Skin Lesions Of Herpes Zoster Research Articles

Epidural Block Treatment on Postherpetic Neuralgia and Comorbid Spine Metastasis of Malignant Tumor: Two Cases of Report

Abstract Introduction: Postherpetic neuralgia (PHN) is a painful condition that occurs after herpes zoster skin lesions have subsided and that lasts for more than 1 month. PHN is usually difficult to treat. We herein present two cases of PHN comorbid with spinal metastasis of a malignant tumor. Both patients responded well to an epidural block. Case presentation: Patient 1 was a 54-year-old woman who had PHN for 35 days. Patient 2 was a 74-year-old woman who had PHN for 65 days. Both patients were treated with an epidural block and found to have spinal metastasis from a malignant tumor. Discussion: The routinely used dermatological medications for the treatment of herpes zoster and PHN have slow and unsatisfactory analgesic effects. Epidural block treatment provides a new approach for patients who cannot tolerate or do not respond to these commonly used drugs. Physicians should pay special attention to patients who have a history of a malignant tumor or are suspected to have spinal disease. Computed tomography or magnetic resonance imaging of the spine is recommended for such patients, and epidural block treatment should be performed after a spinal tumor or other lesions have been excluded. Conclusion: Epidural block treatment provides a new approach for patients of herpes zoster or PHN, but the treatment should be performed after a spinal tumor or other spinal lesions have been excluded.

Incidence of and Risk Factors for Cutaneous Scarring after Herpes Zoster

About 20% of children have cutaneous scars following chickenpox. In contrast, skin scars are not often reported after herpes zoster (HZ). Risk factors for post-HZ scarring remain undetermined. Our objective was to prospectively study the incidence of and risk factors for post-HZ scarring. This was a 3-year prospective study of patients with HZ attending a tertiary university hospital. Baseline data, including age, sex, immunosuppression, prior history of scarring, severity and extension of HZ, afflicted HZ dermatome, and antiviral treatment received, were recorded. At 1month after the HZ skin lesions had healed, patients were screened for skin scars at the prior HZ site. These patients were followed every 2months for 6months. At 6months, 11 (9.7%) of 113 HZ patients still had post-HZ scarring (fair-skinned patients: hypopigmented [n = 3], hyperpigmented [n = 2], atrophic cicatricial [n = 3], and hypertrophic cicatricial [n = 1]; dark-skinned patients: severe hyperpigmented hypertrophic scarring [n = 2]). HZ was extensive and severe in all cases. Nine of the 11 patients were immunocompromised. Three cases had a history of hypertrophic/keloid scarring but no post-varicella scars. The most frequent location was the trunk (n = 5), followed by the cervical region (n = 3) and the face (n = 3). Given the study setting, it is possible that immunocompromized patients with severe HZ were overrepresented in this study. Scarring after HZ is probably overlooked. The principal risk factors seem to be severe HZ and immunosuppression. Hence, prompt instigation of antiviral treatment for HZ and HZ vaccination could help reduce the incidence of post-HZ scarring.

Age-Associated Differences in Infection of Human Skin in the SCID Mouse Model of Varicella-Zoster Virus Pathogenesis.

Varicella-zoster virus (VZV) is the skin-tropic human alphaherpesvirus responsible for both varicella-zoster and herpes zoster. Varicella-zoster and herpes zoster skin lesions have similar morphologies, but herpes zoster occurs disproportionally in older individuals and is often associated with a more extensive local rash and severe zoster-related neuralgia. We hypothesized that skin aging could also influence the outcome of the anterograde axonal transport of VZV to skin. We utilized human skin xenografts maintained in immunodeficient (SCID) mice to study VZV-induced skin pathology in vivo in fetal and adult skin xenografts. Here we found that VZV replication is enhanced in skin from older compared to younger adults, correlating with clinical observations. In addition to measures of VZV infection, we examined the expression of type I interferon (IFN) pathway components in adult skin and investigated elements of the cutaneous proliferative and inflammatory response to VZV infection in vivo Our results demonstrated that VZV infection of adult skin triggers intrinsic IFN-mediated responses such as we have described in VZV-infected fetal skin xenografts, including MxA as well as promyelocytic leukemia protein (PML), in skin cells surrounding lesions. Further, we observed that VZV elicited altered cell signaling and proliferative and inflammatory responses that are involved in wound healing, driven by follicular stem cells. These cellular changes are consistent with VZV-induced activation of STAT3 and suggest that VZV exploits the wound healing process to ensure efficient delivery of the virus to keratinocytes. Adult skin xenografts offer an approach to further investigate VZV-induced skin pathologies in vivoIMPORTANCE Varicella-zoster virus (VZV) is the agent responsible for both varicella-zoster and herpes zoster. Herpes zoster occurs disproportionally in older individuals and is often associated with a more extensive local rash and severe zoster-related neuralgia. To examine the effect of skin aging on VZV skin lesions, we utilized fetal and adult human skin xenografts maintained in immunodeficient (SCID) mice. We measured VZV-induced skin pathology, examined the expression of type I interferon (IFN) pathway components in adult skin, and investigated elements of the cutaneous proliferative and inflammatory response to VZV infection in vivo Our results demonstrate that characteristics of aging skin are preserved in xenografts; that VZV replication is enhanced in skin from older compared to younger adults, correlating with clinical observations; and that VZV infection elicits altered cell signaling and inflammatory responses. Adult skin xenografts offer an approach to further investigate VZV-induced skin pathologies in vivo.

