Herpes zoster (shingles), including ophthalmic and Ramsay Hunt

shingles · herpes zoster · zoster · ophthalmic shingles · Ramsay Hunt syndrome · zoster ophthalmicus

A unilateral dermatomal vesicular rash - and the two variants that matter are the eye and the ear.

GPBand C

Red flags

Any ophthalmic involvement - refer for same-day ophthalmology assessment; sight is at risk
Facial palsy with ear or palatal vesicles - Ramsay Hunt syndrome, needing urgent treatment and ENT involvement, with a worse recovery than Bell palsy
Immunosuppression, or lesions outside the affected dermatome - disseminated zoster needs admission and intravenous treatment
Zoster in a young adult with no obvious cause - consider undiagnosed immunosuppression including HIV
Severe pain that is not controlled - a predictor of post-herpetic neuralgia and a reason to treat aggressively early

Recognise

On light skin

Grouped vesicles on an erythematous base in a dermatomal band, evolving to pustules and crusts, preceded by burning or shooting pain for days.

On brown and black skin

The erythematous base is often not visible, so the eruption reads as grouped grey-white vesicles or darker crusted papules on unremarkable skin - and early, before vesicles form, there may be nothing visible at all, only pain. The dermatomal distribution with a sharp midline cut-off is the diagnosis and is entirely tone-independent - map it against a dermatome chart rather than looking for redness. Post-inflammatory hyperpigmentation along the dermatome afterwards is prominent and long-lasting, and can be mistaken for continuing disease or for scarring.

In any skin tone

Unilateral, dermatomal, stopping at the midline - if it crosses the midline, think again
Prodromal pain, burning or itch for two to three days before any rash
Grouped vesicles at the same stage within a dermatome, unlike the mixed stages of chickenpox
Ophthalmic zoster: any involvement of the forehead, upper eyelid or nose. A lesion on the tip or side of the nose (Hutchinson sign) predicts eye involvement
Ramsay Hunt: ear pain with vesicles in the ear canal or on the pinna and a facial nerve palsy
Disseminated disease - lesions well outside the dermatome - suggests immunosuppression

Distribution

Unilateral, confined to one or two adjacent dermatomes, stopping abruptly at the midline. Thoracic dermatomes are commonest; ophthalmic division of the trigeminal nerve is the one that threatens sight.

Photographs

Herpes zoster. The clustered white pustules and the sharp band they sit in are the whole diagnosis - the erythematous base described in text — Herpes zoster. **The clustered white pustules and the sharp band they sit in are the whole diagnosis** - the erythematous base described in textbooks is absent on this skin. Follow the line of the lesions and check whether it stops at the midline; that, not the colour, is what makes it zoster.
Fitzpatrick IV (Fitzpatrick type estimated from the photograph, not stated by the source) · Oladokun RE, Lehloenya RJ, Hlela C, Ubesie AC, Katibi SO, Malande OO, Eley BS · Atlas of Paediatric HIV Infection, UCT Libraries Press 2018 - Chapter 2: Viral Skin Infections, p30 · CC BY 4.0

The same dermatome after healing: a band of pale, scarred, hypopigmented skin. On dark skin this is the lasting consequence and patients are — The same dermatome after healing: **a band of pale, scarred, hypopigmented skin.** On dark skin this is the lasting consequence and patients are often more troubled by it than by the original rash. It is also a mimic - a sharply bounded pale patch here can be mistaken for vitiligo, but it is segmental, scarred, and follows a dermatome.
Fitzpatrick IV-VI (Fitzpatrick type estimated from the photograph, not stated by the source) · Oladokun RE, Lehloenya RJ, Hlela C, Ubesie AC, Katibi SO, Malande OO, Eley BS · Atlas of Paediatric HIV Infection, UCT Libraries Press 2018 - Chapter 2: Viral Skin Infections, p31 · CC BY 4.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Herpes simplex — Recurrent grouped vesicles that are NOT dermatomal and recur in the same small area are simplex, not zoster
Chickenpox (varicella) — Widespread lesions at mixed stages rather than a single dermatome at one stage
Eczema herpeticum — Widespread monomorphic erosions on eczematous skin, not dermatomal
Cellulitis — Early zoster before vesicles appear can be mistaken for cellulitis, but the pain and the dermatomal limit fit neither

What to do in the ED

Offer an oral antiviral within 72 hours of rash onset to the groups CKS names: anyone immunocompromised, aged 50 or over, with non-truncal involvement, with moderate or severe pain or rash, or with a predisposing skin condition. Consider it on clinical judgement in others under 50. CKS does not recommend antiviral treatment for immunocompetent children, and in pregnancy or breastfeeding it says to seek specialist advice before prescribing. CKS adds that where treatment within 72 hours is not possible, antiviral treatment can be considered up to one week after rash onset, especially in those at higher risk of severe disease or complications - so a late presentation is not automatically a no
Examine the eye and the nose in every facial presentation. Refer same-day to ophthalmology for any ophthalmic division involvement
Examine the ear canal and test the facial nerve in any patient with ear pain - Ramsay Hunt is missed by not looking
Analgesia matched to severity, and treat neuropathic pain as neuropathic pain rather than with simple analgesics alone
Advise that the patient is infectious to anyone without immunity to varicella until all the vesicles have crusted over, approximately 7 days after rash onset (CKS), and that contact with pregnant women, neonates and the immunosuppressed should be avoided until then
Cover the rash; transmission is by contact with vesicle fluid rather than airborne in localised zoster
Consider immunosuppression in disseminated or recurrent disease, or in a young patient

Disposition

Antiviral and analgesia with GP follow-up for uncomplicated dermatomal zoster. Same-day ophthalmology for ophthalmic involvement, urgent ENT for Ramsay Hunt, and admission for disseminated disease or immunosuppression.

Safety-netting

Return immediately if the eye becomes red or painful, if your vision changes, if you develop weakness of the face, if the rash spreads well beyond the original band, or if you become unwell with a fever. Keep the rash covered and avoid contact with pregnant women, newborn babies and anyone with a weak immune system until every blister has crusted. You do not have to stay off work or school just because you have shingles. UKHSA asks people to stay away only if the rash is still oozing fluid and cannot be covered with loose clothing or a non-sticky dressing, or until it has dried out - once the blisters have scabbed over you can attend as usual. Nerve pain can persist after the rash clears - tell your GP if it does, because it is treatable.

Sources

Open this entry in the interactive tool