Clinical Snapshot

Three Case Studies of Herpes Zoster

Rhonda Lesniak Kristin Mareno The Clinical Snapshot series provides a concise examination of a clinical presentation including history, treatment, patient education, and nursing measure s. Using the format here, you are invited to submit your Clinical Snapshot to Dermatology Nursing.
History: Case study 1. An 83-year-old female presented with complaints of a burning and tingling sensation behind her right shoulder, followed 1 day later by an eruption of an erythematous rash which originated behind her right shoulder and extended down her right arm, hand, and fingers (see Figures 1-3). There were multiple clusters of grouped vesicular lesions following a linear pattern along dermatomes C5, C6, and C7. The lesions were evolving from maculopapular to vesicular lesions approximately 1 to 5 mm in size. There were no signs of infection. The patient complained of intense pain and denied exposure to poison ivy, oak, or sumac, or any other irritating exposure out of her ordinary routine. She was unsure about recent exposure to chickenpox and denied any compromise of her immune system. She had been using hydrocortisone 0.5% cream with only minimal relief. Case study 2. A 70-year-old male presented with complaints of a rash on his left buttock and the back of his left thigh (see Figure 4). He reported a sharp, stabbing pain at the top of the posterior left leg and down the posterior leg 2 days prior to the eruption of the rash. He also experienced chills at that time. He denied any exposure to harsh or irritating allergens or substances. He had been applying body lotion to the rash with no relief. The erythematous maculopapular and vesicular lesions were evolving and spreading in clustered groups from his left buttock at dermatome S3 and going down the posterior left leg, following dermatome S2, and ending at mid-calf, with no signs of infection. Case study 3. A 46-year-old female presented with complaints of a stinging pain on the left side of her back, followed the next day by an eruption of red bumps which became more pronounced and raised over the next several days (see Figure 5). The pain became bothersome and interfered with sleep. She used anti-itch cooling gel topicalRhonda Lesniak, PhD, ARNP, FNP-BC, is an Adjunct Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL, and a Family Nurse Practitioner, The Little Clinic, Deerfield Beach, FL. Kristin Mareno, MS, ARNP, FNP-BC, is a Family Nurse Practitioner, The Little Clinic, Deerfield Beach, FL.

Figure 1. Erythematous rash originated behind the right shoulder and extended down the right arm, hand, and fingers.

Figure 2. The lesions were evolving from maculopapular to vesicular.

Figure 3. The lesions followed a linear pattern along dermatomes C5, C6, and C7.

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Figure 4. The erythematous maculopapular and vesicular lesions were in clustered groups from left buttock traveling down to mid-calf.

Figure 5. Erythematous papules and clustered vesicles began on the back.

Figure 6. The lesions wrapped around the left flank, ending just above the umbilicus.

ly with some relief and took diphenhydramine (Benadryl) at night to help her sleep. The patient reported mild itching and pain which seemed beneath the surface of the skin. She had chickenpox as a child. However, she denied any recent exposure to plants, detergents, or other irritating substances. There were erythematous papules, along with clustered vesicles, beginning at dermatomes T8 to T10 in the middle of her back, traveling around her left flank, and ending just above the umbilicus (see Figure 6). Description: Herpes zoster (HZ) or shingles is a cutaneous viral infection usually involving the skin of a single dermatome. It is characterized by unilateral pain followed by a vesicular or bullous eruption. HZ results from reactivation of varicella zoster virus (VZV) or chickenpox. In the United States, 90% to 100% of adults have serologic evidence of VZV, putting them at risk for herpes zoster. Lifetime incidence ranges from 10% to 20%. It affects all ages; however, most cases occur in those greater than 55 years of age. In addition to advanced age, other risk factors include malignancy, immunosuppressive illnesses, drugs (such as corticosteroids), and medical treatments (such as radiation). Location: The distribution of the rash is dermatomal and unilateral, not crossing the midline of the body. Although the eruption is usually isolated to a single der-

matome, it may involve one or two adjacent dermatomes. Thoracic dermatomes are most commonly affected followed by cervical, lumbrosacral, and trigeminal involvement. Vesicles and erosions can occur in the mouth, vagina, and bladder depending on dermatome involvement. Infection in the ophthalmic branch of the trigeminal nerve can result in severe and permanent eye damage. Etiology: Herpes zoster results from the reactivation of VZV that previously entered the cutaneous nerves from an episode of chickenpox. The virus travels to the dorsal root ganglia where it remains in a latent form until reactivation. Virus reactivation is triggered by the decline in

