Herpes zoster in Adult
See also in: Cellulitis DDx,Anogenital,Hair and Scalp,Oral Mucosal LesionAlerts and Notices
Synopsis
Cutaneous herpes zoster usually begins with a 1- to 3-day prodrome of burning pain or paresthesias in the affected dermatome, followed by eruption of erythematous papules and vesicles in the same distribution.
Involvement of a thoracic dermatome may simulate acute myocardial infarction. Involvement of the ophthalmic branch of the trigeminal nerve may lead to herpes zoster ophthalmicus. Herpes zoster oticus (Ramsay-Hunt syndrome) occurs with involvement of the vestibulocochlear nerve. Herpes zoster duplex is the simultaneous occurrence of zoster in 2 noncontiguous dermatomes, and herpes zoster multiplex refers to this phenomenon occurring in more than 2 dermatomes. Disseminated zoster, defined as more than 20 vesicles outside of the primary and adjacent dermatomes, is chiefly a problem of immunocompromised patients (patients with HIV, patients with cancer, and those on immunosuppressive drugs). Some patients may suffer acute segmental neuralgia, known as zoster sine herpete, without ever developing a visible skin eruption. Regional adenopathy may be seen.
Zoster may be accompanied by pain acutely. Additionally, a major concern after a zoster outbreak is postherpetic neuralgia, defined as pain and neuropathic symptoms that persist in a dermatome one month beyond resolution of the rash. Risk factors for postherpetic neuralgia include older age, female sex, presence of a prodrome, greater rash severity, and acute pain. Postherpetic neuralgia can be intractable and debilitating, and prevention is an important goal. Other less frequently encountered post-zoster sequelae include herpes zoster granulomatous dermatitis (where a granulomatous eruption develops weeks to months after zoster resolution) and skin infiltration of the site of healed zoster by cells from an underlying hematologic malignancy (so-called isotopic response).
Cerebrovascular accidents, peripheral motor neuropathies, neurogenic bladder, and diaphragmatic paralysis have been associated with zoster. Postherpetic abdominal pseudohernia refers to the abdominal asymmetry that is secondary to a motor neuropathy following zoster of a lower thoracic or lumbar dermatome. Herpes zoster encephalitis usually appears in the first 2 weeks after the onset of lesions, and it has a 10%-20% mortality rate. Lesions may also be at risk for bacterial superinfection. In extreme cases, necrotizing fasciitis may occur.
Immunocompromised patient considerations: Immunocompromised patients have a higher risk of disseminated zoster. In patients with HIV and AIDS, multidermatomal, necrotic, or recurrent zoster may occur. Persistent ulcers and chronic hyperkeratotic zoster are further manifestations. A strong association of herpes zoster multiplex with underlying malignancy (especially lymphoma) was reported in one retrospective study.
Codes
ICD10CM:B02.9 – Zoster without complications
SNOMEDCT:
4740000 – Herpes zoster
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Herpes simplex virus infection
- Cellulitis or erysipelas
- Allergic contact or irritant contact dermatitis
- Folliculitis
- Insect bites
- Molluscum contagiosum
- Other poxviruses (cowpox, monkeypox)
- Zosteriform metastases from an internal solid organ malignancy
- Pyoderma gangrenosum
- Primary varicella infection and disseminated varicella can occur, particularly in the immunocompromised.
- During the prodromal phase, herpes zoster pain may mimic acute myocardial infarction or biliary colic.
- Urticaria
- Bullous fixed drug eruption
- Eczema herpeticum
- Sweet syndrome
- Vasculitis
- Herpangina
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
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Last Reviewed:04/11/2018
Last Updated:03/28/2022
Last Updated:03/28/2022
Patient Information for Herpes zoster in Adult
Overview
Herpes zoster, commonly called shingles, is a painful rash caused by the varicella-zoster virus, the same virus that causes chickenpox. After a person recovers from chickenpox, the virus remains inactive (dormant) in certain nerves in the body. As you age, your immune system becomes weaker and may not be strong enough to control the virus. Shingles occurs when the virus becomes active again, growing down the nerves to reach the skin and appearing as small, painful, fluid-filled bumps (blisters).Who’s At Risk
Although anyone who has had chickenpox or the chickenpox vaccine can get shingles, it usually occurs in people older than 50. People in their 70s are 15 times more likely to get shingles than younger adults. It can also be seen in people with weakened immune systems, such as those with cancer, organ transplants, autoimmune diseases, and HIV/AIDS. Shingles affects approximately 1 million people in the United States each year. Most people who have shingles will not get it again, although on rare occasions, it can reappear.Signs & Symptoms
Pain, itching, and burning or tingling in a specific location on the skin are the first shingles symptoms that develop. After a few days, the affected area will develop painful, smooth, red papules (small, solid bumps). In darker skin colors, the redness may be harder to see, but clustered bumps can be felt. The papules become vesicles (small blisters that are firm to the touch) over 1-2 days and then burst after 5-7 days, leaving sores on the skin that eventually form scabs. Individuals with shingles may also have fever, chills, headache, and generalized body aches. Because the virus travels down a nerve to the skin, shingles usually appears on only one side of the body and affects a specific area of the skin. Shingles commonly occurs on the chest, but it may also affect other parts of the body, including the face. The blisters may be in a cluster or in a linear pattern. Most people completely recover from shingles within 4 weeks.A particularly serious form of shingles occurs on the face and can affect the eye, possibly affecting vision if it is not promptly treated.
One of the most common complications of shingles is chronic pain in the area of the skin where the rash occurred. This is called postherpetic neuralgia. It is more common in older individuals and in people who had severe symptoms with the initial rash. It occurs in almost half of people who are older than 60 when they get shingles.
Self-Care Guidelines
Although shingles usually heals without medical care, call your health professional if you suspect shingles before following these self-care instructions:- Keep the area clean with mild soap and water.
- For pain, apply cool, damp compresses, and take either acetaminophen (Tylenol) or ibuprofen (Advil, Motrin).
- Apply calamine (Caladryl) lotion to help relieve itching.
When to Seek Medical Care
Call your health provider if you think you may have shingles, as there are medications that may speed healing if they are given within the first 72 hours after the rash appears.Treatments
Oral antiviral medication, such as acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir) may help if given within 72 hours after shingles lesions first appear. These medicines do not cure shingles, but they can decrease the amount of time you have pain and a rash. Antiviral medications may also decrease your chance of getting postherpetic neuralgia and may decrease your risk of developing visual problems if you have shingles on the face.Oral corticosteroids and pain relievers, such as acetaminophen and ibuprofen, may also be given to control pain. If the area is healed but you still have pain, your health provider may prescribe a topical medication called capsaicin (Capzasin P, Zostrix) or a cream or local anesthetic patch containing lidocaine (Lidoderm).
If you have shingles on your face, your health provider will likely send you to an eye specialist to evaluate if the virus is affecting your eye.
The Centers for Disease Control and Prevention (CDC) recommends the vaccine Shingrix to prevent shingles and postherpetic neuralgia. It is recommended for anyone older than 50, regardless of whether they have had shingles before. It is a two-dose injection that can be given by a clinician or pharmacist in the upper arm.
Herpes zoster in Adult
See also in: Cellulitis DDx,Anogenital,Hair and Scalp,Oral Mucosal Lesion