A Case of Zoster Duplex Bilateralis

The skin lesions of herpes zoster are classically limited to a single dermatome and most cases of multidermatomal herpes zoster have contiguous skin lesions. Simultaneous involvement of two noncontiguous dermatomes is very rare and it has been referred to as zoster duplex unilateralis or bilateralis, depending whether one or both halves of the body are involved. A 67-year-old woman presented with a group of painful vesicles on the right buttock and thigh, and left anterior chest and back. The Tzanck smear and skin biopsy were consistent with a herpetic infection. We report a rare case of zoster duplex bilateralis.

Chronic Steroid and Immunosuppressant Therapy in Children

1. Abraham Gedalia, MD* 2. Avinash K. Shetty, MD† 1. *Professor of Pediatrics and Head, Division of Pediatric Rheumatology, Louisiana State University Health Sciences Center and Children’s Hospital, New Orleans, La 2. †Assistant Professor of Pediatrics, Division of Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC After completing this article, readers should be able to: 1. Describe the mechanism of action, list indications for therapy, and discuss the adverse effects of corticosteroid therapy in children. 2. Delineate the mechanism of action and adverse effects of other immunosuppressive agents frequently used in children. 3. Discuss the immunization recommendations for children receiving immunosuppressive therapy. Corticosteroids are the most potent, naturally occurring anti-inflammatory agents known. Despite more than 50 years of controversy regarding their clinical use, risks, and benefits, corticosteroids still play a significant role in the management of a wide variety of diseases. They have reduced the morbidity and mortality significantly in children afflicted with leukemia, asthma, rheumatic diseases, and other inflammatory disorders. In this article, we review the mechanism of action, clinical indications, and adverse effects of corticosteroids and other commonly used immunosuppressive agents in children. We also review immunization recommendations for children receiving immunosuppressive therapy. Corticosteroids have a diverse role in the human body at the physiologic level. The actions of glucocorticoids include: 1) negative feedback modulation of corticotropin-releasing factor and adrenocorticotropic hormone; 2) regulation of blood glucose and liver glycogen levels; 3) maintenance of water-electrolyte homeostasis; 4) influence on the metabolism of protein, fat, and purine; 5) maintenance of normal cardiovascular, central nervous system (CNS), and renal functions; 6) influence on circadian rhythmicity; 7) maintenance of bone and muscle work capacity; and 8) protection of the body against moderate stress. Glucocorticoids also have pharmacologic properties that are used in the treatment of rheumatic and other inflammatory diseases. Cellular receptors for cortisol are ubiquitous in cell cytoplasm, reflecting the critical role of the hormone in maintaining cell homeostasis. The type 1 glucocorticoid receptor, known as the mineralocorticoid receptor, has high affinity for aldosterone. The type 2 glucocorticoid receptor, known as the glucocorticoid receptor, exhibits strong affinity for dexamethasone. Although …

Prognostic value of Hutchinson's sign in acute herpes zoster ophthalmicus.

