Herpes zoster (HZ), or shingles, is reactivation of the latent varicella-zoster virus with dermatomal distribution. Up to 20% of people experience HZ during their lives.1 Incidence of herpes zoster among whites is 1.3 cases per 1000 people per year2; incidence is much lower among African-Americans. Herpes zoster ophthalmicus (HZO) involves the ophthalmic division of the trigeminal nerve (Vj). This area is involved in approximately 10% of all affected patients, second only to spinal dermatomes, which comprise the vast majority of cases. Conditions that immunocompromise patients can trigger HZ and must be considered. Most patients are immunocompetent, however, and the most common predisposing factor for development of HZ (especially HZO) is increasing age. Patients with HZO present with painful, vesicular dermatitis not crossing the midline that sometimes involves the forehead, scalp, upper eye lid, and nose. The skin lesions begin as erythematous papules, progress to vesicles and then to pustules until they rupture and form crusts. Patients can experience a mild prodrome with fever, malaise, fatigue, and dysesthesia. buy tamsulosin 400 online
Diagnosis of HZO is made clinically. Herpes simplex, the other entity to be considered in differential diagnosis, can often be excluded because its vesicular rash often extends beyond the midline and does not have a strict dermatomal distribution.
The eyes are involved in 20% to 70% of all HZO cases; conditions include blepharitis, conjunctivitis, episcleritis, scleritis, keratitis, uveitis, increased intraocular pressure, retinitis, choroiditis, optic neuritis, and orbital apex syndrome. Those with vesicles on the tip of the nose, supplied by the nasociliary branch of Vj (Hutchinson’s sign), are twice as likely to have ocular complications (but not eyelid involvement) as those who do not. Buy Dutasteride online
Although the dermatitis is self-limiting, immunocompetent patients presenting within the first 72 hours of development of the vesicular rash should be treated with oral antiviral agents. These agents help to achieve faster resolution of lesions and decrease viral shedding. They might also prevent ocular complications and decrease neuralgia. Antivirals currently in use include acyclovir 800 mg five times daily for 7 days, valacyclovir 1000 mg three times daily for 7 days, and famciclovir 250 mg three times daily for 7 days.
Vesicular involvement of the eyelids constitutes HZO blepharitis. It is self-limiting, but must be monitored for secondary cellulitis and deformities caused by scars. Deformities include lid retraction, ectropion, entropion, or trichiasis, which could require surgical correction. Buy Revatio 20 mg
Keratitis is the most common ocular complication of HZO. It can manifest in a variety of forms, including punctate epithelial erosions, pseudodendrites, stromal involvement, and neurotrophic ulcers. Most patients with keratitis will have symptoms such as sensation of a foreign body in the eye, tearing, blurry vision, or photophobia. It is important to note that the pseudodendrites of HZO are different from those of herpes simplex keratitis. They consist of a whitish, elevated plaque with a “stuck-on” appearance. They do not respond to topical antiviral drops, and therefore should be treated with abundant lubrication only. Buy Valacyclovir 500
Patients with persistent discomfort for longer than 1 month from onset of HZ are considered to have postherpetic neuralgia (PHN), which is found more frequently in those with HZO and in older patients. It can be difficult to manage and often involves primary care physicians. Various agents have been used with varying success. Topical capsaicin cream can be tried, but must be used cautiously around the eye; oral tricyclic antidepressants, corticosteroids, and anticonvulsants can be used. Amitriptyline, the most extensively used medication for this purpose, is initially prescribed at bedtime at a dose of 25 mg. This can be gradually increased to 75 mg at bedtime and, if necessary, 25 mg three times daily also. Prednisone drug does not have any effect on PHN. Rarely used surgical management involves trigeminal ganglion ablation.
This patient was assessed by her family physician, who started her on 250 mg of famciclovir orally three times daily for 7 days. She applied hot compresses and polysporin ointment to the skin lesions three times daily. She had the sensation of a foreign body in the eye and photophobia. She was referred for ophthalmologic assessment and was seen within a couple of days. She had dendritic keratitis that was treated with erythromycin ointment three times daily and lubricants every 2 hours. She also had an anterior uveitis with increased intraocular pressure that was managed with 1% prednisolone drops four times daily, 2% homatropine drops three times daily, and timolol drops twice daily. She had a chronic course and experienced recurrences when steroid treatment was tapered. Buy Pioglitazone 30 online
All immunocompetent patients presenting within 72 hours of onset of HZO dermatitis should receive oral antiviral therapy. Patients with ocular symptoms of sensation of a foreign body in the eye, tearing, blurry vision, or photophobia should be referred on a semiurgent basis for ophthalmologic evaluation. Postherpetic neuralgia is often managed by primary care physicians and can be challenging. Buy Avandia Online