Acute herpes zoster: Difference between revisions
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== Background ==
==Background==
*Caused by Varicella Zoster Virus (VZV) causing varicella (chicken pox) and later zoster (shingles)  
[[File:Dermatoms alt.png|thumb|Sensory dermatomes by spinal level.]]
*Virus is dormant in dorsal root ganglion and reactivates causing characteristic rash in dermatomal distribution  
*Also known as shingles
*Caused by [[varicella zoster virus]] (VZV; also known as Human Herpes Virus 3) causing [[Varicella]] (chicken pox) and later zoster (shingles)  
*Virus is dormant in dorsal root ganglion and reactivates causing characteristic vesiculopapular rash in dermatomal distribution  
*Occurs once immunity to virus declines (elderly, immunosuppressed, post transplant, HIV)
*Occurs once immunity to virus declines (elderly, immunosuppressed, post transplant, HIV)


== Clinical Features ==
===Prevention===
*Prodrome: Headache, malaise, photophobia  
*Patient is contagious until lesions are crusted over
*Antecedent pruritis, paresthesia, pain to dermatome 2-3 days prior to rash  
*Consider varicella-zoster immunoglobulin to immunosupressed, pregnant, neonate contacts
*Maculopapular rash progresses to vesicles (and can coalesce to bullae) in dermatomal distribution lasting 10-15 days  
*Zoster vaccination if >60
 
{{Herpes viruses}}
 
==Clinical Features==
[[File:Zoster.jpeg|thumb|Herpes Zoster]]
[[File:Shingles.jpg|thumb|Herpes Zoster]]
*Prodrome: [[Headache]], [[Weakness|malaise]], photophobia  
*Antecedent [[pruritus]], [[paresthesia]], pain to dermatome 2-3 days prior to rash  
*Maculopapular [[rash]] (see below) progresses to vesicles, may coalesce to bullae, in dermatomal distribution lasting 10-15 days  
*Does not cross midline  
*Does not cross midline  
*Typically affects chest/face  
*Typically affects chest/face
*Herpes Zoster Opthalmicus- See [[Herpes Zoster Ophthalmicus]]  
*Lumbar and sacral dermatomes may display skin sparing between the feet and groin
*Herpes Zoster Oticus (Ramsay Hunt Syndrome)
*V3 involvement can present initially as dental pain
[[File:Herpes Zoster.jpg|thumb]]


== Work-Up  ==
==Differential Diagnosis==
*Further evaluation if disseminated VZV
{{Bullous rashes DDX}}
{{VZV types}}


*Immunocompromised
==Evaluation==
*If more than 3 or more dermatomes affected
===Workup===
*If young, previously healthy adult-may be initial presentation with HIV
*Generally a clinical diagnosis
*Further evaluation for pneumonitis, hepatitis, encephalitis as clinically indicated
*May consider viral Culture, antigen, PCR of vesicle fluid
*Atypical illness/severe disease
**Viral Culture, antigen, PCR of vesicle fluid


== DDx  ==
===Evaluation===
*Smallpox
*Confirm that the patient does not have:
*Cellulitis
**[[Herpes zoster ophthalmicus]]
*Contact Dermatitis
**[[Herpes zoster oticus]] (Ramsay Hunt syndrome)
*Measles
*Consider further evaluation for immunocompromized state (may be initial presentation of [[HIV]]) if:
**Disseminated
***For skin, disseminated is defined as more than 20 lesions outside the primary and adjacent dermatomes<ref>Bolognia, J. L., Schaffer, J. V., & Cerroni, L. (n.d.). Dermatology: 2-Volume Set. Elsevier.3 or more dermatomes affected.</ref>
***Can also disseminate to other organs including liver, lung, and brain.
**Atypical illness/severe disease
*In immunocompromised patients consider further evaluation for:
**Pneumonitis
**[[Hepatitis]]
**[[Encephalitis]]


== Treatment  ==
==Management==
*Pain
===[[Analgesia]]===
**PO narcotics
*Analgesia is very important and should be prescribed along with an antiviral
*Antiviral
*Consider [[lidocaine]] patch, [[NSAIDS]], oral [[opioids]], or [[gabapentin]]
**Reduces risk/duration of postherpetic neuralgia
*[[Diphenhydramine]] and [[ranitidine]] for itch/pain
**Immunocompetent patients:
***Give acyclovir if <72hr of onset of rash or >72hr if new vesicles present/developing
***Acyclovir 800mg PO 5x/day x 7d
**Immunosuppressed patients:
***Give antiviral therapy at any stage of onset of rash
***Acyclovir 10 mg/kg IV q8h OR 800mg PO 5x/day x 7d or foscarnet for acyclovir-resistant VZV, disseminated zoster, CNS involvement, ophthalmic involvement, advanced AIDS, recent transplant
*Steroids not shown to be beneficial


== Disposition ==
===[[Antivirals]]===
*Admit for disseminated VZ, CNS involvement, severely immunosupressed
*Reduces risk/duration of [[postherpetic neuralgia]] with dosing based on immune status and time course of disease
*Not effective in treating postherpetic neuralgia once it has developed
'''Immunocompetent patients:'''
*[[Acyclovir]] 800mg PO 5x/day x 7d if <72hr of onset of rash or >72hr if new vesicles present/developing<ref>Cohen, J. Herpes Zoster. N Engl J Med 2013; 369:255-263. DOI: 10.1056/NEJMcp1302674</ref>
*[[Valacyclovir]] (can also be given but is generally more expensive than acyclovir)
**1g PO q8hrs (CrCl normal)
**1g PO q12hrs (CrCl 30-49 mL/min)
**1g PO q24hrs (CrCl 10-29 mL/min(
**500mg q24hrs PO (CrCl < 10ml/min)
'''Immunosuppressed patients:'''
*Antiviral therapy should be given regardless of the time of onset of rash
*[[Acyclovir]] 10mg/kg IV q8h OR 800mg PO 5x/day x 7d or [[Foscarnet]] for acyclovir-resistant VZV, disseminated zoster, CNS involvement, ophthalmic involvement, advanced AIDS, or recent transplant
*Isolation precautions
**Disseminated zoster requires airborne precautions
 
