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INTRODUCTION

Herpes zoster is most common in older adults and immunosupressed
individual.
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Zoster is caused by reactivation of Varicella Zoster Virus. Following
primary infection, VZV remains latent in the sensory dorsal root ganglion cells.
The dermatomes most frequently affected are the thoracic (55%), cranial (20%,
with the trigeminal nerve being the most common single nerve involved), lumbar
(15%), and sacral (5%).
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Incidence of zoster rises steadily until adulthood and remains constant
with about 23 cases per 1,000 per year until the end of the fourth decade of life.
In persons older than 50 years of age the incidence strongly increases to
approximately 5 cases per 1,000 persons per year. Individuals in the sixth to
seventh decade have an incidence rate of 67 cases per 1,000 and individuals
beyond the age of 80 have an incidence of more than 10 cases per 1,000 per year.
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Important elements in establishing the diagnosis by observation include
painful or abnormal sensory prodrome in dermatomal distribution, grouped
vesicles multiple sites filling the dermatome, especially where divisions of the
sensory nerve are represented, lack of history of a similar rash in the same
distribution (to rule out recurrent zosteriform herpes simplex; and (6) pain and
allodynia in the area of the rash. Allodynia, which is common in both HZ and
PHN, is pain evoked by a stimulus that does not normally cause painfor
example, light brushing of the affected area with a cotton swab.
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The lession of varicella and herpes zoster are indistinguishable by
histopatology. The presence of multinucleated giant celss and ephitelial cell
containing acidophillic intranuclear inclusion bodies distinguishes the cutaneous
lession produced by VZV from all other vesivular eruptions. These celss can be
prepared bedside, material is scrapped from the base of an early vesicles and
spread on a glass slide, fixed in acetone or methanol and stained with giemsa.
Punch biopsies provide more reliable material for histopatologic examination than
tzanck smears and facilitate diagnosis in the prevesicular stage and in typical
lessions. VZV is extremely labile and only 30%-60% of cultures from proven
cases are generally positive. Deetection of VZV DNA in clinical specimens after
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amplification by PCR provides the greatest assay sensitivity, very high specifity
and rapid turn-around time. It has revolutionized the diagnosis of VZV
infections.
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Antiviral therapy is first-line treatment and should be initiated within 72
hours of rash onset to increase the rate of healing and decrease pain. Acyclovir,
famciclovir, and valacyclovir are approved by the U.S. Food and Drug
Administration (FDA) for the treatment of acute herpes zoster. Antivirals alone
are usually insufficient to relieve the often debilitating pain of acute herpes zoster.
Mild to moderate pain may be controlled with acetaminophen or nonsteroidal
anti-inflammatory drugs, alone or in combination with a weak opioid or tramadol.
Moderate to severe pain requires scheduled opioids (e.g., oxycodone, morphine).
If pain does not rapidly respond to opioid analgesics or if opioids are not tolerated,
the prompt addition of an adjunctive therapy should be considered. Nortriptyline,
gabapentin, and pregabalin have been recommended, but they have not been
extensively studied for pain relief in patients with acute herpes zoster.
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Postherpetic neuralgia is the most common complication of herpes zoster.
Postherpetic neuralgia may persist from 30 days to more than six months after the
lesions have healed, and most cases resolve spontaneously. Herpes zoster
ophthalmicus (ophthalmic zoster) occurs in 5 to 10 percent of patients with herpes
zoster and may lead to permanent vision loss and cranial nerve palsies. Other
complications are superimposed bacterial skin infections with streptococci and
staphylococci should be treated with appropriate oral antibiotics. Encephalitis,
meningitis, myelitis, and disseminated cutaneous and visceral disease may occur
in patients with severe immunosuppression.
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Herpes zoster ophthalmicus (HZO) is manifested by localized pain over
the distribution of the first division of the trigeminus cutaneous vesicular eruption
around the forehead. There are also frequently lymph node enlargement in the
defined area, headache, sometimes neck stiffness and a red eye.
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