Herpes Zoster (Shingles)

Herpes zoster (also known as shingles) is a viral, reactivation infection caused by the varicella-zoster virus Varicella-Zoster Virus Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Varicella-zoster infections are highly contagious and transmitted through aerosolized respiratory droplets or contact with infected skin lesions. Varicella-Zoster Virus/Chickenpox (VZV). Latent VZV remains dormant in the dorsal root ganglion after the primary infection phase of varicella ( chickenpox Chickenpox Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Chickenpox is the primary infection and occurs most commonly in children. The typical clinical presentation includes prodromal symptoms and a generalized, intensely pruritic vesicular rash. Varicella-Zoster Virus/Chickenpox). Age, stress, or immunocompromised states can trigger the reactivation of the virus. Herpes zoster clinically presents in a single, dermatomal distribution as a painful, unilateral rash. The diagnosis is primarily made from the history and physical examination. However, laboratory testing (such as PCR) can be performed if the diagnosis is unclear. Management includes antiviral therapy and symptomatic treatment.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

Herpes zoster (also known as shingles) is a viral, reactivation infection caused by the varicella-zoster virus Varicella-Zoster Virus Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Varicella-zoster infections are highly contagious and transmitted through aerosolized respiratory droplets or contact with infected skin lesions. Varicella-Zoster Virus/Chickenpox (VZV) manifesting as a unilateral, dermatomal, painful, vesicular eruption.

Epidemiology

  • Annual incidence in the United States: 1.2 million people
  • Approximately 30% of the population will experience herpes zoster during their lifetime.
  • More common in:
    • Older age
    • Immunocompromised
    • Women
  • Only individuals previously affected with chickenpox Chickenpox Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Chickenpox is the primary infection and occurs most commonly in children. The typical clinical presentation includes prodromal symptoms and a generalized, intensely pruritic vesicular rash. Varicella-Zoster Virus/Chickenpox

Etiology

Causative organism: VZV

  • Also known as human herpesvirus 3
  • Enveloped, double-stranded DNA DNA The molecule DNA is the repository of heritable genetic information. In humans, DNA is contained in 23 chromosome pairs within the nucleus. The molecule provides the basic template for replication of genetic information, RNA transcription, and protein biosynthesis to promote cellular function and survival. DNA Types and Structure virus
  • Belongs to the herpesviridae family

Transmission: 

  • Direct contact with blisters
  • Respiratory droplets (from individuals with disseminated disease)
  • Causes chickenpox Chickenpox Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Chickenpox is the primary infection and occurs most commonly in children. The typical clinical presentation includes prodromal symptoms and a generalized, intensely pruritic vesicular rash. Varicella-Zoster Virus/Chickenpox in exposed individuals without immunity
Single varicella zoster virus herpes zoster

Transmission electron microscopic image showing the single varicella-zoster virus Varicella-Zoster Virus Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Varicella-zoster infections are highly contagious and transmitted through aerosolized respiratory droplets or contact with infected skin lesions. Varicella-Zoster Virus/Chickenpox (VZV), also known as human herpesvirus 3, which causes chickenpox Chickenpox Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Chickenpox is the primary infection and occurs most commonly in children. The typical clinical presentation includes prodromal symptoms and a generalized, intensely pruritic vesicular rash. Varicella-Zoster Virus/Chickenpox

Image: “Ultrastructural features exhibited by a single varicella-zoster virus Varicella-Zoster Virus Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Varicella-zoster infections are highly contagious and transmitted through aerosolized respiratory droplets or contact with infected skin lesions. Varicella-Zoster Virus/Chickenpox (VZV), also known as human herpesvirus 3 (HHV-3), the cause of chickenpox Chickenpox Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Chickenpox is the primary infection and occurs most commonly in children. The typical clinical presentation includes prodromal symptoms and a generalized, intensely pruritic vesicular rash. Varicella-Zoster Virus/Chickenpox.” by CDC. License: Public Domain

Risk factors

  • Immunocompromised patient:
    • Transplant
    • Immunosuppressive therapy
    • Human immunodeficiency virus (HIV)
    • Autoimmune disorder
  • Active or chronic illness
  • Physical trauma
  • Family history
  • Age
  • Stress

Pathophysiology

Varicella-zoster virus causes 2 distinct syndromes:

Primary infection ( chickenpox Chickenpox Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Chickenpox is the primary infection and occurs most commonly in children. The typical clinical presentation includes prodromal symptoms and a generalized, intensely pruritic vesicular rash. Varicella-Zoster Virus/Chickenpox): 

  • Transmitted through aerosol → targets mucoepithelial cells
  • Viremia → contagious, febrile illness occurs
  • After resolution, viral particles remain in the dorsal root ganglia or other sensory ganglia.
  • Host immune system suppresses replication of the virus → lays dormant for years to decades (latency period)

