Herpes zoster - Hair and Scalp
See also in: Overview,Cellulitis DDx,Anogenital,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. 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.
Pediatric patient considerations: Annual incidence is less than 1/1000 in children aged younger than 10 years. Maternal varicella infection during pregnancy, infection during the first year of life, and immunocompromised status are risk factors for zoster development in childhood. Although the onset of cutaneous zoster in adults typically involves a 1- to 3-day prodrome of pain or tingling in the affected dermatome, this is rarely observed in children. Postherpetic neuralgia is also rare in children.
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
- Cellulitis or erysipelas
- Herpes simplex virus infection
- 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
- Urticaria
- Eczema herpeticum
- Herpes simplex virus infection occurring within a dermatomal distribution is the primary differential diagnosis. Serology, viral culture, or PCR may be necessary to distinguish this diagnosis from zoster.
- Allergic contact dermatitis may present as a well-defined vesicular plaque. A dermatomal distribution suggests zoster.
- Molluscum contagiosum, when inflamed, can be confused with varicella-zoster. Cases are typically of longer duration, and VZV PCR studies are negative. The presence of coexisting non-inflamed molluscum lesions is a helpful diagnostic clue.
- Cellulitis or erysipelas
- Folliculitis
- Insect bites
- Other poxviruses (cowpox, monkeypox)
- Pyoderma gangrenosum
- Primary varicella infection and disseminated varicella
- Urticaria
- Bullous fixed drug eruption
- Eczema herpeticum
- Vasculitis
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Management Pearls
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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:07/01/2018
Last Updated:10/11/2021
Last Updated:10/11/2021
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Herpes zoster - Hair and Scalp
See also in: Overview,Cellulitis DDx,Anogenital,Oral Mucosal Lesion