Diagnosis and management of common viral skin infections

Skin infections caused by viruses are the standard primary treatment. This article outlines the most frequent skin infections that are caused by viruses, such as the varicella virus (chickenpox) and herpes zoster (shingles), as well as the molluscum contagiosum and roseola. The review also discusses the riskier groups and guidelines for when a  referral to a specialist should be sought.


The cause of chickenpox is the Varicella Zoster virus (VZV) which may be dormant within dorsal nerve cells of the root ganglia in the spine before reactivation. One chickenpox is higher in children but can be seen in adults and cause infections like encephalitis, pneumonia, and dehydration. It is a widespread childhood illness, and over 90% of those aged 15 or older are believed to have been affected by this disease. 2 Three out of every 1000 pregnant women contract chickenpox during pregnancy.


Itchy red spots can be found anywhere in your body (see Figure 1.). They develop into blisters filled with fluid (vesicles) that can rupture in the future and then spread across other areas within the body. The blisters may also scab over and may be caused by high temperatures, generalized myalgia, and fatigue.

Figure 1Open in Figure viewer PowerPoint Chickenpox is characterized by itchy red spots that turn into fluid-filled blisters.

Diagnosis and investigation

A majority of people with chickenpox do not require examinations. It is a medical diagnosis that is by appearance. If there is doubt about the diagnosis, swabs of viral particles may be collected, and blister fluid is taken for analysis by a laboratory. If a person has a history of chickenpox recurrence, Further investigations must be analyzed to determine the reason and whether they have an immune system disorder.


Most children who contract chickenpox don’t require specific treatment unless they have an immune system disorder or belong to a different category (see Table 1).3-6 The treatment typically is supportive and emphasizes relief from symptoms such as paracetamol and other over-the-counter creams for itch relief, such as calamine lotion.7 NSAIDs are not recommended because of their association with a higher chance of severe skin or soft tissue infections.8

Table 1. Treatment of chickenpox in specific patient groups

Patient group management tips

  • Pregnancy The treatment for symptoms
  • If the fever continues or the itchy rash persists after six days, consult a hospital emergency evaluation. This is due to the potential for superimposed infection with bacteria. 3.4
  • A seven-day course of oral Acyclovir (with informed consent and discussions with an Obstetrician) when the woman has symptoms within 24 hours of the beginning of the skin rash and is more than at least 20 weeks or more than 5
  • Immunocompromised NICE recommends seeking advice from a specialist on managing immunocompromised patients who suffer from chickenpox since they have an increased risk of developing severe illness and complications.
  • Ensure you take care of yourself by ensuring adequate liquid intake, shorter nails to avoid damage caused by scratching, and wearing cotton sheets for sleeping 6.

If treatment for antiviral disease is required, Aciclovir is the standard treatment option recommended in NICE guidelines. The NICE Clinical Knowledge Summary (CKS) 7 on chickenpox recommends the use of Aciclovir for immunocompetent adults or teenagers (aged 14 years and over) with chickenpox that manifest within the first 24 hours after the onset of rash, particularly those with severe chickenpox or are more susceptible to problems (such being smokers). The recommended dose for those patients is 800mg of oral Aciclovir five times daily for seven days.

A Cochrane systematic review of the use of Aciclovir to treat chickenpox in otherwise healthy adolescents and children discovered that it efficiently reduced the days of fever and the highest number of lesions. However, the effect on soreness and itching was unknown, and its impact on the patient was unclear. 9

Management of special groups

Aciclovir is to be taken with caution in patients with renal impairment. Adjusting doses depending on the route used and the renal function is recommended. If a woman is breastfeeding and nursing, it is recommended to use BNF recommends utilizing Aciclovir with cautiousness. When pregnant, it is advised to take antiviral medications in cases where the potential benefits outweigh the risk. Immediate advice from a specialist must be sought for pregnant women suffering from chickenpox due to the danger of suffering serious complications and higher risk for the infant of fetal varicella syndrome. If a pregnant woman has come into contact with chickenpox (and did not have previously not had it), they should be alert and inform their healthcare provider whenever they notice any signs. It is important to be warned against contact with other vulnerable individuals, including pregnant women and infants. Any pregnant woman who has had chickenpox in their pregnancy with symptoms should inform their midwife/obstetrician so they are aware of the increased risk of fetal varicella syndrome. Varicella zoster immunoglobulin should be considered for pregnant women exposed during the early 20 weeks of pregnancy (Public Health England’s recommendation following the shortage of varicella zoster immunoglobulin). 10 For women who have been told for 20 weeks or more, it is recommended to use antiviral medications, but varicella zoster immunoglobulin may be utilized.


