QuestionSBA
QuestionChoice
Ink burrow testing is performed to diagnose scabies. This is more commonly associated with fine, silvery lines usually seen in the interdigital spaces
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Ink burrow test
QuestionChoice
The image shows the early onset of shingles. This is caused by the reactivation of the varicella zoster virus. The initial infection of the varicella virus would have caused chickenpox. The diagnosis is usually clinical, as often the virus is difficult to recover from swabs. The likelihood of developing shingles increased by up to 40% in patients diagnosed with cancer
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Swab for varicella zoster polymerase chain reaction (PCR)
QuestionChoice
The causative organism of shingles is the reaction of varicella zoster rather than herpes simplex. Herpes simplex can also present with localised blistering, so it is a common differential of shingles
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Swab for herpes simplex polymerase chain reaction (PCR)
QuestionChoice
The image shows the early onset of shingles. This is caused by the reactivation of the varicella zoster virus. The initial infection of the varicella virus would have caused chickenpox. There are no signs of an overlying bacterial infection
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Bacterial swab
QuestionChoice
There are different types of skin biopsies which are used to both investigate skin lesions. A punch biopsy would not be appropriate in this case because the diagnosis is shingles, which can be identified via PCR
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Punch skin biopsy
Concept
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# Summary 

Shingles is a reactivation of the varicella zoster virus which can lie dormant in nerve ganglia following primary infection (chickenpox). It commonly occurs in the elderly and shingles in young adults should prompt investigation for an underlying immune condition. Management normally includes oral antivirals, but intravenous antiviral medications can be used if severe or if the patient is immunocompromised.

# Signs & Symptoms

Shingles can manifest first as a tingling feeling in a dermatomal distribution. Progresses to erythematous papules occurring along one or more dermatomes within a few days, which develop into fluid-filled vesicles which then crust over and heal. May be associated with viral symptoms e.g. fever, headache, malaise.

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**Herpes zoster ophthalmicus (HZO)** presents with symptoms including a painful red eye, fever, malaise, and headache, followed by an erythematous vesicular rash over the trigeminal division of the ophthalmic nerve. A lesion on the nose, known as **Hutchinson's sign,** may suggest ocular involvement.



# Management

- Oral antiviral (e.g. valaciclovir 1g three times per day for 7 days) within 72h of rash onset if immunocompromised (and infection is not severe) or moderate/severe rash or moderate/severe pain, or non-truncal involvement.
- Admit to hospital for IV antivirals if severe disease or immunocompromise, ophthalmic symptoms or suspicion of meningitis/encaphalitis/myelitis
- Advise avoiding contact with pregnant women, babies and those who are immunocompromised until the lesions are fully crusted over, as transmission can occur via skin contact
- Pain can be managed with NSAIDs (e.g. ibuprofen). If unsuccessful, consider offering amitriptyline (off-label use), duloxetine (off-label use), gabapentin, or pregabalin

# Shingles vaccine

There is a one-off vaccine available for shingles that is typically advised for those in their 70s.

# Complications

- Secondary bacterial infection of skin lesions
- Corneal ulcers, scarring and blindness if eye involved
- Post-herpetic neuralgia
  - Pain occurring at site of healed shingles infection
  - Can cause neuropathic type pain (burning, pins and needles)
  - Can cause allodynia (perception of pain from a normally non-painful stimulus e.g. light touch)

# NICE Guidelines

[NICE Clinical Knowledge Summary (CKS): Shingles](https://cks.nice.org.uk/topics/shingles/)

[NICE Treatment Summary: Varicella-zoster vaccine](https://bnf.nice.org.uk/treatment-summary/varicella-zoster-vaccine-2.html)
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Another example of the appearance of a shingles rash, this time situated on the chest
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Dermatology
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An example of the typical appearance of a shingles rash
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Dermatology
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The likelihood of developing shingles increased by up to 40% in patients diagnosed with cancer
Picture
An example of the typical appearance of a shingles rash
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Shingles.jpg
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Dermatology
A 23-year-old woman presents to her GP with a rash. She has just undergone chemotherapy for acute lymphoblastic leukaemia.

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What investigation would give a definitive diagnosis?
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