Mpox: Treating severe lesions
Accurate diagnosis of lesions is crucial and should start with an assessment of the patient and potential risk factors for mpox (monkeypox), disease severity, and complications. Risk factors for mpox include history of known or possible exposure, relevant travel and sexual behaviors (e.g., sex associated with commercial sex venues, sex parties, group sex, or engagement in sex work or sex trades), history of sexually transmissible infections, housing status, chronic diseases, and other relevant factors.1-5 Risk factors for severe disease may include HIV infection and other forms of immunocompromise; atopic dermatitis and other exfoliative skin diseases; complications involving edema or strictures; and infections involving the penile foreskin, vulva, urethral meatus, or anorectum which could require procedural intervention.6-8 Since super- and co-infections of mpox lesions can occur, diagnosis should also include the identification of additional pathogen(s) that may be present through the use of lesion swabs, serologies, or tissue cultures.1 When super- or coinfection is confirmed, appropriate systemic therapy should be administered in conjunction with mpox treatment(s).
Wound bed preparation will depend on the pathogens involved and severity of lesions.9 Our general guide is as follows:
Wounds should be cleansed with gentle soap and water. Routine care may include a broad-spectrum antimicrobial soak to remove biofilms and surface colonizing organisms; use a dilute (0.25%) acetic acid solution or one tablespoon of plain white vinegar mixed with one cup of tap water as a cost-effective alternative. There is no need to scrub the skin, as this may induce trauma.
Creating a moist wound healing environment
As keratinocytes migrate best in a moist environment, most wounds would benefit from application of topical plain white petrolatum. Occlusive non-stick dressings (e.g., Telfa™, Xeroform™, or Vaseline™-impregnated gauze) should be used to promote an optimal healing environment.9
Protecting skin at borders of a large wound
For large or highly exudative wounds, intact skin at wound edges can be protected from exudates and trauma by applying a protective coating such as white petrolatum, zinc oxide paste, or a silicone film.10
Special considerations for perianal skin
In addition to creating a moist wound healing environment and protecting the borders at the edge of large wounds as above, an adult incontinence pad may be helpful if discharge or exudate is observed between dressing changes.
Routine use of topical antimicrobial agents, particularly over-the-counter options, is not indicated and may result in irritation, contact dermatitis, or delayed wound healing.11
Debridement is generally not recommended for mpox lesions (with rare exceptions, such as devitalized or necrotic tissue).12
Consultation with an experienced dermatologist, wound care clinic, infectious disease specialist, plastic or burn surgeon, or other complex wound care specialist should be sought for severe wounds with significant involvement of high-risk anatomic sites (e.g., eyelids/periocular, perioral, ear, genitalia, and perianal).1,13,14
Hyper- or hypopigmentation and pitting or scarring of the skin may occur as lesions heal.15-19 It is important to properly care for skin to promote skin healing and minimize scarring.20
Coinfection of mpox lesions with other pathogens is common. In addition, any open, eroded, or otherwise ulcerated skin lesions may leave the skin vulnerable to superinfection. During the current outbreak, there have been reports of complications such as cellulitis, paronychia, sepsis, and lymphangitis as a result of coinfection or superinfection.21-24 Comprehensive evaluation for other pathogens is especially important for patients presenting with widespread, severe, or recalcitrant lesions. Patients with mpox are often diagnosed with other infections, including STIs (e.g., syphilis, chlamydia, gonorrhea, and trichomoniasis), herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus, Staphylococcus aureus (including MRSA), and Mycoplasma species.21,25-32 Given the morphologic overlap of lesions caused by HSV, VZV, and mpox virus, there should be a low threshold for testing of these in suspected lesions by PCR or culture. While swabbing lesions remains the first-line method for diagnosing mpox infection, physicians may consider tissue biopsy in severe cases to identify other pathogens that may be involved.33
Individuals who are sexually active should be screened for HIV,25,34-36 which often supports reflexive screening for other STIs, especially syphilis. Screening for hepatitis and herpes viruses may also be indicated.21
Antimicrobial selection should be based on any culture or testing results (when available), anatomic site of involvement, individual patient risk factors, history, and local antimicrobial resistance patterns.
Resources for mpox coinfection
Sexually Transmitted Infections Treatment Guidelines, 2021 | MMWR (cdc.gov)
Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020 | MMWR (cdc.gov)
Cytomegalovirus (CMV) for Healthcare Providers | CDC
Herpes - STI Treatment Guidelines (cdc.gov)
Talking to patients about sexually transmitted infections (aad.org)
Pain management should be considered for both immediate and longer-term pain; NSAIDs may be used for acute pain, but opioids may be needed in more severe cases.9
Treatments that have been used for mpox include the antivirals tecovirimat, cidofovir, and brincidofovir and vaccinia immune globulin. Tecovirimat is the most used antiviral. Patients at high risk for severe disease, including severely immunocompromised patients, or those with progressive disease despite tecovirimat, should be considered for combination of the previously mentioned therapies. Cidofovir has been used intravenously, topically, and intralesionally in patients with poxviruses and other viral lesions, with topical compounds ranging in concentration from 1-3%; however, there is no clinical effectiveness data to support this approach.37,38 If intravenous cidofovir is used, dosing similar to that used for the licensed indication (treatment of CMV retinitis in persons with AIDS) can be considered.39,40 Brincidofovir, which is a prodrug of cidofovir, is available in oral or suspension form.40 It is less nephrotoxic than cidofovir and may be better tolerated.8,40 There is minimal data on the effectiveness of vaccinia immune globulin in mpox, but it may be considered for severe mpox cases.8 Prescribers should follow best practices in terms of monitoring patients for drug side effects and toxicity.
Tetanus vaccination status should be assessed and updated as indicated.2
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