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A 17-year-old man, who was being treated for Hodgkin lymphoma, presented for medical attention because of the presence of extremely painful “sores” on his lip. A 10-year-old boy is brought by his mother for evaluation of persistent “acne” that started when the boy was a baby. Orofacial acute herpes zoster (shingles) is an acute viral disease affecting the trigeminal nerve (CN V).
Individuals aged 60–70 years (6–7 cases per 1000 person-years) and older than 80 years (>10 cases per 1000 person-years).
Macules and papules progress into vesicles and pustules that eventually dry, leaving a crusting appearance after 5–7 days. Ramsay Hunt syndrome, which induces facial palsy, loss of taste, buccal ulceration and appearance of rash in the auditory canal on the affected side; intraoral mucosal ulceration may also be part of the spectrum with or without full manifestation of Ramsay Hunt syndrome.
Order laboratory tests, such as direct immunofluorescence assay for VZV antigen or a polymerase chain reaction (PCR) for VZV DNA for atypical rash. Based on the patient's medical history and on clinical findings, such as blisters, swelling and laboratory results, a diagnosis of acute herpes zoster can be established. Unilateral rashes (not crossing midline) and blisters are key signs for ruling out the diagnosis of herpes zoster virus affecting the trigeminal nerve. Pain management is one of the most important factors in the management of acute herpes zoster infection.Always consider prescribing anticonvulsants for management of neuropathic pain conditions, as patients do not respond well to strong analgesics, such as opioids.
Nortriptyline 25 mg (orally, 1 time daily at bedtime, increasing the dosage by 25 mg every 2–3 days as tolerated).
Corticosteroids have been shown to be effective in reducing duration of pain in elderly patients.
The most common complication of acute herpes zoster is the progression of disease into a prolonged phase known as postherpetic neuralgia. Other less common complications include encephalitis, herpes zoster–related opthalmicus with delayed contralateral hemiparesis, myelitis and VZV-related retinitis. If a patient presents with signs and symptoms of shingles, wait for the viral infection to resolve then consider for vaccine to prevent reoccurrence of herpes zoster infection. Zostavax® should not be administered in children or in patients with known: allergic reaction, immunosuppression, ongoing cancer therapy or pregnancy.
After the vaccine has been administered, the patients might experience redness and rash-like appearance near the site of injection. All statements of opinion and supposed fact are published on the authority of the author who submits them and do not necessarily express the views of the Canadian Dental Association. Publications of an advertisement does not necessarily imply that the Canadian Dental Association agrees with or supports the claims. A 3-year-old boy with high fever, malaise, anorexia, and drooling of 3 days' duration was brought to the emergency department (ED). After 3 days, the child was brought back to the ED with a fever, which had remained high despite treatment, and multiple shallow ulcerations on the gums, tongue, and soft and hard palate (A and B). This child has primary herpetic stomatitis, the first infection of oral tissues with herpes simplex virus (HSV). The diagnosis of primary herpetic stomatitis is often based on the clinical history and presentation. Tell the parents of children with primary herpetic stomatitis that herpetic whitlows can develop in young children who bite their cuticles or suck their fingers. Treat both with dicloxacillin, oxacillin, cephalexin, augmentin PO.  Can also give mupirocin 2% as topical treatment. Eczema herpeticum is typically treated with intravenous acyclovir, although some reports note successful management with oral acyclovir (2,4).
Erythematous macules and papules which become confluent and turn coppery-colored.  Begins in hairline and moves down the body. Macular erythema on face, followed ~2 days later by erythematous macular eruption, then lacy erythema.  Rash progresses from face to extremities. Common, inflammatory disease with many etiologies including drugs, infections, physical agents, pregnancy, malignancy, and connective tissue disease but in 50% of cases, no etiology found.
Common benign skin eruption of unknown etiology (possibly viral) often seen in older children and adolescents and more often in the winter. Highly contagious disease spread by respiratory droplets most commonly seen in preschoolers or unvaccinated individuals. Contagious disease produced by streptococcal erythrogenic toxin (Group A beta-hemolytic strain) originating in the pharynx or skin.
