DERMA ZERO TERM TOPICS
Zoster (Herpes Zoster, Shingles) - definition, epidemiology, pathogenesis, clinical
features, complications, different diagnosis, treatment.
- Zoster “Herpes Zoster, Shingles” – segmental “dermatomal” painful skin
disease caused by VZV “HHV3” reactivation. In 50-70. Chickenpox (varicella)
affects children & Shingles affects adults.
▪ Epidemiology: ∼ 1 in 3 people in US will develop HZ during their life
▪ Pathogenesis: spread by close-skin contact. VZV persists life-long in infected pts
in sensory ganglia of spinal cord & spinal nerves. When reactivated, follows
nerves to skin.
▪ Clinical manifestations:
▪ Prodromal phase: dysesthesia or pain in area of nerve for 7 days
▪ Eruption of vesicles, then pustules on erythematous base for 7 days, in
dermatomes (& immediate neighbours), on trunk or face
▪ Healing with drying, crusting & scarring
▪ Complications:
▪ Ocular involvement – ophthalmic nerve involvement. Produce s
keratitis, corneal erosions, conjunctivitis, iridocyclitis, glaucoma, optic
neuritis, double vision, facial paralysis.
◦ Hutchinson sign – vesicles on tip of nose. Indicates nasociliary nerve
involvement.
▪ Otic involvement – vestibulococclear nerve involvement. Leads to reduced hearing,
vertigo & zoster lesions in tympanic membrane & outer ear.
◦ Ramsay Hunt Syndrome – involvement of facial & vestibulococclear nerves. Leads
to facial paralysis, hearing loss, vertigo & zoster lesions.
▪ Generalized zoster – in HIV.
▪ Complications: Postherptic neuralgia – pain in involved dermatome lasting more than 6
weeks.
▪ Differential diagnosis: HSV, impetigo, candida, CD, DH
▪ Diagnostic approaches: tzanck smear, immuno smear.
▪ Therapy:
▪ Acute zoster: drying measures, antiviral therapy.
▪ To avoid PHN, since we have skin lesion we have 24h
to treat pt with Acyclovir (5x800mg /day)
◦ If PHN occurs, give oral GCS
▪ Postherpetic neuralgia:
◦ Stage 1: NSAIDs
◦ Stage 2: Add weak opiate analgesics such as tramadol or codeine
◦ Stage 3: Add strong central-acting opiate such as buprenorphine or morphine
◦ If very neuralgic pain, consider adding carbamazepine (antiepileptics) (1st line)
, Herpes simplex virus infection - definition, pathogenesis, epidemiology, clinical features
typical and complications, differential diagnosis, therapy
Genital HSV infections - epidemiology, clinical features and treatment.
- Herpes Simplex Virus – diseases caused by HSV1 or HSV2
▪ Pathogenesis:
▪ Initial infection: HSV enters via small defects in skin or mucosa & replicates locally.
Then spreads via axons to sensory ganglia for further replication. Thg centrifugal
spread via other nerves affects wider areas. After resolution of primary infection, virus
remains latent in sensory ganglia. Incubation period is 6-8 days.
▪ Recurrent infection: reactivation of virus by stimuli (UV, fever, immunosuppression),
leads to seeding of virus into area served by sensory ganglia
▪ Epidemiology:
▪ Almost everyone suffers HSV1. First infection is silent in
90%, non-specific in 9% & clinically manifests in 1%. HSV2
appears in sexually active & affects 25-50% of population.
Both viruses can be shed when pt is asymptomatic.
▪ Orofacial HSV infections:
▪ Initial infection – herpetic gingivostomatitis. In infants,
extensive erosions with haemorrhagic crusts on lips &
oral mucosa.
▪ Recurrences – small blisters on erythematous base
rapidly become pustules & then eroded. Often painful
with dysesthesia & neuralgias. On lips “herpes labialis”,
chin, cheeks, periorbital region
▪ Eczema herpeticum – pts with Atopic Dermatitis develop
extensive orofacial HSV infections which disseminate
(especially to neck)
▪ Periungual HSV infection “Herpetic Whitlow” (infection of skin around fingernail) –
most often in doctors, dentists & health personal. Periungual erythema, pain & then
vesicles. OBS do not mistake with bacterial or candidal infection, check
lymphadenopathy to exclude HSV
▪ Genital HSV infections:
▪ Initial infection – disseminated, rapidly eroded vesicles leading to small painful
superficial ulcers & bilateral lymphadenopathy.
◦ Burning or pain on urination
◦ Cervix involved in women
◦ Systemic symptoms: malaise, fever, headache
◦ Healing after 2-3 weeks
▪ Recurrences – blisters or pustules on erythematous base
▪ Herpes gladiatorum - HSV1 infection in wrestling or other close sports
▪ HSV encephalitis – HSV1 is the most common cause of viral
encephalitis in adults. In temporal lobes & limbic system. Quick
diagnosis by MRI. 80% mortality.
▪ Neonatal HSV – HSV2 in birth canal with infection to newborn. Potential
for HSV sepsis. Course in newborns tends to be severe due to incomplete
immunity. Caesarean section is indicated.
