TELEDERMATOLOGY READER REPORT1
HISTORY
Chief complaint: presenting for diagnosis and therapeutic options.
History of Present Illness
A 36-year-old male presents with a vesicular eruption along the right posterior neck near the hairline that he says has been present for 48 hours. The eruption was preceded by a sensation of heat and burning. Primary treatment: none. Primary symptom: pain and pruritus in the area of rash. Prior biopsy: none. The patient has no past dermatological history, including no history of skin cancer. He denies history of being immunocompromised.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
There is one image provided with this consult. The image shows grouped vesicles on an erythematous base on the right posterior neck, near the hairline. In addition, an ill-defined erythematous plaque is noted to the right of the midline over the cricoid arch (see Figure 1).
INTERPRETATION OF IMAGES
Lesion A
Findings
The morphology of the lesions, distribution, and history are characteristic for herpes zoster infection, also known as shingles.
RECOMMENDATIONS
Skin Care Recommendations
No topical treatment is necessary, but many patients benefit from cool compresses as well as Burow's solution.
Medication Recommendations
Because the onset of the lesions was within 72 hours, it is appropriate to begin antiviral therapy such as acyclovir 800 mg, five times daily for 7 days.
RECOMMENDED FOLLOW-UP
Type of Visit
Return to primary care provider for treatment.
CLINICAL PEARL
Herpes zoster, or shingles, is a reactivation of the varicella-zoster virus (the virus that causes chicken pox). After a primary infection with varicella (chicken pox), the virus can lay dormant within the sensory nerve ganglia for decades. Classically, reactivation occurs in approximately 20% of the immunocompetent population during late adulthood, in the 60-year-old and older age group, and correlates with immune senescence. When shingles occurs in younger, ostensibly immunocompetent patients, testing for HIV may be prudent if clinically indicated. The most common clinical presentation includes symptoms of pain, pruritus tingling, or other sensory abnormalities in a dermatomal distribution followed by a painful, vesicular rash.
Ideally, treatment with antiviral therapy will begin within 72 hours of the cutaneous eruption to decrease the acute symptoms and also potentially decrease the severity of postherpetic neuralgia. First-line therapy consists of acyclovir 800 mg, five times daily x 7-10 days. Alternatively, famciclovir (500 mg orally, three times daily x 7 days) or valacyclovir (1 g orally, three times daily x 7 days) may be used (Mendoza et al., 2012). Non steroidal anti-inflammatory drugs or other analgesics can be used for acute and subacute herpetic neuralgia. The patient should be reassessed at 3 months for symptoms of postherpetic neuralgia, and if warranted, additional treatment options may be considered at this time (Jeon, 2015).
REFERENCES