The most common thrombocytopenic purpura of childhood characterized by a profound deficiency of circulating platelets. Vasculitis seen in children ages 2-10 years characterized by palpable purpura on legs and buttocks, abdominal pain, GI bleeding, arthralgias, and hematuria.

Febrile illness caused by Rickettsia rickettsii (tick bite) seen in spring to early fall in south Atlantic states and Oklahoma. Purpura fulminans is a nonspecific sign of sepsis that appears rapidly and occurs in association with several infections (Group A Strep, Strep pneumo, Staph, RMSF, Meningococcus.
Other viruses with associated petechial rash include Herpes Simplex, Epstein-Barr, CMV, Hepatitis, and enteroviruses.
Common contagious skin infection produced by Group A, alpha hemolytic streptococci or staphylococci or both. Common contagious viral illness from infection with Coxsackie viruses, strain A16 most common, or enterovirus 71.
Skin manifestation of a Type 1 hypersensitivity reaction which produces significant itching. It is the result of reactivation of the varicella zoster virus (VZV) that remained dormant in the trigeminal nerve root ganglion following exposure or clinical manifestation of chickenpox.
At times, patients present with postherpetic neuralgia, which becomes a diagnostic challenge as the neuropathy persists after resolution of the skin or mucosal lesions.
The Centers for Disease Control and Prevention (CDC) states that patients aged 60 years and older should be vaccinated regardless of prior exposure to VZV.  However, the vaccine is approved for patients as young as 50 years. Klasser is associate professor, Louisiana State University School of Dentistry, department of diagnostic sciences, New Orleans, LA, USA.
Ahmed is a PhD candidate, faculty of dentistry, McGill University, Oral Health and Society Research Division, Montreal, Canada.
The effects of pre-emptive treatment of postherpetic neuralgia with amitriptyline: a randomized, double-blind, placebo-controlled trial. The PINE study of epidural steroids and local anaesthetics to prevent postherpetic neuralgia: a randomised controlled trial. Herpes zoster vaccine effectiveness against incident herpes zoster and post-herpetic neuralgia in an older US population: a cohort study. Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). CDA Oasis is intended to serve as a rapidly accessible, initial clinical reference resource and not as a complete reference resource. Most children acquire their initial infection through direct contact (eg, a kiss from a parent with an active, primary, or recurrent lesion, as in this child's case).
Patients may have nonspecific symptoms, such as cervical lymphadenopathy, malaise, and low-grade fever, without discrete clinical lesions. When needed, cytologic smears of intact or recently broken vesicles may demonstrate epithelial giant cells with intranuclear eosinophilic viral inclusions, typical of herpes viral infections. An antiviral agent given within 48 hours of the first symptoms can potentially shorten the duration of the illness. Lesions include intact vesicles (V), a pustule (P) that originated as a vesicle, and crusted areas (C) where the vesicles have burst.
Antistaphylococcal antibiotics are an important part of treatment.  Minor relapses do not require a second course of acyclovir. Consider in all children who present with rash and fever but most common under age 4 years.
More common precipitants are HSV (recurrent), EBV, Streptococcal, Mycoplasma, fungal infections; sulfa, penicillin, anticonvulsant drugs. Herald patch appears first (single oval or round lesion on trunk or extremities that resembles tinea corporis).
Prodrome characterized by harsh cough, coryza, conjunctivitis, photophobia and fever 10-12 days after exposure.
Sudden onset of high fever (103-106\F) for several days, decreased appetite, mild URI symptoms, febrile seizures, lymphadenopathy. Patients are ill appearing and should receive a full sepsis work-up and broad-spectrum antibiotic coverage (ampicillin and gentamycin for infants, ampicillin and ceftriaxone or cefotaxime for older children plus chloramphenicol for very ill patients in whom RMSF is suspected. Tingling, itching or pain precedes the eruption of a red papule which evolves into a vesicle. Significant number of causes: penicillin, sulfa, food allergies, insect bites, viral infections, analgesics, physical factors, chemicals. Key point: The multiple shallow to deep erosions on the lower lip began, by history, as blisters. The vaccine reportedly reduces the incidence of herpes zoster by 48%, but it is less effective in immunosuppressed patients. Klasser, Louisiana State University School of Dentistry, department of diagnostic sciences, 1100 Florida Ave., Box 140, New Orleans, LA 70119, USA. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP).