Shingles (also known as herpes zoster) can be caused due to the reactivation of varicella zoster’s virus in the body. It is most commonly seen in older people. There are a few known triggers for shingles, and they are listed in Table 2. The frequency of shingles is believed to be between 790 and 880 cases for every 100,000 those between the ages of 70 and seventy-nine years old.

Table 2. Potential triggers for shingles (herpes zoster)

  • Distitis, for example, can be a sign of infection.
  • Surgery for the spine
  • Infection with the varicella Zoster virus
  • Radiotherapy at the level of the affected nerve root


Shingles manifest as the dermatomal region and are usually accompanied by the appearance of a painful red rash that blisters (see Figure 2.). The inflammation can often cause patients to feel burning sensations and neuropathic pain for several months after it has cleared and is referred to by the post-herpetic nerve. Patients typically describe a sense of burning or pain triggered by minor events like a slight breeze or clothing that gently touches the area affected.

Figure 2 Open in Figure viewer Power Point Shingles (herpes zoster) usually present with a painful, blistering rash.

Diagnostic and investigation

Shingles are diagnosed clinically in most cases, and patients don’t require any tests. If someone suffering from shingles experiences problems (see below), they may require hospitalization and further tests.

The most frequent complications of herpes zoster are post-herpetic neuralgia and ocular complications (particularly when the ophthalmic nerve of the trigeminal nervous system is affected). Approximately 3 percent of patients end up admitted to the hospital. 11


The non-pharmacological treatment advice for shingles is remarkably like that of chickenpox. Patients should be advised not to share clothes or towels, wear loose-fitting clothing to minimize irritation, cover lesions not covered by clothing while the rash continues to weep, and wash their hands frequently. It is also recommended to avoid scratching because it could cause more permanent scarring.

Lesions can be painful, but the primary complication is post-herpetic neuralgia. The treatment focuses on addressing the pain and any difficulty that might occur. The NICE recommendations  on treating shingles are described in Table

Table 3. Treatment options for Shingles (herpes Zoster) 

For most patients refer or admit you to a hospital

  • Control the pain using analgesics from the WHO analgesic ladder.
  • The doctor will prescribe an oral antiviral therapy within 72 hours after rash onset in the case of severe or extreme pain or if you are immunocompromised.
  • You should consider prescribing oral antiviral treatments within 72 hours after rash onset for all patients over 50 years old to lower the risk of post-herpetic neuralgia.
  • It is recommended to prescribe oral corticosteroids within the first two weeks following the onset of the rash in patients with a severe immune deficiency who suffer from pain (in conjunction with antiviral treatment)
  • If there are serious issues (including meningitis or encephalitis)
  • If an immunocompromised individual has shingles, they should seek treatment.
  • If there is an eye injury, it’s due to the high risk of eye complications.
  • In the most severe of cases, and especially in cases where there is a spread of disease (intravenous antiviral therapy may also be suggested)
  • If you experience severe pain or if new vesicles have formed within seven days of treatment for antiviral symptoms

For adults, options for treatment for pain in the brain include amitriptyline, duloxetine, gabapentin, and pregabalin. Other guidelines, like those provided by the International Herpes Management Forum, consider using steroids to decrease inflammation that could contribute to acute pain.

While most patients heal without complications, There is a group of patients classified as having a higher risk of developing complications, such as pregnant women, the elderly, and those with recurring infections.

What is the appropriate time to use

NICE recommends seeking advice from a specialist in the event that new vesicles start to form after 7 days of oral antiviral therapy. The agency also recommends referral when patients who are not immunocompromised suffer two episodes of shingles. It is also recommended to refer when there is a recurring infection in immunocompromised patients as they might require prophylaxis over a long period to avoid re-infection.

The need for urgent specialist advice or admission to the hospital is advised if:

  • The ophthalmic region is affected by shingles of the trigeminal nerve, which may manifest as an itch on the side or tip of your nostrils (known by the name Hutchinson’s sign), as well as visual symptoms or an undiagnosed red eye.
  • The risk of serious complications (such as encephalitis, meningitis, and myelitis) is feared.
  • A person who is severely immunocompromised suffers from shingles. Or an immunocompromised individual has shingles with a severe, extensive rash or has a general illness.
  • A child who is immunocompromised has shingles.


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