SUPERVISOR

dr. ROSMINI MAROLA, Sp.KK

ADVISOR
dr. RATNA WULANDARI

PRESENTED BY
Anis Nadzirah Zainuddin C111 08 772
Norlisa Zakirai @ Zakaria C111 08 806
Ayu Nurmuliawati Hanapi C111 08 328
 HERPES ZOSTER
Commonly known as shingles.
Herpes zoster is a viral disease
characterized by a painful skin rash with
unilateral and segmental blisters
distribution.
 Epidemiology
Increasing age
Immunosuppression
Bone marrow and solid organ transplantation
Patients with hematological malignancies
and solid tumors
HIV
Immunosuppressive medications
Early varicella (in utero, infancy): Increased
risk of zoster in childhood
 Etiology
Reactivation of varicella zoster virus
(VZV)
The structure of the virus has
icosahedral nucleocapside surrounded
by a lipid envelope.
150-200 nm in diameter and has a
molecular weight of about 80 million
Pathophysiology
Varicella Zoster Virus (VZV)
Spreads by hematogenic or
neural retrograd transport

VZV establishes permanent latent

infection in dorsal root and cranial
nerve ganglion

During primary varicella infection, the

virus in the blood will replicate in the
regional lymphnodes for 3-4 days.

Secondary viremia develops after

the second cycle of viral
replication in the liver, spleen, and
other organs
Epidermal capillary endothelial
cells around 14-16 days

From the skin and mucosal lesions to

invade the dorsal root ganglion

The reactivation of the virus replicates and

then damage the sensory ganglion
inflammation
1. Pre-eruptive or Pre-herpetic Neuralgia
(PHN) phase
Prodromal symptoms:
-Hyperaesthesia at subcutaneous area
-Fever, lymphadenopathy, malaise &
headache
Prodromal sign usually negative for
children
2. Eruptive phase
Erythematous plaque/maculopapular appeared following the
nerve dermatomes within 12-24 hours.
Vesicle appeared at the middle of plaque after 2-4 days and the
vesicle confluent with each other.
After 72 hours, they evolved to pustule .
The confluent of vesicle after they ruptured, it turns to crust
and it takes 2-3 weeks.
3. Chronic or Post-herpetic Neuralgia
This phase begin as all the lesion become
crusted or acute infection or recurrent of
disease occurred.
Pain in PHN divided into 2 type:
-burning sensation + hyperaesthesia
-shooting spasmodic
Syndrome that cause from Herpes Zoster:
-Trigeminal Herpes zoster, Motoric involvement,
Trigeminal Herpes Zoster, Opthalmicus Herpes
Zoster, Oticus Herpes Zoster, Ramsay-Hunt
syndrome
 Lagophthalmus and Bell
Ophthalmicus Herpes Zoster Palsy appearance in
Herpes Zoster
 Laboratory examination
Tzank test
Biopsy
PCR Datia cell or multinuclear cell appearance

Virus Culture
Serologic test

Subcorneal vesicle with multinuclear

squamous cell
 Diagnosis
HERPES ZOSTER
Efflorescence: Lesion are Polymorphic,
unilateral and follow the dermatome that
involved.
Reactivation of VZV after primary infection
occurs.
Tzank test and histopathologic examination
are positive Datia cell or multinuclear
giant cell or Lipschutz bodies
 Differential Diagnosis
1.Herpes Simplex
2.Contact dermatitis
3.Insect bite
 Treatment and Management
1. Topical therapy
Cold compress Reduce the lesion
symptoms
Lidocaine patch maximally applied as
much as 3 patches per day
2. Systemic therapy
Antivirus
For normal patient:
- Acyclovir (5 x 800 mg for 7 days)
- Famciclovir (500 mg every 8 hours for 7 days)
- Valaciclovir (1 g 3 times per day for 7 days)

For immunosuppressive patient:

- Acyclovir (10 mg/kg Intravenously every 8
hours within 7 -10 days)
3. Corticosteroid
Prednison
- Starting dosage: 60 mg, given everyday
for 7 days. Then, tapper the dosage as
much as 30 mg and given for 7 days. The
dosage tappered until 15mg for 7 days.
After that, stop the treatment with
corticosteroid.
4. Analgetic
Opiod analgetic (oxycodone)
- Starting dosage: 5 mg every 4 hours.
Given when necessary
Tramadol
- Starting dosage: 50 mg once/twice per
day
 Complication
Ocular
- Conjunctivitis, ptosis paralytic, epithelial
keratitis, scleritis, iridocyclitis, uveitis,
glaucoma
Skin
- Scarring, keloid, granulomatosis dermatitis,
granulomatosis vasculitis, comedo
Neurology
- Post herpetic neuralgia (PHN)
 Prognosis
Generally, the prognosis is good.
For ophthalmic herpes zoster, the prognosis is
based on early diagnosis and treatment.
The lesion of herpes zoster usually subside
within 10 to 15 days.
For older patients, they are tend to develop
PHN, bacterial infection, and scarring.