Q&A: Recognizing monkeypox in a dermatology setting

Monkeypox has recently been declared a public health emergency of international concern by the WHO, and more than 15,000 cases have been reported in the United States during the ongoing outbreak.

Some patients may seek care for the cutaneous manifestations of the virus with dermatologists, and specialists should be aware not only of its signs and symptoms, but also how it is spread and how it can be prevented.

Healio spoke with Erica Dommasch, MD, MPH, assistant professor of dermatology at Harvard Medical School and a practicing dermatologist at Beth Israel Deaconess Medical Center, about monkeypox and what dermatologists should be most aware of in terms of the virus.

Healio: What is monkeypox and how is it spread?

Dommasch: There are two distinctive clades of the monkeypox virus: the Congo Basin and the West African clades, which the World Health Organization recently renamed Clade I and Clade II. Clade I is thought to cause more severe disease and be more lethal than Clade II. The current virus seen in cases in the U.S. is the less severe Clade II, and thankfully no deaths have been reported to date in the U.S. from monkeypox from more than 10,000 cases, although 12 have been reported to date worldwide.

Monkeypox can be transmitted from animal to human, but human to human contact has been the primary cause of this outbreak. Although it’s possible that transmission can occur through large respiratory droplets or contaminated items such as bedding, monkeypox during this outbreak has almost exclusively been transmitted through skin-to-skin contact and bodily fluids. Contact during sex can spread monkeypox, but it is not classically a sexually transmitted disease — it is simply that during sex, there is skin to skin contact. Most cases thus far, around 98%, have been in men who have sex with men (MSM).

Healio: What are the signs and symptoms of monkeypox, what do the lesions look like and where are they most likely to appear?

Dommasch: The incubation period for monkeypox is usually 7 to 14 days but can span up to 21 days. Classically, initial signs and symptoms of monkeypox can include fever, headache, swollen lymph nodes, muscle aches and fatigue. Within 1 to 3 days after a fever appears, patients will develop a rash. In prior outbreaks, the rash generally started on the face, arms and legs, and then spread to other parts of the body.

However, during this outbreak, patients sometimes have no other symptoms aside from a rash. The rash also tends to present in areas of sexual contact, such as the groin, genitals, or in the rectum. It may stay in that area and never spread.

The rash evolves from macules, to papules, to vesicles, to pustules before scabbing and eventually crusting over. It can look like a blister or pus-filled bump, and for some patients can be extremely painful.

Healio: How is monkeypox diagnosed and how can it be differentiated from other similar rashes/skin conditions?

Dommasch: There are a number of differential diagnoses for monkeypox, including molluscum, varicella (chickenpox), secondary syphilis, herpes, hand-foot-and-mouth and medication-associated rashes. Swollen lymph nodes are characteristic.

Most individuals born in the U.S. are immune to chickenpox, either from natural infection or via vaccination. Further, varicella lesions would not usually be present on the palms and soles of the feet, or exclusively in areas of intimate contact.

The rash associated with smallpox is similar to that of monkeypox and progresses through similar phases. However, smallpox was eradicated in 1980 and now just exists in a few laboratories.

Healio: How long does monkeypox infection last?

Dommasch: Once all crusts have fallen off, a person is no longer contagious. Generally, the duration of diseases is between 2 to 4 weeks. Unfortunately, pitted scars and discolored skin may remain after the crusts have fallen off.

Healio: How can someone prevent themselves from contracting monkeypox?

Dommasch: Monkeypox is transmitted through skin-to-skin contact, and primarily through sexual contact during this outbreak. Any sexual partners should be asked about rashes or if they are feeling unwell, and close contact with individuals with a new rash should be avoided.

If you have a potential exposure or are in a group that is at high risk for being exposed (MSM in certain areas), you may be eligible for either the Jynneos or ACAM2000 vaccination. The older vaccine has many contraindications.

The CDC is currently recommending postexposure prophylaxis (PEP), in that anyone with a known or presumed exposure to monkeypox should be vaccinated, ideally within 4 days. They are also recommending expanded post-exposure prophylaxis (PEP++) vaccination, which means that anyone with certain risk factors and recent exposures that may increase the risk of contracting monkeypox, should consider vaccination. Eligibility for vaccination will likely change as more vaccines becomes available.

People more likely to get monkeypox include:

• people who have been identified by public health officials as a contact of someone with monkeypox;
• people who are aware that one of their sexual partners in the past 2 weeks has been diagnosed with monkeypox;
• people who had multiple sexual partners in the past 2 weeks in an area with known monkeypox;
• people whose jobs may expose them to orthopoxviruses, such as laboratory workers who perform testing for orthopoxviruses or who handle cultures or animals with orthopoxviruses; and
• some designated health care or public health workers.

Healio: How should dermatologists handle monkeypox in their patients?

Dommasch: Swabs of the surface and/or exudate, roofs from more than one lesion, or lesion crusts are recommended for laboratory confirmation of monkeypox. If you have a suspected case of monkeypox, contact the state health department for state-specific guidance on specimen collection.

The current recommendations for PPE for possible and confirmed monkeypox cases by the CDC are gowns, gloves, NIOSH approved N95 respirators and eye protection.

Healio: When should an individual contact a dermatologist vs. a general physician or an infectious disease expert?

Dommasch: Most general physicians and infectious disease doctors should be able to perform testing. If the appearance is atypical, testing for monkeypox is negative, or if a biopsy might be needed, they should contact a dermatologist.