HERPES ZOSTER (SHINGLES)

Question 1

typically occurs years after primary VZV infection

varicella

Answer 1

Herpes Zoster (Shingles)

Question 2

Characteristic prodrome may precede rash by 1-5 days;
paresthesias with allodynia or hyperesthesia described by Pt as a
deep “burning,” “throbbing,” or “stabbing” sensation

Answer 2

Acute Neuritis with Prodrome:

Question 3

Derm Manifestations:

Answer 3

(a) Typically unilateral dermatomal rash without midline crossing that
favors the thoracic, cranial (particularly trigeminal), lumbar, and
cervical dermatomes.
(b) Overlap to adjacent dermatomes reported in 20% of patients;
involvement of noncontiguous dermatomes almost never occurs.
(c) Begins with red macules & papules that progress to clear vesicles
within 1-2 days, with new vesicles forming over 3-5 days.
(d) Vesicles evolve into pustules within 7 days; ulcerating & crusting
of pustules by day 14.
(e) Lesions usually heal within 2-4 weeks

Question 4

Treatment

Answer 4

(1) Goal is to limit the extent/duration/severity of pain & rash in the primary
dermatome & to prevent disease elsewhere.
(2) <72 hours after onset
(a) Antiviral therapy should be initiated to maximize benefits of
treatment.
(b) Valacyclovir: 1000 mg three times daily for seven days.
(c) Acyclovir: 800 mg five times daily for seven days.
(d) Topical treatment with antiviral agents is not effective.
(3) >72 hours after onset
(a) Antiviral therapy initiated if new lesions are appearing at time of
presentation (indicates ongoing viral replication).
(b) Minimal benefit of antivirals in the patient whose lesions that have
encrusted.
(4) Although antiviral therapy reduces pain associated with acute neuritis,
pain syndromes associated with herpes zoster can still be severe.
(a) NSAIDS and acetaminophen are useful for mild pain, either alone,
or in combination with a weak opioid analgesic (eg, codeine or
tramadol).
(b) For moderate to severe pain that disturbs sleep, stronger opioid
analgesics (eg, oxycodone or morphine) may be necessary

Question 5

Occurrence of pain for months or years in

the same dermatomal distribution as was affected by the herpes zoster

Answer 5

Postherpetic neuralgia (PHN)
PHN refers to pain persisting beyond four months from the initial
onset of the rash

Question 6

(1) frequently involves the ophthalmic division of the trigeminal nerve.
(2) Presents with malaise, fever, headache, and periorbital burning/itching.
(3) Approximately 50 percent of patients with HZO experience direct ocular
involvement if antiviral therapy is not used.
(4) Hutchinson’s Sign: Vesicles on the tip/side of the nose precedes the
development of HZO.

Answer 6

Herpes Zoster Opthalmicus

Question 7

Differential Diagnosis

Answer 7

(1) Poison Oak dermatitis
(2) Herpes Simplex virus
(3) Eczema Herpeticum
(4) Smallpox (hopefully not)

Question 8

(4) Smallpox (hopefully not)

Answer 8

(1) Light duty - based on location, presentation of patient, symptoms, pain
management and complications.
(2) Patients with Herpes Zoster on the face should be referred to Medical
Officer for further evaluation

Question 9

Complications

Answer 9

(1) Secondary bacterial infections