Woman With Vesicles and Crusts on Her Forehead

For 3 days, a 60-year-old woman hashad a tender rash on her forehead. Thelesions erupted 2 days after she sustainedminor trauma to the left side ofthe forehead (Figure 1); no scratchesor bleeding were associated with theinjury. She noted a burning sensationand mild tenderness at the site shortlybefore the lesions arose.The patient has no significantmedical history; she takes no medicationsand did not receive the varicellavaccine. She does not recall any similareruptions in the past anywhere onher body.Vesicles and crusts on an erythematousbase in a linear distribution arepresent on the left aspect of the forehead(Figure 2). The lesions do not cross themidline. The eyes and the nasal apexare not affected; lymph nodes are notpalpable.Herpes zoster ophthalmicus (HZO)following trauma to the forehead isstrongly suspected. The diagnosis is confirmedby polymerase chain reaction(PCR) for varicella zoster virus (VZV)DNA. Oral valacyclovir, 1000 mg tid, isprescribed.Seven days later, the pain has subsidedand a crust has formed on theforehead at the site of the vesicles (Figure3). Post-herpetic neuralgia has notdeveloped.CLINICAL FEATURES
HZO--cutaneous lesions in thedermatome associated with the ophthalmicdivision of the trigeminalnerve (cranial nerve V1)--results fromreactivated VZV that travels down theophthalmic nerve from the trigeminalganglion; the virus reaches the nerveendings within 3 to 4 days.^1,2 Cranialnerve V1 comprises the frontal nerve;the lacrimal nerve; and the nasociliarynerve, which provides sensory innervationto the cornea, ciliary body,iris, and conjunctiva. The terminalbranch is the anterior ethmoidal nerve,which innervates the sides and tipof the nose. HZO most often involvesthe supraorbital and supratrochlearbranches of the frontal nerve, whichinnervate the upper eyelid andforehead.Paresthesias or pain along the involveddermatome may precede thedevelopment of the vesicles. Vesiculareruption on the forehead, lymph nodeenlargement in the drainage areas,fever, malaise, headache, occasionalneck stiffness, and a reactive conjunctivitiswith or without corneal involvementfollow. Prodromal lymphadenopathycan be confused with later reactiveadenopathy that is caused bysecondary infection of vesicles.The presence of VZV vesicles onthe side or the tip of the nose in thedistribution of the nasociliary nerve(Hutchinson sign) may herald ocularinvolvement. However, severe ocularcomplications can occur with a vesicularrash anywhere on the forehead.Herpes zoster develops in about20% of persons who were exposedto VZV during childhood.³ Risk factorsfor reactivation of the latent VZVare diabetes, advancing age, cancer, surgery, radiation, chemotherapy, immunosuppressingdrugs, systemiccorticosteroid therapy, stress, andAIDS.^1,4 Persons with HIV infectionare at increased risk for herpes zosterand are more likely to have severedisease. Thus, suspect HIV infectionin patients younger than 45 yearswho present with herpes zoster.⁵Trauma to the skin from injuryor sunburn can also cause the VZVto reactivate, as in this patient. Olderage, prolonged prodromal pain, andsevere acute pain are risk factors forsevere post-herpetic neuralgia.^6,7CONFIRMING THE DIAGNOSIS
Several methods are available toconfirm the diagnosis of a herpesvirusinfection.Tzanck smear. A cytologicsmear of scrapings from the base ofa vesicle is prepared with Wright orGiemsa stain. Multinucleated giantcells are characteristic of herpeszoster, varicella, and herpes simplex.Punch biopsy. This techniqueprovides more dependable materialfor histologic examination, particularlywhen a bacterial or fungal infectionis present. Usually, results show multinucleatedgiant cells and Cowdrytype A intranuclear inclusion bodies.Results of the biopsy can confirm thepresence of Herpesviridae but--like a Tzanck smear--cannot identify thespecific herpesvirus.Viral culture. A viral culturecan distinguish among herpes simplex1, herpes simplex 2, and VZV.VZV infection is best confirmed byisolation of virus in tissue culture.Often, a positive result is availablewithin 48 hours of specimen inoculation;however, cytopathic effects maytake up to 5 days.Direct immunofluorescenceassay (DFA). This test uses fluorescein-tagged antibody directed againstviral antigen. DFA has a highersensitivity and specificity than Tzancksmear in vesicular lesions. Thismethod yields rapid results and candifferentiate herpes simplex virusfrom VZV.PCR. This method is growing inuse and availability. It is a rapid, sensitive,and simple technique for diagnosisof VZV infection.COMPLICATIONS
