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Mpox: Treating severe lesions

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Wound care

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.

Additional points

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.

Other considerations

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

  1. Leong HN, Kurup A, Tan MY, Kwa ALH, Liau KH, Wilcox MH. Management of complicated skin and soft tissue infections with a special focus on the role of newer antibiotics. Infect Drug Resist. 2018;11:1959-1974.

  2. Centers for Disease Control and Prevention (CDC). CDC Yellow Book 2020: Health information for international travel. Chapter 11: Skin and soft tissue infections. https://wwwnc.cdc.gov/travel/page/yellowbook-home-2020

  3. Burnham JP, Kollef MH. Treatment of severe skin and soft tissue infections: a review. Curr Opin Infect Dis. Apr 2018;31(2):113-119.

  4. Silverberg B. A Structured Approach to Skin and Soft Tissue Infections (SSTIs) in an Ambulatory Setting. Clin Pract. Feb 1 2021;11(1):65-74.

  5. Centers for Disease Control and Prevention (CDC). Case Definitions for Use in the 2022 Mpox Response. https://www.cdc.gov/poxvirus/monkeypox/clinicians/case-definition.html.

  6. Kumar AM, Chen ST, Merola JF, et al. Monkeypox outbreak, vaccination, and treatment implications for the dermatologic patient: Review and interim guidance from the Medical Dermatology Society. J Am Acad Dermatol. Dec 14 2022.

  7. Centers for Disease Control and Prevention (CDC). Severe manifestations of monkeypox among people who are immunocompromised due to HIV or other conditions. 2022; https://emergency.cdc.gov/han/2022/han00475.asp.

  8. Centers for Disease Control and Prevention (CDC). Treatment Information for Healthcare Professionals. 2022; https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html#anchor_1655488137245.

  9. Fujimoto M, Asai J, Asano Y, et al. Wound, pressure ulcer and burn guidelines - 4: Guidelines for the management of connective tissue disease/vasculitis-associated skin ulcers. J Dermatol. Oct 2020;47(10):1071-1109.

  10. Childs DR, Murthy AS. Overview of Wound Healing and Management. Surg Clin North Am. Feb 2017;97(1):189-207.

  11. Lipsky BA, Dryden M, Gottrup F, Nathwani D, Seaton RA, Stryja J. Antimicrobial stewardship in wound care: a Position Paper from the British Society for Antimicrobial Chemotherapy and European Wound Management Association. J Antimicrob Chemother. Nov 2016;71(11):3026-3035.

  12. Manna B, Nahirniak P, Morrison CA. Wound Debridement. StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.

  13. Peetermans M, de Prost N, Eckmann C, Norrby-Teglund A, Skrede S, De Waele JJ. Necrotizing skin and soft-tissue infections in the intensive care unit. Clin Microbiol Infect. Jan 2020;26(1):8-17.

  14. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. Mar 8 2018;378(10):971.

  15. Kaler J, Hussain A, Flores G, Kheiri S, Desrosiers D. Monkeypox: A Comprehensive Review of Transmission, Pathogenesis, and Manifestation. Cureus. Jul 2022;14(7):e26531.

  16. Kawsar A, Hussain K, Roberts N. Monkeypox: key pointers for dermatologists. Clin Exp Dermatol. Dec 2022;47(12):2282-2284.

  17. Hernandez LE, Jadoo A, Kirsner RS. Human monkeypox virus infection in an immunocompromised man: trial with tecovirimat. Lancet. Sep 10 2022;400(10355):e8.

  18. Beatty NL, Small C, Degener T, Henao Martinez AF. Monkeypox infection and resolution after treatment with tecovirimat in two patients with HIV disease. Ther Adv Infect Dis. Jan-Dec 2022;9:20499361221138349.

  19. Gessain A, Nakoune E, Yazdanpanah Y. Monkeypox. N Engl J Med. Nov 10 2022;387(19):1783-1793.

  20. American Academy of Dermatology. Monkeypox rash: dermatologists’ tips for treating your skin. https://www.aad.org/public/diseases/a-z/monkeypox-self-care#:~:text=While%20you%20have%20monkeypox%20rashes%20on%20your%20skin,...%206%20Look%20for%20signs%20of%20infection.%20

  21. Ortiz-Martínez Y, Rodríguez-Morales AJ, Franco-Paredes C, et al. Monkeypox - a description of the clinical progression of skin lesions: a case report from Colorado, USA. Ther Adv Infect Dis. Jan-Dec 2022;9:20499361221117726.

