HERPES ZOSTER

Oleh:
Nurul Iska Ulmarika Idris C111 10 831
R u t h Fa u s t i n e J . R ay o C 1 1 1 1 0 1 8 0
Advisor:
d r. E l f a W i r d a n i F i t r i

Supervisor:
d r. A i r i n M a p p e w a l i , S p . K k , M . K e s

DEFINITION
Herpes zoster is an infectious disease by the

varicella zoster virus that attacks the skin and

mucosa, is a reactivation of the virus infection that
occurs as a reactivation of the varicella zoster virus
entering through periferal nerve during the initial
episode of chickenpox, then settled in posterior
spinal ganglion.

EPIDEMIOLOGY
Herpes zoster occurs sporadically and not seasonally.
The average age of patients with herpes zoster is 64

years, while the average age of the U.S. population is

46 years.
The incidence of shingles ranged from 1.2 to 3.4
cases per 1,000 person-years in the study of
immunocompetent individuals in society, but
increased to 3.9 to 11.8 cases per 1,000 person-years
among those > 65 years aged.

RISK FACTOR
The main risk factor is old age
Immune dysfunction
Female gender
Physical trauma to the affected dermatome
White race
People with a family history of herpes zoster

ETIOLOGY
Varicella and herpes zoster is caused by the same

virus, called varicella-zoster virus (VZV)

VZV contain icosahedral capsid shaped surrounded
by a lipid envelope covering the virus genome, the
genome which contains a linear molecule of doublestranded DNA. 150-200 nm in diameter and has a
molecular weight of approximately 80 million.

PATHOGENESIS

VZV enters body

through URT

Reactivation
(secondary varicella
infection)

Activation of viral
replication and
production of
infectious virus

Primary varicella
infection

Decreasing immunity
(stress, fever,
radiation therapy,
tissue damage)

VZV infects out the

ganglion and the
surrounding
epithelial cells

VZV reach RES

through blood
(hematogenic)

Latent state

Herpes zoster lesion

CLINICAL MANIFESTATION

Fever, Dizzy, Malaise

Muscle pain, Itchy, Soreness

Erythematous macules and papules Vesicle, with edema at the skin base crusts in
the end.

CLINICAL MANIFESTATION
Unilateral, depend of the skin

that innervated by a single sensory

ganglion.
Mostly; trunk from T3 L2,
trigeminal nerve (ophtalmic
division).
Rarely; distal, to the elbows or
knees
Pain; 30 days following rash
onset

CLINICAL MANIFESTATION

CLINICAL MANIFESTATION

DIAGNOSE
Anamnesis & Physical Examination; see the

distribution
Histophatology; intraepidermal vesicle, acantholysis
Tzank Smears; multinucleate
giant cell, with nuclear changes
PCR; detect DNA of VZV
ELISA; enzyme linked
immunosorbent assay

COMPLICATION
Ophtalmic Zoster (1st Trigeminal Nerve);

Neurothropic Keratitis, Chronic Ulceration

2nd & 3rd Trigeminal Nerve; Ramsay-Hunt
syndrome (facial palsy), Tinnitus, Vertigo, and
Deafness
Pain Herpetic Neuralgia (PHN); Neurons
damage in the spinal cord and ganglion, to the
peripheral nerve. Its persists after the rash has
healed.

COMPLICATION
Cutaneous

Visceral

Neurologic

Bacterial Superinfection

Pneumonitis

PHN

Scarring

Hepatitis

Meningoencephalitis

Zoster Gangrenosum

Esophagitis

Tranverse Myelitis

Cutaneous Diseemination

Gastritis

Peripheral Nerve Palsies

Pericarditis

Motor

Cystitis

Autonomic

Arthritis

Cranial Nerve Palsies

Sensory Loss
Deafness
Ocular Complication

DIFFERENTIAL DIAGNOSIS
Herpes Simplex;

Vesicle (with clear fluid &

becoming seropurulen)
with erythematous, and
crusts at the end. Patient
also complaining burning,
itchy and pain feeling.
Herpes simplex can
attacking all parts of the
body.

DIFFERENTIAL DIAGNOSIS

Contact Dermatitis;

Erythema with vesicle, &

edema skin base.
Confirmation test:Patch
Test

THERAPY
Principal for HZ therapy is for (1) limit the extent,

duration, and severity of pain and rash in the primary

dermatome, (2) for prevent disease elsewhere, (3) prevent
the PHN.
Kind of treatment of HZ:
a. Topical therapy
b. Antiviral therapy
c. Anti-inflammatory therapy
d. Analgesics
e. Treatment for PHN
f. Prevention of HZ

TOPICAL THERAPY
Cool compresses
Calamine lotion
Cornstarch
Baking soda

For help to alleviate local symptoms

&hasten the drying of vesicular lesions,
for acute phase of HZ.

ANTIVIRAL THERAPY
Patient Group
Normal
Age <50 years
Age 50 years, and patient of any age,with
cranial nerve imvolvement (ex: ophtalmic
zoster)
Immunocompromised
Mild compromise, including HIV-1
infection
Severe compromise
Acyclovir resistant (ex: advanced
AIDS)

Regimen
Symptomatic treatment alone, or
Famciclovir PO 500 mg, per 8 hours, for 7 days
Valacyclovir PO 1 g, per 8 hours, for 7 days, or
Acyclovir PO 800 mg , per 8 hours, for 7 days
Famciclovir PO 500 mg, per 8 hours, for 7 days
Valacyclovir PO 1 g, per 8 hours, for 7 days, or
Acyclovir PO 800 mg , per 8 hours, for 7 days

Famciclovir PO 500 mg, per 8 hours, for 7 - 10days

Valacyclovir PO 1 g, per 8 hours, for 7 - 10 days
Acyclovir PO 800 mg , per 8 hours, for 7 - 10 days
Acyclovir IV 10 mg/kg , per 8 hours, for 7 - 10 days
Foscarnet IV40 mg /kg, per 8 hours, until healed

ANTI-INFLAMMATORY THERAPY
For prevent PHN and for curing the inflammation of

the sensory ganglion Glucocorticosteroid, during

the acute phase.
For prevent the Ramsay-Hunt syndrome.

Prednison 3 x 20mg, per day

Tappering off.

ANALGESICS
For preventing the PHN complication.
The choice, dosage, and schedule of the drugs are

governed by the patients pain severity, conditions,

and response to specific drugs.
For the pain pain scales (0 10). Prescribe and stop
the analgesics if scale is less than 3 or 4.
Pregabalin; 2 x 75 mg, for 3 7 days.

TREATMENT FOR PHN

Topical therapy
a.
b.
c.
.
a.
b.
c.
d.

5% lidocaine patch, for 12 hours a day

EMLA (Eutectic Mixture Of Local Anesthetics), once a
day
8% capsaicin patch, for 1 hour
Oral angents
Gabapentin
Placebo
Pregabalin
Opioids; morphine and TCA (Tricyclic Antidepressant)

PREVENT THE HERPES ZOSTER

Principal; for preventing reacticvation and spread

of a latent wild-type of VZV, & PHN among older

adults.
CDC: Herpes Zoster vaccine is recommended for
adults 60 years old, for prevent the HZ and its
complication
Zostavax; given by IM, as a single
dose live attenuated virus vaccine.