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General lnternal Medicine Primary Varicella Diagnosis VZV is a DNA virus that causes varicella (chickenpox). It is characterized by the simultaneous onset of fever and a cutaneous eruption. Chickenpox lesions develop in crops, such that lesions in different stages of development (macules, papules, vesicles, pustules, crusted erosions) are present simultaneously on any one part of the body; lesions are most prominent on the trunk rather than the extremities. Herpes Zoster Prevention Administer the recombinant zoster vaccine to adults 50 years and older to prevent or attenuate illness caused by herpes zoster infection and to reduce the risk of postherpetic neuralgia. Physical Examination Localized pain and a vesicular rash in a dermatomal distribution are characteristic features. Dermatomal neuropathic pain may develop before skin lesions occur. Severe, complicated, or recurrent herpes zoster should trigger testing for possible associated HIV infection. Be alert for two special syndromes: . Lesions along the first division of the trigeminal nerve (zoster ophthalmicus), including the tip of the nose, may require urgent referral to an ophthalmologist. . Vesicles in the ears, diminished taste on the anterior two thirds of the tongue, and ipsilateral facial paralysis (Ramsay Hunt syndrome) require referral to an ENT specialist. Testing Herpes zoster is gpically a clinical diagnosis; obtain rapid tests, such as direct fluorescent antibody and PCR studies on scrap- ings from active vesicular skin lesions that have not yet crusted, or viral culture from a vesicle when the diagnosis is unclear. I Treatment Give valacyclovir, famciclovir, or acyclovir if lesion onset is within 72 hours of contemplated treatment. Disseminated zoster requires IV therapy and both contact and airborne precautions. Treat postherpetic neuralgia with gabapentin, pregabalin, tricyclic antidepressants, or topical lidocaine or capsaicin. : : !

Treat postherpetic neuralgia with gabapentin, pregabalin, tricyclic antidepressants, or topical lidocaine or capsaicin. : : ! DOil'T BE TRICKED .\ . Administer recombinant varicella-zoster vaccine to patients 50 years and older regardless of previous history of l varicella infection or previous immunization with live attenuated vaccine. ! l r Do not select topical acyclovir or penciclovir for the treatment ofherpes zoster. o Do not select glucocorticoids to treat herpes zoster. 180

General lnternal Medicine TEST YOURSETF A 72-year-old man has a 4 day history of a painful vesicular rash in the distribution of the first division of the trigeminal nerve and conjunctival infl ammation. ANSWER: Choose zoster ophthalmicus for diagnosis. Select an antiviral agent (valacyclovir, famciclovir, or acyclovir) and ophthal mologist referral as treatment. --S# s-Ih* n w% Herpes Zoster: Herpes zoster is characterized by the dermalomal distribution of painful grouped vesicles on an erythematous base Scabies Diagnosis Scabies is an "itchy rash" frequently occurring bet'ween the fingers and on the wrists, penis, scrotum, areolae, and nipples. Look for burrows appearing as wavy, thread-like, grayish white skin elevations capped with small vesicles at the terminal ends. Patients with AIDS and those in institutions such as nursing homes and hospitals may develop widespread scabies with extensive scaling that may not itch. Testing Microscopic identification of the mite, feces, or eggs using KOH or simple mineral oil is diagnostic. A skin biopsy may also establish the diagnosis. Treatment Treat all family members and close contacts of the patient simultaneously. Topical permethrin is the preferred agent. Oral ivermectin is indicated for relapsed scabies except when treating children and pregnant or lactating women. Clothing, linens, and towels must be washed in hot water and dried at high heat. DOil'T BE TRICKED o Do not re treat scabies because of persistent itching, which can continue for 2 weeks after successful treatment. r Avoid topical lindane because of its associated neurotoxicity. 181