Herpes Zoster (Shingles).

Question 1

What issue / Tx
Hx
Previously infected with varicella zoster virus
-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
Derm manifestation
(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

Answer 1

Herpes Zoster (Shingles).
< 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.
> 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 2

Hutchinson’s Sign:

Answer 2

Vesicles on the tip/side of the nose precedes the development of HZO

Question 3

What issue
-Presents with malaise, fever, headache, and periorbital burning/itching
-frequently involves the ophthalmic division of the trigeminal nerve.
Hutchinson’s Sign: Vesicles on the tip/side of the nose precedes the development of this

Answer 3

Herpes Zoster Opthalmicus

Question 4

Disposition
Patients with Herpes Zoster on the face

Answer 4

should be referred to Medical Officer for further evaluation

Question 5

Differential Diagnosis Herpes zoster

Answer 5

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