Day #42 - Herpes Zoster (Shingles)

This morning we discussed a case of dermatomal vessiculobullous lesions in an immunosuppressed patient.

Differential diagnosis of vessiculobullous lesions::

• Herpes zoster
• Herpes simplex
• Bullous impetigo (staph/strep)
• Ecthyma gangenosum (gram neg esp pseudomonas)
• Hemorhagic bullous cellulitis (nec fasc, clostridial myonecrosis, vibrio
• vulnificus)

• Dermatitis herpeteformis
• Bullous skin diseases (eg bullous pemphigoid)

Treatment of herpes zoster (shingles):

Should be given to:

• Immunocomprimised patients
  
• V1 Zoster (Zoster Opthalmicus)
• Ramsey hunt syndrome
• Pregnant patients
• Age over 50 (decreases incidence of zoster associated pain)
  

Should be offered to all patients within 72h of lesions

Treatment options:

Disseminated Zoster (multiple non-contiguous dermatomes) or visceral/end organ involvement should probably be initially treated with IV.

Acyclovir 10mg/kg iv q8h (needs to be renal dosed, is nephrotoxic - need to keep extremely
well hydrated to prevent acyclovir crystals causing ATN)

Acyclovir 800mg po FIVE TIMES DAILY
Famciclovir 500mg po TID
Valacyclovir 1000mg po TID

Duration depends on clinical context. Non-immunosuppressed uncomplicated zoster - 7 days

The article on the zoster vaccine is here.