===[[Glucocorticoids]]===
*Steroids ''not'' shown to be beneficial<ref>He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2008.</ref>
 
==Disposition==
*Admit for disseminated VZ, CNS involvement, severely immunosuppressed
*Healing of lesions may take 4 or more weeks<ref>Sampathkumar P, et al. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009; 84(3):274–280.</ref>


==Complications==
==Complications==
*Postherpetic neuralgia (risk increases with age), cellulitis, impetigo, necrotizing fasciitis
*[[Postherpetic neuralgia]] (risk increases with age)
 
*[[Cellulitis]]
==Prevention ==
*[[Impetigo]]
*Pt is contagious until lesions are crusted over
*[[Necrotizing Fasciitis]]
*Consider varicella-zoster immunoglobulin to immunosupressed, pregnant, neonate contacts
*[[SIADH]]
*Zoster vaccination if >60


== See Also ==
==See Also==
*[[Herpes Zoster Ophthalmicus]]  
*[[Postherpetic neuralgia]]
*[[Herpes zoster ophthalmicus]]
*[[Herpes zoster oticus]] (Ramsay Hunt syndrome)
*[[Generalized rashes]]


== Source  ==
==References==
*Tintinalli, Rosen's, eMedicine, Epocrates
<references/>
*Images provided by University of Iowa Dept. of Dermatology


[[Category:ID]]
[[Category:ID]]

Latest revision as of 19:07, 29 January 2025

Background

Sensory dermatomes by spinal level.
  • Also known as shingles
  • Caused by varicella zoster virus (VZV; also known as Human Herpes Virus 3) causing Varicella (chicken pox) and later zoster (shingles)
  • Virus is dormant in dorsal root ganglion and reactivates causing characteristic vesiculopapular rash in dermatomal distribution
  • Occurs once immunity to virus declines (elderly, immunosuppressed, post transplant, HIV)

Prevention

  • Patient is contagious until lesions are crusted over
  • Consider varicella-zoster immunoglobulin to immunosupressed, pregnant, neonate contacts
  • Zoster vaccination if >60

Herpes Virus Types

Clinical Features

Herpes Zoster
Herpes Zoster
  • Prodrome: Headache, malaise, photophobia
  • Antecedent pruritus, paresthesia, pain to dermatome 2-3 days prior to rash
  • Maculopapular rash (see below) progresses to vesicles, may coalesce to bullae, in dermatomal distribution lasting 10-15 days
  • Does not cross midline
  • Typically affects chest/face
  • Lumbar and sacral dermatomes may display skin sparing between the feet and groin
  • V3 involvement can present initially as dental pain
Herpes Zoster.jpg

Differential Diagnosis

Vesiculobullous rashes

Febrile

Afebrile

Varicella zoster virus

Evaluation

Workup

  • Generally a clinical diagnosis
  • May consider viral Culture, antigen, PCR of vesicle fluid

Evaluation

  • Confirm that the patient does not have:
  • Consider further evaluation for immunocompromized state (may be initial presentation of HIV) if:
    • Disseminated
      • For skin, disseminated is defined as more than 20 lesions outside the primary and adjacent dermatomes[1]
      • Can also disseminate to other organs including liver, lung, and brain.
    • Atypical illness/severe disease
  • In immunocompromised patients consider further evaluation for:

Management

Analgesia

Antivirals

  • Reduces risk/duration of postherpetic neuralgia with dosing based on immune status and time course of disease
  • Not effective in treating postherpetic neuralgia once it has developed

Immunocompetent patients:

  • Acyclovir 800mg PO 5x/day x 7d if <72hr of onset of rash or >72hr if new vesicles present/developing[2]
  • Valacyclovir (can also be given but is generally more expensive than acyclovir)
    • 1g PO q8hrs (CrCl normal)
    • 1g PO q12hrs (CrCl 30-49 mL/min)
    • 1g PO q24hrs (CrCl 10-29 mL/min(
    • 500mg q24hrs PO (CrCl < 10ml/min)

Immunosuppressed patients:

  • Antiviral therapy should be given regardless of the time of onset of rash
  • Acyclovir 10mg/kg IV q8h OR 800mg PO 5x/day x 7d or Foscarnet for acyclovir-resistant VZV, disseminated zoster, CNS involvement, ophthalmic involvement, advanced AIDS, or recent transplant
  • Isolation precautions
    • Disseminated zoster requires airborne precautions

Glucocorticoids

  • Steroids not shown to be beneficial[3]

Disposition

  • Admit for disseminated VZ, CNS involvement, severely immunosuppressed
  • Healing of lesions may take 4 or more weeks[4]

Complications

See Also

References

  1. ↑ Bolognia, J. L., Schaffer, J. V., & Cerroni, L. (n.d.). Dermatology: 2-Volume Set. Elsevier.3 or more dermatomes affected.
  2. ↑ Cohen, J. Herpes Zoster. N Engl J Med 2013; 369:255-263. DOI: 10.1056/NEJMcp1302674
  3. ↑ He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2008.
  4. ↑ Sampathkumar P, et al. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009; 84(3):274–280.
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