Monkeypox
Mpox (monkeypox) is an acute, re-emerging infectious disease caused by monkeypox virus (MPXV), a large double-stranded DNA virus of the genus Orthopoxvirus, family Poxviridae. Like other poxviruses, MPXV replicates entirely in the cytoplasm of the host cell, causing necrosis of epidermal keratinocytes and a brisk inflammatory reaction in the upper dermis. First identified in laboratory animals in 1958, with the first human case recorded in 1970 in the Democratic Republic of the Congo, mpox has evolved from an animal-to-human infection (zoonosis) confined to parts of Africa into a Public Health Emergency of International Concern (PHEIC), spreading efficiently between people through skin-to-skin and sexual contact.
Genetically, MPXV falls into two main clades. Clade I (formerly the Congo Basin clade) carries a mortality rate of up to 10% and causes more severe disease. Clade II (the West African clade, including clades IIa and IIb) drove the global outbreak that began in 2022; it is clinically milder but spreads very readily through close intimate contact. The single most useful clinical feature separating mpox from other pustular rashes such as chickenpox or smallpox is the early, prominent swelling and tenderness of lymph nodes (lymphadenopathy), either localized or generalized.
At Haute-Derma, managing mpox calls for a complete care pathway: rapid assessment with dermoscopy and real-time PCR with clade typing, followed by a plan to control acute pain, prevent secondary bacterial infection, and restore the skin barrier. By combining advanced topical antiseptic care with tissue-remodeling lasers (fractional CO2 laser, long-pulsed 1064 nm Nd:YAG laser), we help patients get through the outbreak safely and then address the lasting effects, such as pitted scars and dark marks, so they can regain confidence in their skin.
How the Virus Enters and Spreads in the Body
Routes of Entry and Viremia
- Transmission: The virus enters through tiny breaks in the skin or through mucous membranes (mouth, vagina, anus and rectum), via respiratory droplets during prolonged close contact, or from items contaminated with fluid from lesions (bedding, towels).
- Local replication and primary viremia: Once inside, MPXV multiplies in local epithelial cells and Langerhans cells, then travels through the lymphatics to regional lymph nodes, where it replicates rapidly and spills into the blood for the first time.
- Secondary viremia and skin seeding: The virus spreads through the bloodstream to the reticuloendothelial organs and then infects the small-vessel endothelium in the dermal papillae and mucosa. There it destroys epidermal keratinocytes, producing the characteristic umbilicated pustules.
The Immune Response and Lymph Node Reaction
- Reactive enlargement of the lymph nodes (neck, armpit, groin) reflects a vigorous activation of virus-specific CD4+ and CD8+ T cells working to contain the systemic spread of MPXV. This immunologic feature sets mpox clearly apart from the chickenpox virus (VZV).
Signs and Symptoms
Prodromal Phase:
- Incubation period: 5–21 days (typically 6–13 days).
- Systemic viral symptoms: sudden high fever of 38.5–40.0°C, chills, severe headache, muscle and lower back aches, and profound fatigue.
- Swollen lymph nodes (lymphadenopathy): appear 1–2 days before the rash. Nodes in the neck, under the jaw, in the armpits, or in the groin become enlarged (1–4 cm), firm, and tender to the touch.
Skin and Mucosal Rash (Exanthem Phase):
- Onset: the rash appears 1–3 days after the fever starts.
- Appearance and synchronous evolution: lesions in the same body area move through five stages together:
- Macules: flat red spots 2–5 mm across.
- Papules: firm, raised bumps.
- Vesicles: dome-shaped blisters filled with clear fluid.
- Pustules / pseudopustules: lesions filled with cloudy, grayish material, with a sunken center that forms a distinct dimple (umbilication).
- Crusts: lesions dry out, form dark scabs, and fall off after 7–14 days.
- Distribution and local symptoms: the rash is centrifugal, favoring the face, palms, soles, genitals, and the area around the anus. Lesions are very painful at the pustular stage and then become intensely itchy as they crust.
- Mucosal involvement: inflammation of the anus and rectum (proctitis) causing severe pain with urination or bowel movements, mouth ulcers that make swallowing difficult, or corneal involvement that can threaten vision.
How We Diagnose Mpox at Haute-Derma
Clinical Assessment and Dermoscopy:
- We ask about intimate contacts and recent travel, and look for the typical pattern of fever with painful swollen lymph nodes.
- Dermoscopy: umbilicated pustules show a central opaque, whitish area surrounded by a band of intense redness, with dotted vessels arranged in rings around the base of the lesion.
Bedside Microscopy and Microbiology:
- Tzanck smear: the base of a blister is scraped to look for necrotic keratinocytes and cytoplasmic inclusion bodies.
- Gram stain and direct microscopy: to rule out secondary infection with staphylococci (Staphylococcus aureus) or streptococci.
Molecular Testing (MPXV Real-Time PCR): Required to confirm the diagnosis. The doctor swabs fluid from a pustule, or lifts a crust, with a sterile swab and sends it to a biosafety laboratory to detect mpox DNA and identify the clade (Clade I or Clade II).
Treatment and Skin Recovery at Haute-Derma
Systemic Treatment and Symptom Control
- Specific antiviral drugs:
- Tecovirimat (TPOXX): for patients with widespread lesions, lesions in high-risk sites (eyes, mouth, anus), or a weakened immune system. Dose: 600 mg by mouth twice daily for 14 days.
- Cidofovir / brincidofovir: alternatives for tecovirimat-resistant cases.
- Systemic pain control:
- Moderate pain: paracetamol 500 mg plus ibuprofen 400 mg by mouth every 6 hours.
- Severe pain (proctitis, genital ulcers): add a nerve-pain medication (pregabalin 75 mg/day) or tramadol as prescribed by your doctor.
Local Care and Cosmetic Recovery at Haute-Derma
- Pustule and crusting stage:
- Clean the affected skin with an octenidine dihydrochloride or nano-silver antiseptic solution 2–3 times a day to dry out pustules and prevent secondary infection.
- Soak the genital or anal area in warm saline to ease burning pain when using the toilet.
- Recovery and scar treatment at Haute-Derma:
- Once all scabs have fallen off, apply a barrier-repair moisturizer containing ceramides, zinc oxide, panthenol (B5), and niacinamide.
- Fractional CO2 laser: stimulates new collagen to fill in the atrophic, pitted scars left by necrotic pustules.
- Long-pulsed 1064 nm Nd:YAG laser and IPL: treat post-inflammatory hyperpigmentation (dark marks) to even out skin tone.
- Subcision: used for deep, tethered depressed scars to release the fibrous bands in the dermis.