To determine the prognostic value of nasociliary skin lesions (Hutchinson's sign) for ocular inflammation and corneal sensory denervation in acute herpes zoster ophthalmicus. A longitudinal observational study with a 2-month follow-up was performed involving 83 non-immunocompromised adults with acute herpes zoster ophthalmicus, with a skin rash duration of less than 7 days, referred by their general practitioner. All skin lesions at the tip, the side and the root of the nose, representing the dermatomes of the external nasal and infratrochlear branches of the nasociliary nerve, were documented by taking photographs and marking anatomical drawings. Ocular inflammatory signs were observed by slit-lamp biomicroscopy, and corneal sensitivity was measured with the Cochet-Bonnet esthesiometer at 2-month follow-up. Hutchinson's sign was a powerful predictor of ocular inflammation and corneal denervation in herpes zoster ophthalmicus [relative risks: 3.35 (CI 95%: 1.82-6.15) and 4.02 (CI 95%:1.55-10.42), respectively]. The manifestation of herpes zoster skin lesions at the dermatomes of both nasociliary branches was invariably associated with the development of ocular inflammation. Clinicians should be alert for early skin lesions within the complete nasociliary dermatome, because they are a reliable prognostic sign of sight-threatening ocular complications in acute herpes zoster ophthalmicus.

Pathway of viral spread in herpes zoster: detection of the protein encoded by open reading frame 63 of varicella-zoster virus in biopsy specimens.

Reactivation of varicella-zoster virus (VZV) in the dorsal root or trigeminal ganglia causes herpes zoster. The pathway of viral spread from the ganglia to the skin and also within the skin is not yet completely understood. Histological studies have revealed that each skin lesion in herpes zoster progresses sequentially through the stages of erythema, vesicles, pustules and finally ulceration. An immunohistochemical study of the early skin lesions of herpes zoster demonstrated a high incidence of hair follicle involvement and the main localization of the virus at the isthmus. This evidence suggests that VZV initially spreads from the ganglia through myelinated nerves, which predominantly end around the isthmus of hair follicles. To further investigate the viral spread within the skin, we analyzed the sequential appearance of the immediate early proteins encoded by ORF 63 of VZV (IE63), using an anti-IE63 antibody raised by immunization of rabbits with a recombinant protein. This antibody could detect IE63 in a western blot analysis of infected cells and also in immunohistochemical analysis of the skin lesions of herpes zoster. IE63 initially appeared in the nuclei of the follicular epithelial cells and basal or parabasal epidermal cells. Later, the nuclei and cytoplasm of cells in the epidermis and hair follicles became positive. IE63 remained in the virus-infected cells even during their degeneration. When we examined the hair follicles in the early erythematous lesions, cells positive for IE63 were predominantly distributed around the isthmus. In addition, some lymphocytes around the blood vessels were also positive for IE63, but these cells were seldom positive for the structural antigen. Thus, these observations suggest that VZV arriving through myelinated nerves infects not only permissive cells, but also non-permissive cells in the involved skin of herpes zoster.

Severity of skin lesions of herpes zoster at the worst phase rather than age and involved region most influences the duration of acute herpetic pain

Duration of acute herpetic pain (AHP) in 1431 patients for whom treatment was begun within 14 days after the onset of herpes zoster (HZ) was analyzed with respect to age, involved region, and severity of skin lesions. All patients were treated with repeated sympathetic nerve blocks until their pain was almost nil. Severity of the skin lesions at the worst phase was defined as mild when they covered less than one-quarter of the primary dermatome, as severe when they covered more than three-quarters of the primary dermatome, and moderate if they were between mild and severe. Without taking into account the severity of skin lesions, the duration of AHP for those aged 60 years or over and for those with trigeminal involvement was significantly longer than for patients aged under 40 years ( P<0.01 and P<0.001) and for patients with thoracic ( P<0.001) and lumbosacral ( P<0.01) involvement, respectively. However, duration of AHP was significantly longer with increase in the severity of skin lesions in all age groups (the mild group versus the moderate group, P<0.01 and P<0.001; the moderate group versus the severe group, P<0.01 and P<0.001). The mean duration of AHP for patients aged 60 years or over with mild skin lesions ranged from 17.4 to 22.9 days, while that for patients aged 30–59 years with severe skin lesions ranged from 37.2 to 50.1 days. In addition, duration of AHP was significantly longer with increase in the severity of skin lesions in all regions (the mild group versus the moderate group, P<0.01 and P<0.001; the moderate group versus the severe group, P<0.05 and P<0.001). The mean duration of AHP for those with trigeminal involvement with mild skin lesions was 19.5 days, while the range was from 51.3 to 55.0 days for patients with severe skin lesions involving regions other than the trigeminal area. The frequency of severe skin lesions was significantly higher ( P<0.001) in patients aged 60 years or over and in those with trigeminal involvement. Multiple stepwise regression analysis revealed that the most important factors influencing the duration of AHP were the severity of skin lesions of HZ at the worst phase ( r=0.412), age ( r=0.277) and the involved region ( r=-0.101). Thus, AHP in the elderly and in cases of trigeminal involvement is longer because of higher frequencies of severe HZ in the elderly and in trigeminal involvement rather than `being aged' and `trigeminal involvement' itself. We propose that one needs to analyze the results of treatment of AHP with respect to the severity of skin lesions at the worst phase.

