Shingles_0613 Derm Clinic 2
A woman, aged 69 years, presented with a very painful rash on her chest and back. The pain began two days earlier and appeared to worsen rapidly. The woman reported that she had been feeling ill, run down, and fatigued. Her only medications were prescription drugs to control her hypertension and her elevated cholesterol.
Physical examination revealed numerous small vesicles and a few erosions on an inflamed erythematous base, extending from the right mid-back anteriorly to the right anterior chest and right breast.
Submit your diagnosis to see full explanation.
After a chickenpox infection or shingles vaccination, the varicella zoster virus (VZV) remains dormant in the sensory nerves, establishing lifelong latent infection. A reactivation of this virus causes a painful rash in the dermatome innervated by the corresponding sensory ganglion.
In the United States, almost 100% of adults are seropositive for anti-VZV antibodies after age 30 years,1 and thus are at risk for shingles, also known as herpes zoster.
Shingles may occur at any age but are most common in the senior population. Adults younger than age of 45 years have a risk of one in 1,000 of developing shingles; seniors have a risk at least four times that rate.2 This increased risk is likely a result of declining immunity with advancing age. Women have a slightly higher incidence of shingles than do men, and blacks have a lower risk of developing zoster than do whites.
After advanced age, the next largest risk factor is immunosuppression, whether as a result of malignancy, infection or medications. Pregnant women and premature infants should be considered at high risk for infection and more severe disease.
Shingles presents as a unilateral rash that affects only one or two dermatomes. The thoracic, cranial and lumbar dermatomes are the most frequently affected.
Many individuals with shingles describe feeling pain in the affected area prior to the appearance of the rash. Other prodromal symptoms include tenderness, paresthesia and local temperature disturbances. These symptoms usually are attributed to other conditions.
The rash of herpes zoster rapidly appears within a day or two of the onset of pain. The rash may initially present with papules on a base of erythema; however, these papules quickly develop into weeping vesicles that may appear pustular at times. Some lesions may appear necrotic or hemorrhagic. After three to five days, crust formation occurs.
In the mildest cases of shingles, only several lesions may be visible, and patients may not even be aware of the presence of the rash. In the more severe form, the rash may occur on the entire dermatome and even extend to the neighboring dermatomes. Other physical exam findings may include local lymphadenopathy and sensory or motor nerve changes.
The shingles rash usually resolves spontaneously, with the duration being determined by age and immune status. Younger patients may heal in two to three weeks, and elderly patients or those with more severe disease may require six or more weeks to recover. Scarring is dependent on lesion severity. Bacterial superinfection, although uncommon, should be considered in persisting skin lesions.
Zoster affecting the face requires very careful attention. In cases of eye or nose involvement, immediate treatment is prudent to prevent complications. Hutchinson’s sign refers to the presence of a vesicle or other zoster lesion on the tip of the nose, which almost always indicates ocular involvement and the need for immediate ophthalmology referral.
The major morbidity associated with shingles is postherpetic neuralgia (PHN), which is defined as chronic pain persisting weeks, months or even years after the lesions have healed. Since PHN is often associated with depression, all patients with persisting symptoms should be given careful consideration and appropriate treatment.
Diagnosis of herpes zoster is usually made clinically, and prompt assessment is essential. A Tzanck smear or direct fluorescent antibody staining can aid in the diagnosis. The differential diagnoses to consider include acute contact dermatitis with vesiculation (e.g., a phytoallergic response), bullous impetigo, insect bites, necrotizing fasciitis and erysipelas.
If the diagnosis is made less than 72 hours after the onset of symptoms, antiviral systemic therapy should be started to accelerate wound healing, decrease acute pain, and possibly minimize the risk of PHN. Acyclovir (Zovirax) 800 mg orally four times a day for seven to 10 days is often the first line of treatment.
Supportive treatment may include bed rest, application of a moist dressing to the involved dermatome, and nonsteroidal anti-inflammatory drugs. Consider narcotic analgesics to achieve early control of pain, if appropriate. The use of oral prednisone has not been shown to reduce the risk of PHN.
Ophthalmic zoster has the highest incidence of PHN, and IV antiviral agents may be indicated in those situations. Significant immunosuppression and disseminated infection are other indications for IV treatment and hospitalization. The CDC reported an annual incidence of 96 deaths caused by herpes zoster, almost all of which occurred in elderly people and those with compromised immune systems.3
The treatment for PHN includes the use of pregabalin (Lyrica), gabapentin (Horizant, Neurontin) and tricyclic antidepressants. Topical capsaicin or topical anesthetics may be appropriate for more minor and localized symptoms.
The patient in this case was treated with oral famciclovir (Famvir) and educated regarding the disease process as well as risk of transmission to nonimmune children and adults. Five days later, she reported feeling significantly better, and her rash was noted to have a dramatic decrease in erythema and had progressed to crusting.
Esther Stern, NP-C, is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J.
- Fitzpatrick TB, Johnson RA, Wolff K, Suurmond R, eds. Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, N.Y.: McGraw-Hill; 2009:837.
- James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, Pa.: Saunders-Elsevier; 2011:379.
- Mahamud A, Marin M, Nickell SP, et al. Herpes zoster-related deaths in the United States: validity of death certificates and mortality rates, 1979-2007. Clin Infect Dis. 2012;55:960-966.