Herpes zoster: Difference between revisions
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== Background | ==Background== | ||
*Caused by | *Also known as shingles | ||
*Virus is dormant in dorsal root ganglion and reactivates causing characteristic rash in dermatomal distribution | *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 | *Consider varicella-zoster immunoglobulin to immunosupressed, pregnant, neonate contacts | ||
*Maculopapular rash (see below) progresses to vesicles, may 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 | ||
* | *Lumbar and sacral dermatomes may display skin sparing between the feet and groin | ||
* | *V3 involvement can present initially as dental pain | ||
[[File:Zoster. | [[File:Herpes Zoster.jpg|thumb]] | ||
== Differential Diagnosis == | ==Differential Diagnosis== | ||
{{Bullous rashes DDX}} | |||
{{VZV types}} | |||
==Evaluation== | |||
===Workup=== | |||
*Generally a clinical diagnosis | |||
*May consider viral Culture, antigen, PCR of vesicle fluid | |||
== | ===Evaluation=== | ||
* | *Confirm that the patient does not have: | ||
**[[Herpes zoster ophthalmicus]] | |||
**[[Herpes zoster oticus]] (Ramsay Hunt syndrome) | |||
*Consider further evaluation for immunocompromized state (may be initial presentation of [[HIV]]) if: | |||
**Disseminated | |||
***For skin disseminated is 3 or more dermatomes affected. | |||
***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]] | |||
==Management== | |||
===[[Analgesia]]=== | |||
* | *Analgesia is very important and should be prescribed along with an antiviral | ||
* | *Consider [[lidocaine]] patch, [[NSAIDS]], oral [[opioids]], or [[gabapentin]] | ||
* | *[[Diphenhydramine]] and [[ranitidine]] for itch/pain | ||
== | ===[[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<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 | *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 | ==Disposition== | ||
*Admit for disseminated VZ, CNS involvement, severely | *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> | *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> | ||
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*[[Impetigo]] | *[[Impetigo]] | ||
*[[Necrotizing Fasciitis]] | *[[Necrotizing Fasciitis]] | ||
*[[SIADH]] | |||
==See Also== | |||
*[[Herpes zoster ophthalmicus]] | |||
*[[Herpes zoster oticus]] (Ramsay Hunt syndrome) | |||
== See Also | |||
*[[Herpes | |||
*[[Ramsay Hunt syndrome | |||
*[[Generalized rashes]] | *[[Generalized rashes]] | ||
== References == | ==References== | ||
<references/> | |||
[[Category:ID]] | [[Category:ID]] |
Latest revision as of 21:08, 12 July 2023
Background
- 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
- HHV-1: Herpes Simplex Virus-1
- HHV-2: Herpes Simplex Virus-2
- Herpes B virus
- Varicella zoster virus
- Varicella (Chickenpox)
- Herpes zoster (Shingles)
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt syndrome)
- HHV-6 (Roseola infantum)
- HHV-8 (Kaposi’s sarcoma)
- Epstein-Barr virus
- Cytomegalovirus
Clinical Features
- 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
Differential Diagnosis
Vesiculobullous rashes
Febrile
- Diffuse distribution
- Varicella (chickenpox)
- Smallpox
- Monkeypox
- Disseminated gonococcal disease
- DIC
- Purpural fulminans
- Localized distribution
Afebrile
- Diffuse distribution
- Bullous pemphigoid
- Drug-Induced bullous disorders
- Pemphigus vulgaris
- Phytophotodermatitis
- Erythema multiforme major
- Bullous impetigo
- Localized distribution
- Contact dermatitis
- Herpes zoster (shingles)
- Dyshidrotic eczema
- Burn
- Dermatitis herpetiformis
- Erythema multiforme minor
- Poison Oak, Ivy, Sumac dermatitis
- Bullosis diabeticorum
- Bullous impetigo
- Folliculitis
Varicella zoster virus
- Varicella (Chickenpox)
- Herpes zoster (Shingles)
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt syndrome)
Evaluation
Workup
- Generally a clinical diagnosis
- May consider viral Culture, antigen, PCR of vesicle fluid
Evaluation
- Confirm that the patient does not have:
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt syndrome)
- Consider further evaluation for immunocompromized state (may be initial presentation of HIV) if:
- Disseminated
- For skin disseminated is 3 or more dermatomes affected.
- Can also disseminate to other organs including liver, lung, and brain.
- Atypical illness/severe disease
- Disseminated
- In immunocompromised patients consider further evaluation for:
- Pneumonitis
- Hepatitis
- Encephalitis
Management
Analgesia
- Analgesia is very important and should be prescribed along with an antiviral
- Consider lidocaine patch, NSAIDS, oral opioids, or gabapentin
- Diphenhydramine and ranitidine for itch/pain
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[1]
- 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[2]
Disposition
- Admit for disseminated VZ, CNS involvement, severely immunosuppressed
- Healing of lesions may take 4 or more weeks[3]
Complications
- Postherpetic Neuralgia (risk increases with age)
- Cellulitis
- Impetigo
- Necrotizing Fasciitis
- SIADH
See Also
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt syndrome)
- Generalized rashes
References
- ↑ Cohen, J. Herpes Zoster. N Engl J Med 2013; 369:255-263. DOI: 10.1056/NEJMcp1302674
- ↑ He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2008.
- ↑ Sampathkumar P, et al. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009; 84(3):274–280.