STD’S – GENITAL ULCER

for dermatology
medicalstudents

1. STD’ S – GENITAL ULCER KUSHAL

2. Chancroid Also termed soft chancre or “ ulcus molle ” Autoinoculable infection caused by Haemophilus ducreyi characterised by: • painful, necrotizing genital ulcers • painful bubo formation

3. CLINICAL MANIFESTATIONS Incubation period 5-7 days A papule develops initially but goes on to erode into a painful, soft, and non-indurated ulcer 50% of patients will develop painful local adenopathy which may suppurate or rupture

4. Chancroid Microbiology Hemophilus ducreyi Small coccobacillus Grows on special medium not available with <80% sensitivity

5. Chancroid Presentation Painful genital ulcers often multiple with sharply defined edges exudative base bleed when traumatized. I nguinal lymph nodes t ender suppurative drain spontaneously

6. Chancroid diagnostic criteria One or more painful ulcers Typical ulcer and lymph node appearance Negative darkfield or negative RPR at 7 days Negative HSV test of exudate

7. Chancroid ulcers regional adenopathy

8. Chancroid - ruptured node

9. Chancroid Treatment Azithromycin 1g stat. Ciprofloxacin 500 mg ( p.o. ) b.d . for 3 days Erythromycin 500 mg ( p.o. ) q.d.s for 7 days Ceftriaxone 250 mg ( i.m .) stat. Spectinomycin 2 g ( i.m .) stat. In known low resistance areas: Trimethoprim 80 mg/ Sulphamethoxazole 400 mg 2 tablets ( p.o. ) b.d . for 7 days

10. Donovanosis Also termed GRANULOMA INGUINALE Chronic , progressively destructive bacterial infection of the genital region caused by Calymmatobacterium ( Klebsiella ) granulomatis

11. Etiology Klebsiella granulomatis Pleomorphic GNR 99% phylogenetic homology with K. pneumoniae Difficult to grow in culture

12. Early Lesions of Donovanosis

13. Severe, Active Donovanosis in an HIV-Positive Patient

14. Preferred treatment : Doxycycline 100 mg po bid for 3 weeks Alternate Treatments : Azithromycin 1 gm po weekly for 3 weeks Ciprofloxacin 750 mg po bid for 3 weeks Erythromycin 500 mg po quid for 3 weeks TMP/Sulfa DS 1 po bid for 3 weeks

15. Herpes simplex The majority are caused by HSV-2 More aggressive than HSV-1 More likely to relapse than HSV-1 Virus is shed intermittently in the absence of symptoms

16. Development of Herpetic Ulcerations

17. GENITAL HERPES Primary Infection 80-90 % due to HSV-2 Typically most severe, systemic symptoms common Mult . painful vesicles, shallow ulcers, heal 2-3 wks Recurrences Less severe lesions Shorter duration Most patients with HSV-2 asymp . or do not recognize symptoms Asymptomatic viral shedding occurs without outbreaks

18. Features of Primary HSV-2 Infection 3-week illness Many lesions, frequently bilateral Mucosal involvement is common Pain may be severe Lymphadenopathy is common Systemic symptoms are common

19. HERPES SIMPLEX

20. Features of Recurrent Genital Herpes 5 – 10 days Fewer lesions, usually unilateral Mucosal involvement is uncommon Lymphadenopathy is uncommon Systemic symptoms are uncommon

21. RECURRENT HERPES SIMPLEX

22. Diagnosis of Genital Herpes • Microscopy - Tzanck smear • Microscopy - direct immunofluorescence • Electron microscopy • Culture - human fibroblasts / Vero cells • Antigen capture (ELISA) • Polymerase chain reaction (PCR) • Type-specific serology • ELISA • Western blot

23. Treatment of Genital Herpes Primary and Non-primary Initial Infections Treat most patients

24. Treatment of First Episode Acyclovir 400 mg TID for 7-10 days Acyclovir 200 mg 5x/day for 7 – 10 days Valacyclovir 1 g BID for 7 – 10 days Famciclovir 250 mg TID for 7 – 10 days

25. Lymphogranuloma Venerium Etiology: Chlamydia trachomatis, serovars L1, L2, L3 Seen in heterosexuals and MSM

26. Clinical Presentation Unilateral inguinal adenopathy Self-limited papule or ulcer at inoculation site MSM present with proctocolitis mucoid or hemorrhagic discharge Constipation Complications Colorectural fistulas F issures

27. Diagnosis Ulcer/bubo specimens: Culture DFA N ucleic A cid A mplification T est for Chlamydia PCR genotyping Chlamydia Serology

28. Treatment of choice: Doxycycline 100 mg po bid for 21 days Alternate Erythromycin 500 mg po qid for 21 days

29. HPV HPV stands for human papillomavirus. There are more than 100 types of HPV. HPV is so common that three out of four people will have it at some point in their lives.

30. HPV Transmission and Acquisition Nonsexual routes Rare mother to newborn Hypothesized –fomites, clothing Sexual contact Through sexual intercourse Genital-genital, manual-genital, oral-genital not as common modes of transmission Condom use may reduce risk, but it is not fully protective

31. METHODS TO DETECT HPV INFECTION Clinical diagnosis: Genital warts Epithelial defects See cellular changes caused by the virus: Pap smear screening Directly detect the virus: DNA hybridization or PCR* Detect previous infection: (Research Only) Detection of antibody against HPV

32. GENITAL WARTS

33. GENITAL WARTS

34. GENITAL WARTS

35. GENITAL HPV INFECTION TREATMENT OBSERVATION -20% spontaneous regression CRYOTHERAPY -70% cure rate PODOPHYLLIN/ TCA -30% cure rate SURGERY -laser-85% cure rate INTERFERON ALPHA - intralesional and systemic IMIQUIMOD -induces local interferon alpha production CIMETIDINE (Tagamet) – non-specific immune booster

36. Molluscum Contagiosum Pox virus Treat to prevent transmission Central umblication , belly button appearance Contact contagious

37. Must be curetted or removed before meet Single or clustered lesions may be covered by Bioclusive then pre-wrap and tape

38. THANK YOU