Zoster (Herpes Zoster, Shingles) - definition, epidemiology, pathogenesis, clinical
features, complications, different diagnosis, treatment.
- Zoster “Herpes Zoster, Shingles” – segmental “dermatomal” painful skin
disease caused by VZV “HHV3” reactivation. In 50-70. Chickenpox (varicella)
affects children & Shingles affects adults.
▪ Epidemiology: ∼ 1 in 3 people in US will develop HZ during their life
▪ Pathogenesis: spread by close-skin contact. VZV persists life-long in infected pts
in sensory ganglia of spinal cord & spinal nerves. When reactivated, follows
nerves to skin.
▪ Clinical manifestations:
▪ Prodromal phase: dysesthesia or pain in area of nerve for 7 days
▪ Eruption of vesicles, then pustules on erythematous base for 7 days, in
dermatomes (& immediate neighbours), on trunk or face
▪ Healing with drying, crusting & scarring
▪ Complications:
▪ Ocular involvement – ophthalmic nerve involvement. Produce s
keratitis, corneal erosions, conjunctivitis, iridocyclitis, glaucoma, optic
neuritis, double vision, facial paralysis.
◦ Hutchinson sign – vesicles on tip of nose. Indicates nasociliary nerve
involvement.
▪ Otic involvement – vestibulococclear nerve involvement. Leads to reduced hearing,
vertigo & zoster lesions in tympanic membrane & outer ear.
◦ Ramsay Hunt Syndrome – involvement of facial & vestibulococclear nerves. Leads
to facial paralysis, hearing loss, vertigo & zoster lesions.
▪ Generalized zoster – in HIV.
▪ Complications: Postherptic neuralgia – pain in involved dermatome lasting more than 6
weeks.
▪ Differential diagnosis: HSV, impetigo, candida, CD, DH
▪ Diagnostic approaches: tzanck smear, immuno smear.
▪ Therapy:
▪ Acute zoster: drying measures, antiviral therapy.
▪ To avoid PHN, since we have skin lesion we have 24h
to treat pt with Acyclovir (5x800mg /day)
◦ If PHN occurs, give oral GCS
▪ Postherpetic neuralgia:
◦ Stage 1: NSAIDs
◦ Stage 2: Add weak opiate analgesics such as tramadol or codeine
◦ Stage 3: Add strong central-acting opiate such as buprenorphine or morphine
◦ If very neuralgic pain, consider adding carbamazepine (antiepileptics) (1st line)
, Herpes simplex virus infection - definition, pathogenesis, epidemiology, clinical features
typical and complications, differential diagnosis, therapy
Genital HSV infections - epidemiology, clinical features and treatment.
- Herpes Simplex Virus – diseases caused by HSV1 or HSV2
▪ Pathogenesis:
▪ Initial infection: HSV enters via small defects in skin or mucosa & replicates locally.
Then spreads via axons to sensory ganglia for further replication. Thg centrifugal
spread via other nerves affects wider areas. After resolution of primary infection, virus
remains latent in sensory ganglia. Incubation period is 6-8 days.
▪ Recurrent infection: reactivation of virus by stimuli (UV, fever, immunosuppression),
leads to seeding of virus into area served by sensory ganglia
▪ Epidemiology:
▪ Almost everyone suffers HSV1. First infection is silent in
90%, non-specific in 9% & clinically manifests in 1%. HSV2
appears in sexually active & affects 25-50% of population.
Both viruses can be shed when pt is asymptomatic.
▪ Orofacial HSV infections:
▪ Initial infection – herpetic gingivostomatitis. In infants,
extensive erosions with haemorrhagic crusts on lips &
oral mucosa.
▪ Recurrences – small blisters on erythematous base
rapidly become pustules & then eroded. Often painful
with dysesthesia & neuralgias. On lips “herpes labialis”,
chin, cheeks, periorbital region
▪ Eczema herpeticum – pts with Atopic Dermatitis develop
extensive orofacial HSV infections which disseminate
(especially to neck)
▪ Periungual HSV infection “Herpetic Whitlow” (infection of skin around fingernail) –
most often in doctors, dentists & health personal. Periungual erythema, pain & then
vesicles. OBS do not mistake with bacterial or candidal infection, check
lymphadenopathy to exclude HSV
▪ Genital HSV infections:
▪ Initial infection – disseminated, rapidly eroded vesicles leading to small painful
superficial ulcers & bilateral lymphadenopathy.
◦ Burning or pain on urination
◦ Cervix involved in women
◦ Systemic symptoms: malaise, fever, headache
◦ Healing after 2-3 weeks
▪ Recurrences – blisters or pustules on erythematous base
▪ Herpes gladiatorum - HSV1 infection in wrestling or other close sports
▪ HSV encephalitis – HSV1 is the most common cause of viral
encephalitis in adults. In temporal lobes & limbic system. Quick
diagnosis by MRI. 80% mortality.
▪ Neonatal HSV – HSV2 in birth canal with infection to newborn. Potential
for HSV sepsis. Course in newborns tends to be severe due to incomplete
immunity. Caesarean section is indicated.
