Herpes zoster physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; L. Katie Morrison, MD; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Jesus Rosario Hernandez, M.D. [3], Dima Nimri, M.D. [4].

Overview

Physical Examination

Physical examination findings of herpes zoster depend on the location of the rash, as well as the stage of the disease:

  • Rash: the rash of herpes zoster virus is typically unilateral and does not cross the midline. It follows the distribution of one or two adjacent dermatomes. The rash can involve any area of the body, but most common site are the face (ophthalmic division of trigeminal nerve), neck (cervical dorsal root ganglia) or chest (thoracic dorsal root ganglia). The rash is initially an erythematous, maculopapular rash, but over the next 7-10 days, it progresses to pustules and ulceration, with crusts, scabbing or both. Post-inflammatory hyperpigmentation may develop along the affected dermatome(s) as part of the healing process. In the immunocompromised individuals, the rash may be complicated by skin necrosis and scarring.[1][2]
  • Herpes zoster ophthalmicus: when the rash involves the ophthalmic division of the trigeminal nerve, the same characteristic rash will be present in addition to several occular and head and neck findings which may or may not accompany the rash. These include[1][3][4][5]:
    • Hutchinson's sign: a rash on the tip of the nose may be present and it is a strong predictor of eye involvement
    • Blepharoconjunctivitis: edema and inflammation of the outer eyelids
    • Keratitis: presents with signs of corneal inflammation, which presents with eye pain, redness and photophobia
    • Uveitis: presents with eye redness and elevated intraocular pressure
    • Cranial nerve palsies: herpes zoster virus may involves cranial nerves III, VI and less commonly, IV. Involvement of these cranial nerves may present with pain on eye movement (ophthalmoplegia), as well as pupillary dilatation with a sluggish reaction to light when cranial nerve III is involved.[3] [4]
  • Ramsay Hunt Syndrome: Rarely, herpes zoster may present with a maculopapular rash in the external auditory canal (zoster opticus) or the tympanic membrane. Ramsay Hunt Syndrome refers to zoster rash in the external auditory canal, the tympanic membrane, the ipsilateral anterior two-thirds of the tongue or hard palate, associated with ipsilateral weakness or paralysis of the facial muscles, due to involvement of cranial nerve VII. Syndrome may be associated with signs of hearing loss, involuntary eye movements and nystagmus.[1][3][6]

Gallery

Skin

(Images shown below courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

  • Herpes Zoster: Coalesced vesicles resulting from reactivation of HZV infection.

    Herpes Zoster: Coalesced vesicles resulting from reactivation of HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles in patient with HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Shingles on waist

    Shingles on waist

  • Dermatomal involvement of rash

    Dermatomal involvement of rash

  • Dermatomal involvement of skin rash

    Dermatomal involvement of skin rash

  • Herpes zoster on the chest

    Herpes zoster on the chest

  • Varicella zoster

    Varicella zoster

  • Herpes Zoster. (Courtesy of Josh Fierer, M.D. and Charlie Goldberg, M.D.)

    Herpes Zoster.
    (Courtesy of Josh Fierer, M.D. and Charlie Goldberg, M.D.)

  • Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Shingles on face

    Shingles on face

  • Shingles on face

    Shingles on face

  • This 1968 image depicted a number of varicella, or chickenpox lesions on a patient’s back, which were displaying the characteristic “cropping” distribution, or manifesting themselves in clusters, each in a different developmental stage.

    This 1968 image depicted a number of varicella, or chickenpox lesions on a patient’s back, which were displaying the characteristic “cropping” distribution, or manifesting themselves in clusters, each in a different developmental stage.

  • This patient presented with what was differentially diagnosed as a herpes zoster outbreak in order to rule out syphilis.

    This patient presented with what was differentially diagnosed as a herpes zoster outbreak in order to rule out syphilis.

  • This skin disorder was found to be herpes zoster, not syphilitic in nature as was initially suspected.

    This skin disorder was found to be herpes zoster, not syphilitic in nature as was initially suspected.

