1. Herpes Zoster (Shingles)
Presenhtion: Patients complain of pain, paresthesia, or an itch that covers a specific
dermatome and then develops into a characteristic rash. Prior to the onset of the rash,
zoster can be confused with pleuritic or cardiac pain, cholecystitis, or ureteral colic.
Approximately 3-5 days from the onset of symptoms, an eruption of erythematous
macules and papules will appear, first posteriorly then spreading anteriorly along the
course of the involved nerve segment. In most instances grouped vesicles will appear
within the next 24 hours. Herpes zoster most often occurs in the thoracic and cervical
segments.
What to do:
• Prescribe acyclovir (Zovirax) 800mg q4h (five times a day, skip a dose at night)
or famiclovir (Famvir) 500mg tid x7d.
• Prescribe analgesics appropriate for the level of pain the patient is experiencing.
Anti-inflammatory medications may help, but narcotics are often required (e.g.,
Percocet q4h).
• Cool compresses with Burow's solution will be comforting (e.g Domeboro
powder, 2 pkts in 1 pint of water).
• Dressing the lesions with gauze and splinting them with an elastic wrap may also
help bring relief.
• Secondary infection should be treated with povidone-iodine (Betadine) ointment
or systemic antibiotics.
• Ocular lesions should be evaluated by an ophthalmologist and treated with
topical ophthalmic corticosteroids. Although topical steroids are contraindicated
in herpes simplex keratitis, because they allow deeper corneal injury, this does
not appear to be a problem with herpes zoster ophthalmicus. If the rash extends
to the tip of the nose, the eye will probably be involved, because it is served by
the same ophthalmic branch of the trigeminal nerve.
What not to do:
• Do not prescribe systemic steroids to prevent post herpetic neuralgia, especially
for patients at high risk, i.e., with latent tuberculosis, peptic ulcer, diabetes
mellitus, hypertension, and congestive heart failure.
Discussion
Zoster results from reactivation of latent herpes varicella/zoster (chickenpox) virus
residing in dorsal root or cranial nerve ganglion cells. Two-thirds of the patients are
over 40 years old. This is a self-limiting, localized disease and usually heals within 3-4
weeks. Postherpetic neuralgia in patients over 60 years old, however, can be an
extremely painful, recurrent misery. Before the availability of anti-viral agents, the best
prophylaxis was systemic corticosteroids, but these have not been shown to improve
outcome when added to a week of anti-viral treatment.