IL-2
IL-2, IFN-gamma

C6-9
C3bBb3b
C3bBbC3b
C3
microbial surface
polysaccharides
factor B
classical C3 convertase
alternative C3 convertase
alternative C5 convertase
classical C5 convertase
factor D
C4b2a
C4b2a3ab
C1
r
classical pathway:
r
activated by IgG or IgM (Ag bound, not soluble)
r
IgM > IgG3 > IgG1 = IgG2 (IgG4 does not bind C1q)
r
alternative pathway: activated without Ab
r
MB lectin pathway: (structural similarity to C1q)
r
binds various pathogens: Candida, Listeria, Neisseria,
Cryptococcus, Salmonella
r
functions of complement proteins:

nl / ↑↓↓ nl/↓ nl ↓↓ ↓ nl
AAE
type 1
↓↓ ↓↓ ↓ ↓↓
AAE
type 2
nl / ↓↓↓ ↓↓↓↓↓↓↓↓nl
Legend: HAE (hereditary angioedema); AAE (acquired angioedema)
r
subcutaneous edema, upper respiratory/GI tract
involvement
r
no pruritus and no urticaria
r
screening test of choice is C4 (↓from continuous
consumption)
r
HAE type 1 – AD inheritance; ↓ production of normal
C1-INH
r
AAE type 1 associated with lymphoproliferative
diseases
r
AAE type 1 2
◦
anti-idiotypic Ab to monoclonal Ig
synthesized by B lymphocytes; treat with attentuated
androgens
71
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Telangiectasis dilated superficial blood vessel
Wheal irregular edematous plaque
Patch macule with texture change
Secondary Skin Lesions
Scale residual epidermal cells
Crust scab
Erosion focal loss of epidermis
Ulcer focal loss of epidermis and dermis
Fissure linear ulcer/erosion
Excoriation traumatized area (often linear)
(2
◦
scratching)
Lichenification thickening with accentuation of skin lines
(2
◦
rubbing)
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74 Pocket Guide for Cutaneous Medicine and Surgery
Nail Terminology
Onycholysis separation of distal nail plate from nail bed
Onychomadesis separation of entire nail plate beginning
proximally
Onychogryphosis overgrowth of nail (“ram’s horn”
appearance)
Onychocryptosis ingrown nail
Onychauxis thick nail
Onychoschizia splitting of nails into layers parallel to
surface

Blue nails: Wilson’s disease, argyria, AZT, HIV,
antimalarials, busulfan
Red lunulae: carbon monoxide, CV disease, lupus,
alopecia areata
Nail pitting: psoriasis vulgaris, alopecia areata
Psoriasis: nail pitting, oil spots, onycholysis
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76 Pocket Guide for Cutaneous Medicine and Surgery
Pediatric Dermatology
Rubeola (Measles)
r
paramyxovirus
r
8–12 days post-exposure (no signs)
r
prodrome: malaise, fever, cough, coryza, conjunctivitis;
Koplik spots in 2–3 days after onset of symptoms
r
erythematous maculopapular rash ∼5days after onset of
symptoms (cephalocaudal progression)
r
atypical measles (individual vaccinated with killed
vaccine)
Rubella (German measles)
r
rubella virus (RNA togavirus)
r
no prodrome during incubation (14–21 days)
r

spread via oropharyngeal secretion
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Clinical Pearls 77
Erythema infectiosum (Fifth’s disease)
r
parvovirus B-19 (ssDNA)
r
prodrome consists of fever, HA, pharyngitis, malaise
r
slapped cheek appearance
r
erythematous, reticulated, pruritic, macular rash
(arms → trunk, legs) (reticulated hyperpigmentation)
r
aplastic crisis in patients with hemoglobinopathies
r
acute arthropathy in adults (and papular gloves and
stockings)
r
risk of hydrops fetalis and spontaneous abortion
Hand-foot-mouth disease
r
coxsackie A16 virus; enterovirus 71
r
prodrome of fever, anorexia, oral pain followed by oral
mucosal ulcers and erythematous patches and vesicles on
hands, feet, and buttocks
Varicella Zoster Virus (VZV)
r

acral/perineal erythema/desquamation
r
cervical nonsuppurative lymphadenopathy
r
edema/desquamation of hands and feet
r
conjunctivitis
r
strawberry tongue
r
3 phases:
r
acute: lasts 1–2 weeks
r
subacute: begins when fever, rash, LAD resolve;
marked by desquamation and thrombocytosis;
risk of arthritis, coronary aneurysms
r
convalescent: 6–8 weeks after onset; ESR normal
r
treat with aspirin and IVIG
Scarlet fever
r
usually associated with streptococcal pharyngitis
r
erythrogenic toxins B and C most commonly seen
r
highest incidence in children 2–10 (can occur in adults)
r
fever, malaise, pharyngitis → exanthem 48

Requires 4 of 11 for diagnosis:
Malar erythema (tends to spare nasolabial folds)
Discoid lupus erythematosus
Photosensitivity (patient history or examination)
Oral ulcers (oral/nasopharyngeal ulceration; usually painless)
Arthritis (nonerosive) involving ≥2 peripheral joints
(characterized by tenderness, swelling or effusion)
Serositis (pericarditis or pleuritis)
Nephropathy
persistent proteinuria >0.5 g/d or 3+ (or)
cellular casts (red cell, hemoglobin, granular, tubular, mixed)
Neurologic disorder(seizures/psychosis in absence of drugs or
metabolic derangements)
Hematologic disorder
r
hemolytic anemia with reticulocytosis or
r
leukopenia <4000/mm
3
on 2 occasions or
r
lymphopenia <1500/mm
3
on 2 occasions or
r
thrombocytopenia <100,000/mm
3
Immunologic disorder (+LE-prep; anti-DNA Ab or Sm Ag or
false + for syphilis known to be + for ≥6 months)
Antinuclear antibody

anti-histone
Peripheral Chromatin anti-DNA SLE
Nuclear mem anti-laminin
Speckled/ fine Nuclear RNP anti-Sm SLE (nephritis)
anti-Ro/SSA SCLE,Sjögren’s
anti-La/SSB Sjögren’s
anti-U1RNP SLE, MCTD
Chromatin anti-Ku SLE, scleroderma
anti-SCl-70 Scleroderma
Speckle/discrete Chromatin anti-centromere CREST
Nucleolar Nuclear RNP anti-U3RNP Scleroderma
Nucleolar comp anti-RNA Pol I
anti-Pm-SCl
Jaworsky C. Connective tissue diseases. In: Elder D et al. Lever’s Histopathol-
ogy of the Skin. Philadelphia: Lippincott-Raven. 1997: p. 267.
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Clinical Pearls 83
Porphyrias
PORPHYRIAS
Glycine + Succinyl CoA
Pyridoxal phosphate and ALA synthase
Aminolevulinic acid
Hydroxymethylbilane
CEP
Spontaneous
Uroporphyrinogen III
Co Synthase
Uroporphyrinogen III
Uroporphyrinogen I