DERMATOLOGY
VZV/SHINGLES
Prompt
Response
Trigeminal Nerve: V1 = Ophthalmic N, V2 = Maxillary, V3 =Mandibular
Trigeminal Nerve: V1 = Ophthalmic N, V2 = Maxillary, V3 =Mandibular
PromptRASH descriptors
anatomy refresher
anatomy refresherResponseDiagnosis = Herpes zoster (opthalmicus or V1 distribution)
Vescicular “clusters”, Crusting and scabs
Location - unilateral
V1 Trigemiminal dermatome (forehead and eyelid)
Underlying surrounding erythema
+/- absence of alternative pathology - bullae/bilateral involvement/blisters/target
lesions, etc.
Vescicular “clusters”, Crusting and scabs
Location - unilateral
V1 Trigemiminal dermatome (forehead and eyelid)
Underlying surrounding erythema
+/- absence of alternative pathology - bullae/bilateral involvement/blisters/target
lesions, etc.
PromptComplications of zoster opthalmicus
ResponseEye complications (may result in blindness)
Transverse myelitis - neurologic findings in limbs
Bells palsy - Facial weakness including forehead
Deafness - hearing test/tuning fork test
Bacterial superinfection - Heat/redness/purulent
Cerebrovascular event - neurologic abnormalities
Aseptic meningitis - meningism, photophobia
Ramsay hunt - vesicles in ears
- Occulur ulceration/keratitis (zoster opthalmicus) - slit lamp evidcnce of ulceration, altered visual acuity
- Acute glaucoma
- Progressive outer retinal necrosis
- uveitis/scleritis
- Optic neuritis
Transverse myelitis - neurologic findings in limbs
Bells palsy - Facial weakness including forehead
Deafness - hearing test/tuning fork test
Bacterial superinfection - Heat/redness/purulent
Cerebrovascular event - neurologic abnormalities
Aseptic meningitis - meningism, photophobia
Ramsay hunt - vesicles in ears
PromptManagement
ResponseOccular protection - eye taping (not padding due to pressure effects)
Ocular lubrication - Chlorsic grops/ointments 5 times daily + lubricant drops
Analgesia - paracetamol/ibuprofen/opioids >> amitriptyline if ongoing pain 25mg nocte (post hepetic neuralgia)
Antivirals
Ocular lubrication - Chlorsic grops/ointments 5 times daily + lubricant drops
Analgesia - paracetamol/ibuprofen/opioids >> amitriptyline if ongoing pain 25mg nocte (post hepetic neuralgia)
Antivirals
- Aciclovir for skin if <72hrs
- Eye involvement at any time - Aciclovir 800 mg 5 times daily for 1 week (+/- topical acyclovir)
- IV acyclovir if sight threatened/meningioencephalitis
PromptIndications for admission
ResponseSevere ocular involvement of globe
Pain requiring IV opioids
Systemically unwell
Suspicion of meningoencephalitis/disseminated infection
Immunocompromised
Signifiant superinfection
Pain requiring IV opioids
Systemically unwell
Suspicion of meningoencephalitis/disseminated infection
Immunocompromised
Signifiant superinfection
PromptDescribe this Rash in HIV positive person
ResponseDISSEMINATED shingles/Zoster (T2+C8 dermatome)
Crops of vescicular rash, not crossing midline.
Band like pattern
Some crusted, erythematous base
As the rash is inner arm (C8) and chest (T2) = multiple dermatomes so disseminated. Besides the skin, other organs may also be affected, causing hepatitis or encephalitis making this condition potentially lethal.
Nipples = T4, Umbilicus = T10
Investigations
Swab - PCR
CTB
LP (timing)
CXR
Management
IV aciclovir
Analgesia
Crops of vescicular rash, not crossing midline.
Band like pattern
Some crusted, erythematous base
As the rash is inner arm (C8) and chest (T2) = multiple dermatomes so disseminated. Besides the skin, other organs may also be affected, causing hepatitis or encephalitis making this condition potentially lethal.
Nipples = T4, Umbilicus = T10
Investigations
Swab - PCR
CTB
LP (timing)
CXR
Management
IV aciclovir
- 10 mg/kg IV TDS for immunocompromised with disseminated disease (eTG Jun ‘24)
Analgesia
PromptPregnant exposure to zoster
ResponseCollect baseline serology
Emotional support
VZV vaccine if immunocompetent
VZV immunoglobulin if immunocompromised
Emotional support
VZV vaccine if immunocompetent
VZV immunoglobulin if immunocompromised