  22. de Sousa D, Frade J, Patrocínio J, Borges-Costa J, Filipe P. Monkeypox infection and bacterial cellulitis: a complication to look for. Int J Infect Dis. Oct 2022;123:180-182.

  23. Mailhe M, Beaumont AL, Thy M, et al. Clinical characteristics of ambulatory and hospitalized patients with monkeypox virus infection: an observational cohort study. Clin Microbiol Infect. Aug 23 2022.

  24. World Health Organization (WHO). Monkeypox. 2022; https://www.who.int/news-room/fact-sheets/detail/monkeypox.

  25. Miller MJ, Cash-Goldwasser S, Marx GE, et al. Severe Monkeypox in Hospitalized Patients - United States, August 10-October 10, 2022. MMWR Morb Mortal Wkly Rep. Nov 4 2022;71(44):1412-1417.

  26. Rizzo A, Pozza G, Salari F, et al. Concomitant diagnosis of sexually transmitted infections and human monkeypox in patients attending a sexual health clinic in Milan, Italy. J Med Virol. Jan 2023;95(1):e28328.

  27. Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med. Aug 25 2022;387(8):679-691.

  28. Hoff NA, Morier DS, Kisalu NK, et al. Varicella Coinfection in Patients with Active Monkeypox in the Democratic Republic of the Congo. Ecohealth. Sep 2017;14(3):564-574.

  29. Khallafallah O, Grose C. Reassessment of Evidence about Coinfection of Chickenpox and Monkeypox (Mpox) in African Children. Viruses. Dec 15 2022;14(12).

  30. Hughes CM, Liu L, Davidson WB, et al. A Tale of Two Viruses: Coinfections of Monkeypox and Varicella Zoster Virus in the Democratic Republic of Congo. Am J Trop Med Hyg. Dec 7 2020;104(2):604-611.

  31. Prabaker KK, de St Maurice A, Uslan DZ, et al. Case Report: Symptomatic Herpes Simplex Virus Type 2 and Monkeypox Coinfection in an Adult Male. Am J Trop Med Hyg. Dec 14 2022;107(6):1258-1260.

  32. Gomez-Garberi M, Sarrio-Sanz P, Martinez-Cayuelas L, et al. Genitourinary Lesions Due to Monkeypox. Eur Urol. Dec 2022;82(6):625-630.

  33. Centers for Disease Control and Prevention (CDC). Additional Testing of Biopsy Tissues in Severe Mpox Infections. 2022;https://www.cdc.gov/poxvirus/monkeypox/clinicians/prep-collection-specimens/biopsies.html.

  34. Betancort-Plata C, Lopez-Delgado L, Jaén-Sanchez N, et al. Monkeypox and HIV in the Canary Islands: A Different Pattern in a Mobile Population. Trop Med Infect Dis. Oct 19 2022;7(10).

  35. de Sousa D, Patrocínio J, Frade J, Correia C, Borges-Costa J, Filipe P. Human monkeypox coinfection with acute HIV: an exuberant presentation. Int J STD AIDS. Sep 2022;33(10):936-938.

  36. Centers for Disease Control and Prevention (CDC). Update on Managing Monkeypox in Patients Receiving Therapeutics. https://emergency.cdc.gov/han/2022/han00481.asp.

  37. Siegrist EA, Sassine J. Antivirals With Activity Against Mpox: A Clinically Oriented Review. Clin Infect Dis. Jan 6 2023;76(1):155-164.

  38. Napolitano L, Schroedl L, Kerman A, Shea CR. Topical cidofovir for benign human papillomavirus-associated skin lesions. Antivir Ther. Nov 2021;26(6-8):141-146.

  39. Rizk JG, Lippi G, Henry BM, Forthal DN, Rizk Y. Prevention and Treatment of Monkeypox. Drugs. Jun 2022;82(9):957-963.

  40. Shamim MA, Padhi BK, Satapathy P, et al. The use of antivirals in the treatment of human monkeypox outbreaks: a systematic review. Int J Infect Dis. Feb 2023;127:150-161.

Additional resources

CDC treatment information

Access CDC guidance for health care professionals on treatment of mpox.