Secondary infection (shingles):

  • Host immune system fails to contain the virus → VZV reactivates
  • Spreads down the sensory nerve → skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin → rash
  • Inflammatory response in the sensory ganglia: 
    • Involves plasma cells and T lymphocytes T lymphocytes T cells, also called T lymphocytes, are important components of the adaptive immune system. Production starts from the hematopoietic stem cells in the bone marrow, from which T-cell progenitor cells arise. These cells migrate to the thymus for further maturation. T Cells
    • Can result in neuronal damage → neuropathic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
Pathogenesis of varicella-zoster virus herpes zoster

Pathogenesis of varicella-zoster virus Varicella-Zoster Virus Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Varicella-zoster infections are highly contagious and transmitted through aerosolized respiratory droplets or contact with infected skin lesions. Varicella-Zoster Virus/Chickenpox (VZV):
The infection replicates viruses in mucoepithelial cells then spreads throughout the reticuloendothelial (RE) system and bloodstream, causing flu-like symptoms and chickenpox Chickenpox Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Chickenpox is the primary infection and occurs most commonly in children. The typical clinical presentation includes prodromal symptoms and a generalized, intensely pruritic vesicular rash. Varicella-Zoster Virus/Chickenpox. After resolution of the primary infection, a latency period occurs and the virus remains dormant in the dorsal root ganglia. Reactivation of the infection results in shingles.

Image by Lecturio.

Clinical Presentation and Complications

Common presentation

Acute neuritis: 

  • Most common symptom (often precedes the rash)
  • Neuropathic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain:
    • Burning
    • Stabbing
    • Throbbing
    • Constant or intermittent
  • Hypersensitivity
  • Allodynia

Rash:

  • Unilateral
  • Dermatomal distribution
  • Initially appears as erythematous papules 
  • Progresses into bullae or groups of vesicles
  • Becomes pustular or hemorrhagic within 3–4 days
  • Lesions start to crust in 7–10 days (no longer infectious). 
  • Scarring and hypo- or hyperpigmentation may occur.

Systemic symptoms (< 20% of cases):

  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Headache
  • Malaise
  • Fatigue

Disseminated herpes zoster

The following are severe presentations, which may occur in immunocompromised patients:

Cutaneous dissemination:

  • Vesicular lesions are in a generalized distribution.
  • May be accompanied by visceral involvement
  • Associated with ↑ risk of transmission

Visceral organ involvement:

  • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
  • Hepatitis
  • Encephalitis Encephalitis Encephalitis is inflammation of the brain parenchyma caused by an infection, usually viral. Encephalitis may present with mild symptoms such as headache, fever, fatigue, and muscle and joint pain or with severe symptoms such as seizures, altered consciousness, and paralysis. Encephalitis
  • May occur with or without a rash

Other presentations

Herpes zoster ophthalmicus:

  • Involves the ophthalmic division of the 5th cranial nerve
  • Symptoms:
    • Unilateral pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Hypesthesia
    • Headache
    • Malaise
    • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Progression to: 
    • Conjunctivitis Conjunctivitis Conjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis
    • Uveitis Uveitis Uveitis is the inflammation of the uvea, the pigmented middle layer of the eye, which comprises the iris, ciliary body, and choroid. The condition is categorized based on the site of disease; anterior uveitis is the most common. Diseases of the Uvea
    • Episcleritis
    • Keratitis
    • Vision loss

Ramsay Hunt syndrome (herpes zoster oticus):

  • Involves the geniculate ganglion and 8th cranial nerve
  • Triad of symptoms: 
    • Ipsilateral facial paralysis
    • Ear pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Vesicles in the auditory canal or auricle
  • Additional features: 
    • Dysgeusia
    • Hearing abnormalities
    • Lacrimation
Herpes zoster ophthalmicus

Herpes zoster ophthalmicus with involvement of the left eye

Image: “External photograph showing herpes zoster ophthalmicus” by Sudharshan S et al. License: CC BY 2.0

Complications

Postherpetic neuralgia: 

  • Most common complication 
  • Persistence of significant pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain for 90 days after rash development
  • Other symptoms: 
    • Numbness
    • Dysesthesias
    • Pruritus
    • Allodynia

Acute retinal necrosis: 

  • Features: 
    • Acute iridocyclitis
    • Vitritis 
    • Necrotizing retinitis
    • Occlusive retinal vasculitis
  • Complications: 
    • Rapid loss of vision 
    • Retinal detachment Retinal detachment Retinal detachment is the separation of the neurosensory retina from the retinal pigmented epithelium and choroid. Rhegmatogenous retinal detachment, the most common type, stems from a break in the retina, allowing fluid to accumulate in the subretinal space. Retinal Detachment

