Our topic here is shingles.
In other words, herpes zoster.
The etiology is a reactivation of latent Varicella-zoster virus, or VZV,
in a patient that has had chicken pox or has been immunized with the Varicella vaccine.
The latent virus is not infectious,
but when reactivated from the dorsal root ganglion later in life causes a painful dermatomal rash known as shingles.
This can be seen more often in the elderly and can be brought on by severe stress at any age.
And then you can imagine
that this particular virus
is making its way
down the dermatome,
and when it does, whoa,
man, this thing hurts.
Well, you can imagine that if this is
herpes, then what are you going to find?
These fluid-filled type of
structures called vesicles.
So you have a reticular pain followed
by your vesicles and ultimate crusts.
Rarely disseminated in
If you take a look at the dermatome
in this particular individual,
you’ll notice that you have vesicle type of
formation that’s taking place on the skin
and it’s usually some type of history of
immunocompromise in this patient and it hurts.
Most common in elderly.
Immunity to VZV.
Also could be seen with immunosuppression.
With herpes, you automatically think
about, well, Tzanck smear as we shall see.
Not typically diagnosed.
You could tell by the history of your
patient this is what’s taking place.
Fresh lesions can be
scraped with your blade.
Examined in clinic using
perhaps Giemsa and Wright,
but result is called or
from your Tzanck smear.
Both HSV and VZV will show,
as you seen in this picture,
on Tzanck smear.
That’s where you focus
Herpes zoster or herpes in general.
You should be thinking Tzanck
and you should be thinking
and here, specifically, if it’s in
the skin and in your keratinocytes,
as you see in this image.
Management of herpes zoster and the painful rash of shingles includes
oral antiviral medications such as acyclovir, valacyclovir, or famciclovir.
These medications need to be started within 72 hours of the rash outbreak to be effective.
Steroids do not decrease the risk of post-herpetic neuralgia and chronic pain,
but may be used to help with moderate to severe acute pain, along with short-term opioid analgesics.
Most cases of shingles are self-limited, but risk of post-herpetic neuralgia increases with age.
If post-herpetic neuralgia develops,
it may last months or years and may be treated with agents used to help
with chronic pain such as amitriptyline or gabapentin.