Previously infected persons may shed the virus intermittently in their saliva and serve as a source of infection even without active lesions. The virus remains latent for life and may periodically reactivate in the lips, oral mucosa, or other skin sites of some persons. Primary herpetic stomatitis develops in about 5% to 10% of patients initially infected with HSV.
Followed by eruption of salmon colored papular lesions on trunk and proximal extremities, concentrated in lower abdomen.
Koplik spots are bluish-white spots with a red halo found on the buccal mucosa opposite the premolar teeth. Rash develops as fever subsides and is pale pink, confluent slightly raised papules on trunk and neck. Acute onset of generalized petechiae, prominent over the legs with mucous membrane hemorrhage in a well appearing patient. These patients have multiple, discrete, superficial ulcers of about 1 to 3 mm throughout the oral cavity on both mobile (buccal and labial) and attached (gingival and hard palate) mucosa.
Other clinical findings: arthralgias, cough, uveitis, sterile pyuria, aseptic meningitis, hepatitis, diarrhea, vomiting, myocarditis, pericarditis, coronary artery aneurysms. Lesions are polymorphous – red, round maculopapules on hands, feet, extensor surfaces and trunk that appear abruptly. Rash begins on face and spreads to trunk and extremities and is confluent and dark red to purplish (morbilliform). Facial erythema (slapped cheek) is bright red, bilateral and spares the nasolabial fold and perioral region.
Rash is diffuse, erythematous with a sandpapery texture and tender with accentuation in the flexural areas. Starts as a bulla, pustule or vesicle that collapses and becomes a flat, honey crusted lesion. The eruption is most likely an exaggerated version of herpes labialis relating to the patient’s underlying lymphoma.
The oral lesions begin as vesicles that rupture easily during talking and eating and thus are rarely seen clinically.
The disease is most common in areas of active or recently healed atopic dermatitis, particularly the face, but normal skin can be involved. Rash begins 1-2 days after other symptoms of illness on neck and face and spreads to trunk and extremities, spares palms and soles. Rx ? avoidance or withdrawal of precipitant, oral antihistamines (sedating and non-sedating), prednisone or H2 blockers for refractory cases. A viral culture would be useful just to verify the diagnosis, and an intact vesicle facilitates this.
GI symptoms in 40-60%, joint symptoms in 60-80%, nephritis in 20-50% with proteinuria and hematuria. Rx- application of 2% mupirocin ointment TID until lesions have cleared if disease is localized, otherwise 5-10 day course of dicloxicillin or cephalexin. Treatment: Appropriate oral doses of acyclovir, valacyclovir, or famciclovir should be administered, and topical anesthetic given to prevent dehydration from lack of fluid intake relating to labial pain.
Angioedema of the scalp, eyelids, lips, ears, hands, feet, back, scrotum, and perineum may be seen. Rx-supportive care, broad-spectrum antibiotics and tetracycline, doxycycline, or chloramphenicol for definitive therapy.
The systemic reaction varies, but temperatures of 103-105°F for 7-10 days are not uncommon. Complications: GI bleed, intussuception, chronic renal failure, CNS involvement, hepatosplenomegaly. Can be very severe with blistering forms (Stevens-Johnson syndrome, Toxic Epidermal Necrolysis) and even life threatening. Rx: supportive, antipruritics (diphenhydramine or hydroxyzine), cool baths (Aveeno), keep fingernails short to prevent scratching and superinfection, oral Acyclovir if seen within first 24 hours or for siblings, adolescents, immunocompromised individuals.
Rx- hospitalization and IV antibiotics for extensive cases, otherwise oral antibiotics (dicloxicillin or cephalexin), skin lubrication after skin has started to exfoliate, avoidance of tape.
The diagnosis can be accurately established by examination of vesicular fluid with rapid viral diagnostic techniques.

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