Hair follicle involvement in herpes zoster: pathway of viral spread from ganglia to skin.

Herpes zoster is caused by reactivation of varicella-zoster virus (VZV) persisting in dorsal root or trigeminal ganglia. To clarify the pathway of viral spread from the ganglia to skin, 16 biopsy specimens of early skin lesions of herpes zoster obtained from the face and trunk of 13 patients were studied histologically and immunohistochemically using monoclonal antibodies to the structural proteins of VZV. VZV-infected cells were detected in the hair follicles in 10 of the 16 specimens and in the epidermis in 2 specimens. Infected cells were localized in the isthmus of every involved follicle (12/12), frequently in the stem (8/10) and infundibulum (6/10), and never in the bulb. The high frequency of follicular involvement in herpes zoster suggests that VZV spreads to the area of skin innervated by myelinated nerves, which end around the isthmus of hair follicles and sebaceous glands.

Scanning and transmission electron microscopic studies of lesional epidermis in herpes zoster.

The epidermal skin lesions of herpes zoster were studied by scanning (SEM) and transmission electron microscopy (TEM). When erythematous lesions were observed by TEM, many of the infected keratinocytes showed evidence of cell degeneration, being characterized by swollen nuclei, disappearance of desmosomes, and widening of intercellular spaces. Macrophages and/or lymphocytes migrated through the intercellular spaces between degenerated keratinocytes. In the vesicular lesions, SEM and TEM showed some infiltrating neutrophils, directly adhering to the virus-infected keratinocytes, with swollen nuclei and irregularly clumped chromatin. In some specimens, balloon-degenerated keratinocytes were observed in the cavity. In the pustular stage, ruptured keratinocytes and numerous neutrophils were observed in the reticular-degenerated epidermal tissue. These results suggest that, in herpes zoster, the epidermal damage may be due, at least in part, to cell-mediated host immunity as well as to the cytopathic effect of varicella-zoster virus.

Immunohistochemical study of skin lesions in herpes zoster.

Thirty-seven biopsy skin tissues of herpes zoster taken from 27 patients were analysed immunohistochemically using two monoclonal antibodies detecting either nucleocapsid or glycoproteins of varicella-zoster virus (VZV) on paraffin sections of formalin fixed tissues. Skin lesions of herpes zoster were divided clinically into four stages: erythematous, vesicular, pustular and ulcerative. In the erythematous stage, VZV antigens, if detected, were found only within ballooning cells in the lower epidermis or follicular epithelium. In the vesicular stage, antigens were detected in the cells around and within the intraepidermal vesicles and in histiocytes or fibrocytes of the dermis in all cases and in the endothelial or perineural cells in 10 of 14 cases. In the pustular stage, the antigens were observed in degenerated or necrotic keratinocytes and multinucleated giant cells within pustules and some necrotic cells in the dermis. In the ulcerative stage, the viral antigens were detected only at the ulcer margin and around the hair shaft in 2 of 7 cases. These results suggest that VZV initially involves the epidermis in the erythematous stage, subsequently invades the dermis in the vesicular stage, and disappears in the early ulcerative stage.

Viral activity in skin lesions of herpes zoster.

AbstractVaricella‐zoster virus (VZV) was isolated in 41 of 53 (77%) patients with herpes zoster on the first to ninth days after the rash. The isolation rate was highest on the early days, as high as 86% on days one and two of rash, and gradually decreased to the ninth day; the isolation rate depended more upon the condition of skin lesions than the days of illness. The high viral activity in the rash proves its important role as the source of VZV infections and the reliability of virus isolation for the diagnosis of herpes zoster.

Herpes Zoster Ophthalmicus With Contralateral Hemiplegia

A 48-year-old man developed left hemiparesis nine weeks after herpes zoster skin lesions had appeared over the right forehead. Cerebral angiography showed bilateral changes consistent with cerebral arteritis. The patient's condition worsened after the angiographic procedure. Reports from the literature as well as the present case suggest that arteritis and ischemia best explain contralateral neurological symptoms that occur suddenly following herpes zoster ophthalmicus.