Other complications: 

  • Secondary bacterial infections of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
  • Aseptic meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis
  • Peripheral motor neuropathy
  • Guillain-Barré syndrome Guillain-Barré syndrome Guillain-Barré syndrome (GBS), once thought to be a single disease process, is a family of immune-mediated polyneuropathies that occur after infections (e.g., with Campylobacter jejuni). Guillain-Barré Syndrome
  • Stroke syndromes

Diagnosis

Shingles Shingles Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox diagnosis is primarily based on clinical presentation. In patients with atypical presentations, the following can be used:

  • PCR:
    • Utilizes a sample from vesicular lesions to detect VZV DNA DNA The molecule DNA is the repository of heritable genetic information. In humans, DNA is contained in 23 chromosome pairs within the nucleus. The molecule provides the basic template for replication of genetic information, RNA transcription, and protein biosynthesis to promote cellular function and survival. DNA Types and Structure
    • Preferred method of testing due to high sensitivity
    • More rapid than other methods of testing
    • Can be used in all stages of the disease 
  • Direct fluorescent antibody (DFA):
    • Tests lesion scrapings
    • Limited sensitivity 
    • Cannot be conducted on crusted lesions
  • Tzanck smear:
    • Lowest sensitivity and specificity
    • Confirms a herpetic lesion, but does not differentiate herpes viruses
    • Shows multinucleated giant cells
Tzanck smear herpes zoster

Tzanck smear with 3 multinucleated giant cells

Image: “Positive Tzanck test, showing three multinucleated giant cells in center” by NIAID. License: Public Domain

Management and Prevention

Antiviral therapy

  • Antiviral therapy aims to:
    • ↓ Severity and duration of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Aid in rapid healing of the lesions
    • Prevent the formation of new lesions
    • ↓ Viral shedding
    • Prevent complications 
  • Options:
    • Acyclovir
    • Valacyclovir
    • Famciclovir
  • Treatment should be administered:
    •  ≤ 72 hours after symptom onset
    • During the eruption of new lesions
    • In all immunocompromised patients

Supportive care

  • Analgesics:
    • Acetaminophen Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen 
    • NSAID NSAID Nonsteroidal antiinflammatory drugs (NSAIDs) are a class of medications consisting of aspirin, reversible NSAIDs, and selective NSAIDs. NSAIDs are used as antiplatelet, analgesic, antipyretic, and antiinflammatory agents. Nonsteroidal Antiinflammatory Drugs
    • Tricyclic antidepressants Tricyclic antidepressants Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. Tricyclic Antidepressants (TCAs) 
    • Gabapentinoids: 
      • Gabapentin
      • Pregabalin
  • Corticosteroids (e.g., prednisone) for severe pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or neurologic complications
  • Antibiotics: 
    • For suspected secondary bacterial infection
    • Provide staphylococcal and streptococcal coverage

Management of complicated disease

  • Postherpetic neuralgia:
    • TCAs and gabapentinoids are the 1st-line therapy
    • Topical drugs (capsaicin) to control mild-to-moderate pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics or intrathecal glucocorticoids Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. Glucocorticoids only if other measures fail
  • Herpes zoster ophthalmicus:
    • Immunocompetent patients: oral antivirals
    • Immunocompromised patients: IV acyclovir 
    • Strongly consider early ophthalmologic referral.
  • Acute retinal necrosis:
    • Initial: IV acyclovir 
    • Followed by: oral valacyclovir 
    • ↓ Visual acuity: glucocorticoids Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. Glucocorticoids
  • Ramsay Hunt syndrome: 
    • Oral valacyclovir and prednisone
    • Severe symptoms: IV antiviral therapy

Prevention

Measures to prevent transmission:

  • Cover the rash.
  • Avoid contact with:
    • Nonimmune pregnant women
    • Premature infants
    • Immunocompromised patients

Vaccines:

  • Indicated in adults ≥ 50 years of age
  • Types of vaccines:
    • Zoster vaccine Vaccine A vaccine is usually an antigenic, non-virulent form of a normally virulent microorganism. Vaccinations are a form of primary prevention and are the most effective form due to their safety, efficacy, low cost, and easy access. Vaccination live (live-attenuated vaccine Vaccine A vaccine is usually an antigenic, non-virulent form of a normally virulent microorganism. Vaccinations are a form of primary prevention and are the most effective form due to their safety, efficacy, low cost, and easy access. Vaccination):
      • No longer available in the United States, but used in other countries 
      • Contraindicated in immunocompromised patients
    • Recombinant zoster vaccine Vaccine A vaccine is usually an antigenic, non-virulent form of a normally virulent microorganism. Vaccinations are a form of primary prevention and are the most effective form due to their safety, efficacy, low cost, and easy access. Vaccination (recombinant glycoprotein E vaccine Vaccine A vaccine is usually an antigenic, non-virulent form of a normally virulent microorganism. Vaccinations are a form of primary prevention and are the most effective form due to their safety, efficacy, low cost, and easy access. Vaccination)