Post-herpetic complications aremore common in HZO than in othermanifestations of zoster. Withoutprompt detection and treatment, eyeinvolvement threatens the patient's vision.Iritis, iridocyclitis, glaucomasecondary to uveitis, keratitis, cornealneovascularization, corneal tissue ulcerations,scarring, and secondarybacterial or fungal infection are possiblesequelae. Immediate interventioncan prevent or ameliorate complications;however, glaucoma may resultfrom corticosteroid treatment. Palsyof the third cranial nerve, and occasionallyof the fourth and sixth cranialnerves, may occur.^2,3 Post-herpeticneuralgia, which affects more thanhalf of patients with HZO, may be severeand long-lasting; it requires intensivemanagement.¹TREATMENTHerpes zoster ophthalmicus.This disease warrants aggressivetreatment and assiduous follow-up.Obtain ophthalmologic consultationearly for patients with significantocular symptoms. Local therapiesinclude warm, moist compresses.Prescribe ocular lubricants to hydratethe cornea and conjunctivae.Antiviral agents--initiated within72 hours of disease onset--are thecornerstone of systemic treatment.Acyclovir, 800 mg 5 times daily for 7days, can reduce pain and hasten resolutionof lesions. This agent can abortrecurrences if initiated immediatelyat onset of symptoms. Valacyclovir is aprodrug that rapidly converts to acyclovir.Given in the standard oral regimenof 1000 mg tid for 7 days, valacycloviris as effective as acyclovir forthe prevention of ocular complicationsof HZO. Patients tolerate both drugsequally; however, the valacyclovir regimenmay be easier to follow.⁸Famciclovir is also a prodrug;it is biotransformed into the activemetabolite penciclovir. The recommendedoral dose for adults is 500 mgq8h for 7 days. Famciclovir and valacyclovirare equally effective in hasteningthe resolution of zoster-associatedpain and post-herpetic neuralgia⁹;some physicians believe acyclovir maybe comparable to the other agents inthis setting.Systemic corticosteroids areused to ameliorate pain. Oral prednisone,1 to 2 mg/kg qd (not to exceed60 mg/d) tapered over 2 weeks,may be prescribed as symptoms resolve.The use of these agents is controversial;they can increase the riskof visceral and cutaneous dissemination,especially in immunocompromisedpatients.¹⁰Post-herpetic neuralgia. For patientswith post-herpetic neuralgia, applicationsof capsaicin cream, 4 timesdaily, may help deplete pain fibers ofsubstance P and reduce pain impulses.Tricyclic antidepressants, suchas amitriptyline, are often helpful, particularlywhen the agents are initiatedearly in the course of HZO. Analgesics--including narcotics, acetaminophen,aspirin, and NSAIDs--may also be used. When secondarybacterial infection of the vesicles occurs,give an antibiotic that coversgram-positive skin flora.Studies of patients with acuteherpes zoster who were older than50 years showed that antiviral therapy(ie, famciclovir or valacyclovir for 7days) started within 72 hours of rashonset and/or low-dose amitriptylinegiven for 90 days may reduce the incidenceand duration of post-herpeticneuralgia. Corticosteroids and analgesicsdo not prevent post-herpeticneuralgia.¹¹PREVENTION OFTRANSMISSION ANDRECURRENCE
Persons who have not had chickenpoxare at risk for contracting herpeszoster; advise such patients toavoid close contact with persons whohave active zoster lesions. In addition,varicella can be contracted from exposureto herpes zoster.Patients infected with VZV needto avoid known precipitating factors--such as sun exposure, stress, andimmunosuppressive medications--that can lead to recurrence of theinfection.

References:

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