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Skin: Herpes Zoster (Shingles)
MAJ Daniel Schissel, MC, USAIntroduction: Herpes zoster is an acute, localized, recurrence of the varicella-zoster virus (VZV) most
commonly seen in patients over the age of 50. Less than 10% of cases are under the age of 20.
Subjective: Symptoms
A prodrome of pain, tenderness, itching, burning, and/or tingling in a dermatomal distribution precedes
the eruption by 2-7 days. Intense pain in the dermatome usually persists throughout the eruption and
resolves slowly (post herpetic neuralgia). Constitutional symptoms of headache, fever and chills occur in
approximately 5% of patients.
Objective: Signs
Using Basic Tools: Erythematous papules or plaques, followed by umbilicated vesicles and bullae that
commonly evolve to pustules (progression over 48-72 hours) and crust over by 7-10 days; new lesions may
continue to appear for up to 1 week; lesions typically cluster in the distribution of a dermatome. (see Color
Plates Picture 9).
Using Advanced Tools: Lab: Tzanck smear of vesicle (undersurface of the vesicle or bullae has the highest
yield) with multinucleated giant epidermal cells.
Assessment:
Differential Diagnosis
Pain can be intense and may resemble that of cardiac disease, an acute abdomen or vertebral disk
herniation. The eruption of zoster can resemble allergic contact dermatitis, irritant contact dermatitis or a
localized bacterial infection.
Plan:
Shorten course of illness and subsequent development of notalgia paresthetica (back pain numbness and
tingling) - a painful prolonged sequelae
Treatment
Primary: High dose oral acyclovir 800 mg po 5 times a day x 7 days.
Prevention: Prompt treatment during prodrome can lessen severity and shorten course of illness.
Follow-up Actions
Evacuation/Consultation Criteria: Evacuate soldiers whose condition interferes with mission performance.
Refer patients with: Ophthalmic zoster: Look for vesicles on the eyelids and tip of the nose - occur in
30% of patients with involvement of the nasociliary branch. Requires URGENT MEDEVAC. Blindness may
develop if not treated appropriately.
Ramsay Hunt syndrome: Zoster involvement of the facial nerve and auditory nerves resulting in same-side
facial paralysis.
Skin: Molluscum Contagiosum
MAJ Daniel Schissel, MC, USAIntroduction: Molluscum contagiosum is endemic in school age children through casual contact and spread
of the poxvirus. Lesions are discrete, umbilicated, pearly, red papules. Involvement of the diaper area, trunk,
face, and axilla is common. In the adult population, molluscum contagiosum is usually transmitted sexually,
and may resolve spontaneously after several months or may reappear. HIV infected patients may have
hundreds of small (2-3 mm) papules or develop giant 1-2 cm lesions.