Zoster is caused by the reactivation of the varicella-zoster virus (VZV, human herpesvirus 3, HHV-3, chickenpox). After the primary infection, VZV lies dormant in the dorsal root ganglia. The time between the onset of primary chickenpox and reactivation can be any time but usually decades later. Approximately 10% to 20% of the U.S. population eventually develop one or more cases of zoster in their lifetime. The incidence is much higher in immunocompromised patients and older adults. These rates are likely to decrease over time now that a VZV vaccine is given as part of the routine immunization schedule in children.
Patients typically experience pain and paresthesias, followed by the appearance of small groups of vesicles on an erythematous base in a dermatomal distribution (Fig. 33-55). The rash rarely crosses the midline of the body and is usually confined to a single dermatome. The eruption may be accompanied by a fever, headache, and malaise. Lesions usually resolve in 2 to 3 weeks. Pain can be severe and may persist long after skin lesions heal in a condition known as
postherpetic neuralgia. Corneal involvement should be suspected when lesions appear on the tip of the nose or in the distribution of cranial nerve VI and should prompt an emergency ophthalmology consultation because this can cause permanent blindness (Fig. 33-56).
Antiviral therapy such as acyclovir, valacyclovir, and famciclovir should be started within the first 3 days of onset of symptoms, to reduce the severity and duration of symptoms and skin lesions. Early treatment may also reduce the incidence and severity of postherpetic neuralgia. However, benefits can be seen even if started up to 7 days after onset of symptoms. Analgesics such as acetaminophen and even narcotics are sometimes required to control the pain caused by zoster. Cool compresses may also help soothe during the acute phase. Postherpetic neuralgia occurs in up to 40% of adult patients over age 60 but in less than 10% of patients less than 60. In 2006 the FDA approved a live, attenuated vaccine (Zostavax) for adults over 60 years who are immunocompetent and have not already had zoster. The vaccine decreased the burden of illness by 61% and decreased the incidence of postherpetic neuralgia by 67% in large clinical trials (Oxman et al., 2005).
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