Herpes zoster — Clinical Case (Wikimedia Commons)

Diagnosis: Herpes zoster

Shingles or Herpes zoster virus attacking forehead and eye. Clinical photograph sourced from Wikimedia Commons (CC BY-SA 4.0). Attribution: Burntfingers.

Clinical Presentation

Unilateral dermatomal distribution of grouped vesicles on erythematous base, preceded by pain/paresthesias 1-5 days before rash. Thoracic dermatomes most common. Herpes zoster ophthalmicus (V1): risk of ocular complications. Disseminated zoster in immunocompromised.

Clinical History

History of varicella (chickenpox). Age >50 increases risk significantly. Immunosuppression: HIV, malignancy, transplant, immunosuppressive medications. Vaccination status (Shingrix). Assess for prodromal pain, which may mimic MI, cholecystitis, or renal colic.

Treatment

Antivirals within 72 hours of rash: valacyclovir 1g TID × 7 days (preferred) or acyclovir. Pain management: gabapentin, pregabalin, TCAs for PHN. HZO: urgent ophthalmology referral. Prevention: Shingrix vaccine (≥50 years or immunocompromised ≥19 years).

Differential Diagnosis

HSV, Contact dermatitis, Dermatitis herpetiformis, Insect bites, Phytophotodermatitis

Key Learnings

Hutchinson sign (vesicles on nose tip) suggests nasociliary nerve involvement — high risk of ocular complications. Ramsay Hunt syndrome: HZ of geniculate ganglion → facial palsy, ear vesicles, hearing loss. Shingrix is 90%+ effective and recommended even if prior Zostavax.

Tags: herpes zoster, shingles, VZV, viral, dermatomal