Esther Ellen Freeman, MD, PhD: Current Mpox Impact on the Skin

Published on: 

The current pox virus outbreak has become closely synonymous with fewer lesions than past mpox—but dermatology guidance is needed all the same.

The May 2022 mpox (formerly known as monkeypox) outbreak generated a storm of worry and mass speculation over the risk of “twindemics” amid the ongoing COVID-19 pandemic.

Though the scope and scale of the mpox outbreak has paled to match the comprehensive and global burden of COVID-19, the ongoing crisis has provided unique challenges to infectious disease specialists, epidemiologists—and even dermatologists now treating the characteristic and stigmatizing lesions associated with the virus.

In the second segment of an interview with HCPLive during the American Academy of Dermatology (AAD) 2023 Annual Meeting in New Orleans last week, Esther Ellen Freeman, MD, PhD, associate professor of dermatology at Harvard Medical School, discussed key disparities between the dermatologic manifestation of COVID-19 and mpox infection.

Put plainly, it’s a night-and-day comparison: about 98% of patients with mpox present with skin lesions, versus just 10% of patients with COVID-19.

Even when compared to earlier outbreaks of mpox in Africa years ago, clinicians are observing changes in skin manifestation today: current iterations of infection are resulting in lesions spreading from the genital and groin area to the rest of the body, whereas it previously began facially then spread to total body.

“We’re also seeing patients with 1-5 lesions—and certainly a majority of patients with less than 20 lesions,” Freeman explained. “This is in contrast to prior outbreaks when you’d might see lesion counts of 200 - 1000, much much higher.”

As the outbreak is ongoing, it’s been difficult for investigators to fully interpret the consistency of disease—as Freeman noted, these current cases of mpox being reported among US patients would maybe not have been reported at all in Africa, where the standard for disease has been more severe. And because presentation has been different from the textbook standard, so has the treatment strategy.

Freeman discussed her involvement on on an AAD task force dedicated to documenting and setting precedent for care of mpox, in collaboration with the Centers for Disease Control and Prevention (CDC). Thus far, the task force has generated 2 different guidances, Freeman said: one for caring for lesions as either a physician or patient, and the other for managing severe mpox lesions.

The former consists of patient-centric advisory around gentle cleansing practice, emollients, transmission risk reduction and the use of sun protection to avoid scarring and hyperpigmentation.

The latter addresses more long-term and burdensome forms of the common lesions.

“One thing that we’re seeing especially in our immunocompromised patients—such as those with HIV—they can have these really substantial, tricky wounds that are very large, very deep, very oxidative,” Freeman said.

Regarding the risk of scarring, Freeman conceded that current data is limited in understanding long-term impact.

“If you look at prior outbreaks…about 10% of people who had mpox had some sort of long-term scarring,” Freeman siad. “We don’t know what that percentage is going to be with this (2022) outbreak.”