C h a p t e r 4 6
Disorders of Skin Integrity and Function
1159
and famciclovir may be used for prophylaxis. Sunscreen
applied to the lips can prevent sun-induced herpes sim-
plex. Efforts to develop vaccines to prevent HSV infec-
tions are in process.
13
Herpes Zoster.
Herpes zoster (shingles) is an acute,
localized vesicular eruption distributed over a derma-
tomal segment of the skin.
14
It is caused by the same
herpesvirus, varicella-zoster, that causes chickenpox. It
is believed to be the result of reactivation of a latent
varicella-zoster virus infection that was dormant in the
sensory dorsal root ganglia since a primary childhood
infection. During an episode of herpes zoster, the reac-
tivated virus travels from the ganglia to the skin of the
corresponding dermatome (Fig. 46-10A). Although her-
pes zoster is not as contagious as chickenpox, the reacti-
vated virus can be transmitted to nonimmune contacts.
The incidence of herpes zoster increases with age; it
occurs most frequently in persons older than 60 years of
age. The normal age-related decrease in cell-mediated
immunity is thought to account for the increased viral
activation in this age group. Other persons at increased
risk because of impaired cell-mediated immunity are
persons with conditions such as HIV infection and
certain malignancies, and those receiving long-term
corticosteroid treatment, cancer chemotherapy, and
radiation therapy.
The lesions of herpes zoster typically are preceded by
a prodrome consisting of a burning pain, a tingling sen-
sation, extreme sensitivity of the skin to touch, and pru-
ritus along the affected dermatome (see Chapter 35).
Among the dermatomes, the most frequently involved
are the thoracic, the cervical, the trigeminal, and the
lumbosacral.
14
Prodromal symptoms may be present
for 1 to 3 days or longer before the appearance of the
rash. During this time, the pain may be mistaken for
a number of other conditions, such as heart disease,
pleurisy, musculoskeletal disorders, or gastrointestinal
disorders.
The lesions appear as an eruption of vesicles with ery-
thematous bases that are restricted to skin areas supplied
by sensory neurons of a single or associated group of
dorsal root ganglia (Fig. 46-10B). In immunosuppressed
persons, the lesions may extend beyond the dermatome.
Eruptions usually are unilateral in the thoracic region,
trunk, or face. New crops of vesicles erupt for 3 to 5 days
along the nerve pathway. The vesicles dry, form crusts,
and eventually fall off. The lesions usually clear in 2 to
3 weeks, although they can persist up to 6 weeks in some
elderly persons.
Serious complications can accompany eruptions.
Eye involvement can result in permanent blindness and
occurs in a large percentage of cases involving the oph-
thalmic division of the trigeminal nerve (see Chapter
38).
Postherpetic neuralgia,
which is sharp, burning
pain that persists longer than 1 to 3 months after the
resolution of the rash, is seen most commonly in persons
older than 60 years of age (see Chapter 35).
The treatment of choice for herpes zoster is the admin-
istration of an antiviral agent (e.g., acyclovir, valacy-
clovir, famciclovir).
14
Treatment is most effective when
started within 72 hours of rash development. When
given in the acute vesicular stage, the antiviral drugs
have been shown to decrease the amount of lesion devel-
opment and pain. Narcotic analgesics, tricyclic antide-
pressants, gabapentin, anticonvulsant drugs, and nerve
blocks have been used for management of postherpetic
neuralgia. Local application of capsaicin cream or lido-
caine patches may be used in selected cases. Palliative
treatments, such as heat and gentle pressure, may also
be helpful.
A live herpes zoster vaccine is available to prevent
both herpes zoster and postherpetic neuralgia. The vac-
cine is recommended for use in people 60 years of age
and older, although the efficacy of the vaccine continues
to be studied.
15,16
Pustular Disorders
Although acne vulgaris, acne conglobata, and rosacea
may present with a variety of skin lesions, they are char-
acterized by the presence of pustules, which are circum-
scribed skin lesions filled with pus.
AcneVulgaris
Acne vulgaris is a disorder of the pilosebaceous unit (see
Chapter 45, Fig. 45-7) that results in formation of dis-
crete papular or pustular lesions and may lead to scar-
ring.
17–20
Acne can be cosmetically disfiguring and often
psychologically disabling. It typically begins around
puberty, as a result of increased androgen production. It
may begin earlier and persist longer in females; however,
FIGURE 46-10.
Acute herpes zoster. Panel
(A)
shows a
cutaneous eruption in the rightT7 dermatome. Panel
(B)
shows
a close-up of fresh vesicular lesions. (From Gnann JW, Whitley
RJ. Herpes zoster. N Engl J Med. 2002;347:341. Copyright ©
2002. Massachusetts Medical Society.)