Differential Diagnosis

  • Herpes simplex: caused by the herpes simplex virus and spreads via direct contact with herpetic lesions or mucosal surfaces. The primary infection often presents with systemic, prodromal symptoms followed by dysuria, painful lymphadenopathy Lymphadenopathy Lymphadenopathy is lymph node enlargement (> 1 cm) and is benign and self-limited in most patients. Etiologies include malignancy, infection, and autoimmune disorders, as well as iatrogenic causes such as the use of certain medications. Generalized lymphadenopathy often indicates underlying systemic disease. Lymphadenopathy, and clusters of painful, fluid-filled vesicles on an erythematous base. Diagnosis is confirmed with laboratory testing, such as PCR and DFA. Treatment includes antiviral therapy.
  • Cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis: a common bacterial skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin infection affecting the deeper layers of the dermis and subcutaneous tissue. The condition is most commonly caused by Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus aureus and Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus pyogenes. Cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis presents as an erythematous, edematous area, which is warm and tender to the touch. Diagnosis is clinical and management involves antibiotics tailored to the suspected organism.
  • Folliculitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the hair follicles caused by a bacterial or fungal infection. Patients may present with itchy, sore, erythematous papules/pustules around the hair follicles. The diagnosis is clinical. Management is usually supportive, but topical or oral antibiotic therapy may be required for severe cases.
  • Allergic contact dermatitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin due to contact with an allergen. Patients commonly present with a local, red, pruritic rash and blistering may occur. Diagnosis is made through history and examination, but skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin patch testing can be used to determine a trigger. Management includes topical corticosteroids and allergen avoidance.
  • Molluscum contagiosum Molluscum contagiosum Molluscum contagiosum is a viral infection limited to the epidermis and is common in children below 5 years of age. Lesions appear as grouped, flesh-colored, dome-shaped papules with central umbilication. Molluscum Contagiosum: a viral skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin infection caused by a poxvirus typically seen in children < 5 years of age. Lesions are grouped, flesh-colored, dome-shaped papules with central umbilication. The disease is mild in immunocompetent patients and self-resolves within months. An immunocompromised patient may present with extensive lesions and systemic disease requiring treatment. The diagnosis is clinical. Cryotherapy with liquid nitrogen is the 1st-line in patients requiring therapy.

References

  1. Albrecht, M.A., and Levin, M.J. (2021). Epidemiology, clinical manifestations, and diagnosis of herpes zoster. In, Mitty, J. (Ed.), UpToDate. Retrieved April 18, 2021, from https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-herpes-zoster
  2. Albrecht, M.A. (2020). Diagnosis of varicella zoster virus infection. In Mitty, J. (Ed.), UpToDate. Retrieved April 18, 2021, from https://www.uptodate.com/contents/diagnosis-of-varicella-zoster-virus-infection
  3. Albrecht, M.A. (2020). Treatment of herpes zoster in the immunocompetent host. In Mitty, J. (Ed.), UpToDate. Retrieved April 18, 2021, from https://www.uptodate.com/contents/treatment-of-herpes-zoster-in-the-immunocompetent-host
  4. Albrecht, M.A., and Levin, M.J. (2020). Vaccination for the prevention of shingles (herpes zoster). In Mitty, J. (Ed.), UpToDate. Retrieved April 18, 2021, from https://www.uptodate.com/contents/vaccination-for-the-prevention-of-shingles-herpes-zoster
  5. Janniger, C.J., and Eastern, J.S. (2021). Herpes zoster. In Elston, D.M. (Ed.), Medscape. Retrieved April 18, 2021, from https://emedicine.medscape.com/article/1132465-overview#a4
  6. Center for Disease Control and Prevention (2019). Shingles (herpes zoster). Retrieved April 18, 2021, from https://www.cdc.gov/shingles/hcp/diagnosis-testing.html
  7. Kaye, K.M. (2019). Herpes zoster. [online] MSD Manual Professional Version. Retrieved April 18, 2021, from https://www.msdmanuals.com/professional/infectious-diseases/herpesviruses/herpes-zoster
  8. Nair, P.A., and Patel, B.C. (2021). Herpes zoster. [online] StatPearls. Retrieved April 18, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK441824/

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