  • These skin lesions on the forehead of an elderly woman are due to the herpes zoster virus on the 21st day of the illness.

    These skin lesions on the forehead of an elderly woman are due to the herpes zoster virus on the 21st day of the illness.

  • A case of shingles that demonstrates the typical dermatomal distribution, in this case C8/T1

    A case of shingles that demonstrates the typical dermatomal distribution, in this case C8/T1

Head
Trunk
Extremities
Neck
Genitourinary System
Skin

(Images shown below courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

  • Herpes Zoster: Coalesced vesicles resulting from reactivation of HZV infection.

    Herpes Zoster: Coalesced vesicles resulting from reactivation of HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles in patient with HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Shingles on waist

    Shingles on waist

  • Dermatomal involvement of rash

    Dermatomal involvement of rash

  • Dermatomal involvement of skin rash

    Dermatomal involvement of skin rash

  • Herpes zoster on the chest

    Herpes zoster on the chest

  • Varicella zoster

    Varicella zoster

  • Herpes Zoster. (Courtesy of Josh Fierer, M.D. and Charlie Goldberg, M.D.)

    Herpes Zoster.
    (Courtesy of Josh Fierer, M.D. and Charlie Goldberg, M.D.)

  • Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Shingles on face

    Shingles on face

  • Shingles on face

    Shingles on face

  • This 1968 image depicted a number of varicella, or chickenpox lesions on a patient’s back, which were displaying the characteristic “cropping” distribution, or manifesting themselves in clusters, each in a different developmental stage.

    This 1968 image depicted a number of varicella, or chickenpox lesions on a patient’s back, which were displaying the characteristic “cropping” distribution, or manifesting themselves in clusters, each in a different developmental stage.

  • This patient presented with what was differentially diagnosed as a herpes zoster outbreak in order to rule out syphilis.

    This patient presented with what was differentially diagnosed as a herpes zoster outbreak in order to rule out syphilis.

  • This skin disorder was found to be herpes zoster, not syphilitic in nature as was initially suspected.

    This skin disorder was found to be herpes zoster, not syphilitic in nature as was initially suspected.

  • These skin lesions on the forehead of an elderly woman are due to the herpes zoster virus on the 21st day of the illness.

    These skin lesions on the forehead of an elderly woman are due to the herpes zoster virus on the 21st day of the illness.

  • A case of shingles that demonstrates the typical dermatomal distribution, in this case C8/T1

    A case of shingles that demonstrates the typical dermatomal distribution, in this case C8/T1

Gallery

References

  1. ↑ 1.0 1.1 1.2 Cohen KR, Salbu RL, Frank J, Israel I (2013). "Presentation and management of herpes zoster (shingles) in the geriatric population". P T. 38 (4): 217–27. PMC 3684190. PMID 23785227.
  2. ↑ Cohen JI, Brunell PA, Straus SE, Krause PR (1999). "Recent advances in varicella-zoster virus infection". Ann. Intern. Med. 130 (11): 922–32. PMID 10375341.
  3. ↑ 3.0 3.1 3.2 Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA (2008). "Varicella zoster virus infection: clinical features, molecular pathogenesis of disease, and latency". Neurol Clin. 26 (3): 675–97, viii. doi:10.1016/j.ncl.2008.03.011. PMC 2754837. PMID 18657721.
  4. ↑ 4.0 4.1 Karmon Y, Gadoth N (2005). "Delayed oculomotor nerve palsy after bilateral cervical zoster in an immunocompetent patient". Neurology. 65 (1): 170. doi:10.1212/01.wnl.0000167287.02490.76. PMID 16009918.
  5. ↑ Shaikh S, Ta CN (2002). "Evaluation and management of herpes zoster ophthalmicus". Am Fam Physician. 66 (9): 1723–30. PMID 12449270.
  6. ↑ Sweeney CJ, Gilden DH (2001). "Ramsay Hunt syndrome". J. Neurol. Neurosurg. Psychiatr. 71 (2): 149–54. PMC 1737523. PMID 11459884.
  7. ↑ 7.0 7.1 "Public Health Image Library (PHIL)".


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