Clinical Snapshot

Three Case Studies of Herpes Zoster

Rhonda Lesniak
Kristin Mareno

Figure 1.
The “Clinical Snapshot” series provides a concise Erythematous rash originated behind the right
examination of a clinical presentation including shoulder and extended down the right arm,
history, treatment, patient education, and nursing hand, and fingers.
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 Figure 2.
erythematous rash which originated behind her right shoul- The lesions were evolving from maculopapular
der and extended down her right arm, hand, and fingers to vesicular.
(see Figures 1-3). There were multiple clusters of grouped
vesicular lesions following a linear pattern along der-
matomes 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 Figure 3.
with only minimal relief. The lesions followed a linear pattern along
Case study 2. A 70-year-old male presented with com-
dermatomes C5, C6, and C7.
plaints 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 experi-
enced 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 der-
matome 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 com-
plaints of a stinging pain on the left side of her back, fol-
lowed the next day by an eruption of red bumps which
became more pronounced and raised over the next sever-
al days (see Figure 5). The pain became bothersome and
interfered with sleep. She used anti-itch cooling gel topical-

Rhonda 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.

DERMATOLOGY NURSING/July-August 2009/Vol. 21/No. 4 211

 Figure 4. Figure 5.
The erythematous maculopapular and vesicular lesions Erythematous papules and clustered vesicles began
were in clustered groups from left buttock traveling on the back.
down to mid-calf.

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 sub-
stances. There were erythematous papules, along with clus-
tered 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 cuta-
neous 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 reacti-
vation of varicella zoster virus (VZV) or chickenpox. In the matome, it may involve one or two adjacent dermatomes.
United States, 90% to 100% of adults have serologic evi- Thoracic dermatomes are most commonly affected fol-
dence of VZV, putting them at risk for herpes zoster. lowed by cervical, lumbrosacral, and trigeminal involve-
Lifetime incidence ranges from 10% to 20%. It affects all ment. Vesicles and erosions can occur in the mouth, vagi-
ages; however, most cases occur in those greater than 55 na, and bladder depending on dermatome involvement.
years of age. In addition to advanced age, other risk factors Infection in the ophthalmic branch of the trigeminal nerve
include malignancy, immunosuppressive illnesses, drugs can result in severe and permanent eye damage.
(such as corticosteroids), and medical treatments (such as Etiology: Herpes zoster results from the reactivation
radiation). of VZV that previously entered the cutaneous nerves from
Location: The distribution of the rash is dermatomal an episode of chickenpox. The virus travels to the dorsal
and unilateral, not crossing the midline of the body. root ganglia where it remains in a latent form until reacti-
Although the eruption is usually isolated to a single der- vation. Virus reactivation is triggered by the decline in

212 DERMATOLOGY NURSING/July-August 2009/Vol. 21/No. 4

virus-specific, cell-mediated immune responses that occur the affected area for 20 minutes several times daily.
naturally with age as well as immunosuppression from dis- Domeboro® (aluminum sulfate; calcium acetate) soaks may
ease, drugs, trauma, tumor, or irradiation. The disease also be utilized and Betadine® (povidone-iodine) soaks may
manifests in three clinical stages: prodromal, active, and help to remove the crust and serum. The patient may find
chronic. The prodrome of tingling, itching, pain, and paras- oatmeal baths to be soothing, as well as topical treatments,
thesia along the dermatome precedes the eruption by as such as calamine or diphenhydramine. The patient should
much as 3 weeks to a few days, and symptoms may include be encouraged to wear cool, loose-fitting clothing to avoid
headache, fever, and malaise. The active or eruptive phase rubbing the lesions with the clothing. Emotional support is
lasts for 3 to 7 days and evolves through stages of pustula- encouraged as the pain and stigma can be debilitating.
tion, ulceration, and crusting. In 2 to 4 weeks healing
occurs and the crusts fall off. The chronic phase refers to the Suggested Readings
postherpetic neuralgia or chronic pain that persists greater Bielan, B. (20 08). What’s your assessment?: A collection of classic dermatol -
than 4 weeks after the onset of lesions or after the lesions ogy case presentations and differential diagnoses. Pitman, NJ: Jannetti
Publications, Inc.
have healed. Goldsmith, L.A., Lazarus, G.S., & Tharp, M.C. (1997). Adult and pedi -
Hallmark of the Disease: The classic presentation of atric dermatology: A color guide to diagnosis and treatment.
this disease is the unilateral manifestation of red, swollen Philadelphia: F.A. Davis Company.
plaques involving a single dermatome forming a band-like Graham, M.V. (20 03). Skin problems in children and adults. In C.R.
Uphold & M.V. Graham (Eds.), Clinical guidelines in family prac -
pattern on one side of the body. These lesions evolve into
tice (pp. 247-315). Gainesville, FL: Barmarrae Books, Inc.
clusters of vesicles with an erythematous base. The rash is Habif, T.P. (20 04). Clinical dermatology: A color guide to diagnosis and ther -
preceded by pain, itching, or burning along the der- apy. Philadelphia: Mosby.
matome. Constitutional symptoms of fever, headache, and Habif, T.P., Campbell, J.L., Chapman, M.S., Dinulos, J.G., & Zug,
malaise may also precede the eruption by several days. K.A. (20 06). Dermatology DDxDeck. Philadelphia: Mosby.
Wolff, K., Johnson, R., & Suurmond, D. (20 05). Fitzpatrick’s color atlas
Diagnosis: In most cases, diagnosis is based strictly on & synopsis of clinical dermatology. New York: McGraw-Hill.
clinical findings; lab confirmation is usually not necessary.
Laboratory confirmation uses the same methods for identi-
fying herpes simplex. The test of choice is the Tzanck
smear. This cytologic smear cannot differentiate herpes
simplex from varicella. Other possible methods for identi-
fication 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 shed-
ding, 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 antide-
pressants may be prescribed. Oral steroids may be admin-
istered to control acute pain. Postherpetic neuralgia may be
prevented by early and aggressive treatment.
Normal Course: The lesions may resolve over a peri-
od 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 pos-
therpetic neuralgia. Persons 60 years of age and older are
advised to have the Zostavax® vaccine.
Nursing Measures: Apply cool, wet compresses to

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