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.
References:
Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK,
Crooks J: A randomized trial of acyclovir for 7 days or 21
days with and without prednisolone for treatment of acute
herpes zoster. N Eng J Med 1994;330:896-900.
