Herpes zoster
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Background
- Caused by varicella zoster virus (VZV) causing Varicella (chicken pox) and later zoster (shingles)
- Virus is dormant in dorsal root ganglion and reactivates causing characteristic 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
Clinical Features
- Prodrome: Headache, malaise, photophobia
- Antecedent pruritis, 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
Differential Diagnosis
- Smallpox
- Cellulitis
- Contact Dermatitis
- Measles
Varicella zoster virus
- Varicella (Chickenpox)
- Herpes zoster (Shingles)
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt syndrome)
Diagnostic 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
- If more than 3 or more dermatomes affected
- Atypical illness/severe disease
- In immunocompromized patients consider further evaluation for:
- Pneumonitis
- Hepatitis
- Encephalitis
Management
Analgesia
- Analgesia is very important and should be prescribed along with an antiviral
- Consider NSAIDS, oral opioids, or gabapentin
Antiviral
- Reduces risk/duration of postherpetic neuralgia with dosing based on immune status and time course of disease
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 < 10 ml/min)
Immunosuppressed patients:
- Antiviral therapy should be given regardless of the time 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, 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 immunosupressed
- Healing of lesions may take 4 or more weeks[3]
Complications
- Postherpetic Neuralgia (risk increases with age)
- Cellulitis
- Impetigo
- Necrotizing Fasciitis
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.