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virus-specific, cell-mediated immune responses that occur naturally with age as well as immunosuppression from disease, drugs, trauma, tumor, or irradiation. The disease manifests in three clinical stages: prodromal, active, and chronic. The prodrome of tingling, itching, pain, and parasthesia along the dermatome precedes the eruption by as much as 3 weeks to a few days, and symptoms may include headache, fever, and malaise. The active or eruptive phase lasts for 3 to 7 days and evolves through stages of pustulation, ulceration, and crusting. In 2 to 4 weeks healing occurs and the crusts fall off. The chronic phase refers to the postherpetic neuralgia or chronic pain that persists greater than 4 weeks after the onset of lesions or after the lesions have healed. Hallmark of the Disease: The classic presentation of this disease is the unilateral manifestation of red, swollen plaques involving a single dermatome forming a band-like pattern on one side of the body. These lesions evolve into clusters of vesicles with an erythematous base. The rash is preceded by pain, itching, or burning along the dermatome. Constitutional symptoms of fever, headache, and malaise may also precede the eruption by several days. Diagnosis: In most cases, diagnosis is based strictly on clinical findings; lab confirmation is usually not necessary. Laboratory confirmation uses the same methods for identifying herpes simplex. The test of choice is the Tzanck smear. This cytologic smear cannot differentiate herpes simplex from varicella. Other possible methods for identification include skin biopsy, antibody titers, vesicular fluid immunofluorescent antibody stains, electron microscopy, and culture. Treatment: To reduce pain and inflammation, prevent postherpetic neuralgia, vesicle formation, and viral shedding, oral antiviral medications are indicated, preferably initiated within 48 hours of prodromal symptoms or rash eruption. The recommended agents are valacyclovir (Valtrex) 1 gram by mouth three times daily for 7 days, or famciclovir (Famvir) 500 mg by mouth three times daily for 7 days, or acyclovir (Zovirax) 800 mg by mouth five times daily for 7 to 10 days. Valtrex and Famvir are more effective in preventing the development of postherpetic neuralgia. Antihistamines may be used at night to aid in sleeping. For acute pain, short-acting narcotics and antidepressants may be prescribed. Oral steroids may be administered to control acute pain. Postherpetic neuralgia may be prevented by early and aggressive treatment. Normal Course: The lesions may resolve over a period of 2 to 4 weeks; however, this may take longer with those who are immunocompromised or elderly. There may be scarring and pigmentation changes. Patient Education: The patient should be educated about the potential of developing secondary lesions, which may become infected, if too much scratching occurs. Also, the patient should be warned about exposure to babies, pregnant women, and persons with compromised immune systems. They also need to be aware of symptoms of postherpetic neuralgia. Persons 60 years of age and older are advised to have the Zostavax vaccine. Nursing Measures: Apply cool, wet compresses to

the affected area for 20 minutes several times daily. Domeboro (aluminum sulfate; calcium acetate) soaks may also be utilized and Betadine (povidone-iodine) soaks may help to remove the crust and serum. The patient may find oatmeal baths to be soothing, as well as topical treatments, such as calamine or diphenhydramine. The patient should be encouraged to wear cool, loose-fitting clothing to avoid rubbing the lesions with the clothing. Emotional support is encouraged as the pain and stigma can be debilitating.
Suggested Readings
Bielan, B. (20 08). Whats your assessment?: A collection of classic dermatol ogy case presentations and differential diagnoses. Pitman, NJ: Jannetti Publications, Inc. Goldsmith, L.A., Lazarus, G.S., & Tharp, M.C. (1997). Adult and pedi atric dermatology: A color guide to diagnosis and treatment. Philadelphia: F.A. Davis Company. Graham, M.V. (20 03). Skin problems in children and adults. In C.R. Uphold & M.V. Graham (Eds.), Clinical guidelines in family prac tice (pp. 247-315). Gainesville, FL: Barmarrae Books, Inc. Habif, T.P. (20 04). Clinical dermatology: A color guide to diagnosis and ther apy. Philadelphia: Mosby. Habif, T.P., Campbell, J.L., Chapman, M.S., Dinulos, J.G., & Zug, K.A. (20 06). Dermatology DDxDeck. Philadelphia: Mosby. Wolff, K., Johnson, R., & Suurmond, D. (20 05). Fitzpatricks color atlas & synopsis of clinical dermatology. New York: McGraw-Hill.

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