Factores de risco e tratamento do herpes zoster

Herpes Zoster Risk Factors

• Age (50% in patients over 60 years old)
• Female sex
• Prodromal pain
• Severe pain
• Severe, widespread rash

Herpes Zoster Treatment

• General: Loose cotton clothing, maintain social activities
• Medications:
  • Tricyclic antidepressants
  • Gabapentin/Pregabalin
  • Opioids
  • Lidocaine 5% patches
• Referral to pain management specialist

Herpes Zoster Prevention and Referral

• Zostavax: Live attenuated vaccine, more concentrated than varicella vaccine (now discontinued)
• Shingrix: Recombinant zoster virus vaccine
  • Can be given to immunosuppressed patients
  • 2 doses separated by 2-6 months
• Referral to specialist if:
  • More than 1 dermatome affected
  • Hemorrhagic or necrotic lesions
  • Involvement of the ophthalmic branch (refer to ophthalmologist, leave ointment)
  • Widespread lesions
  • Immunocompromised patient

Impetigo Vulgar

• Caused by Staphylococcus aureus and Streptococcus pyogenes
• Frequently seen in exposed areas (face), periorificial (mouth, nose)
• Clinical Presentation:
  • Erythematous macule → vesicle → pustule → erosion
  • Superficial crust with yellow crust (melicerica)
• Differential Diagnosis:
  • Herpes simplex
  • Eczema
  • Insect bites
  • Chickenpox

Impetigo Vulgar Treatment

• Local Management:
  • Local cleansing and debridement
• Topical Antibiotics:
  • Mupirocin 2% 3 times a day
  • Fusidic acid 2% twice a day for 1 week, chloramphenicol
• Systemic Antibiotics:
  • First-generation cephalosporins: cefadroxil (30 mg/kg/day divided every 12 hours for 10 days)
  • Flucloxacillin (50 mg/kg/day divided every 8 hours)
  • Penicillin allergy:
    • Erythromycin (30-50 mg/kg/day divided every 6 hours)
    • Azithromycin (10 mg/kg/day for 5 days)

Bullous Impetigo

• More common in skin folds, especially in young children

• Caused by Staphylococcus aureus

• Clinical Presentation:

  • Vesicles rapidly transform into flaccid, transparent bullae
  • Sharp margins without an erythematous halo
  • Halo of scales
  • Bullae rupture easily, leaving a dry, shiny erosion with a thin crust
  • Heals faster than impetigo vulgaris

• Complications:

  • If epidermolytic toxin spreads hematogenously, it can lead to Staphylococcal Scalded Skin Syndrome (SSSS), a generalized form of bullous impetigo

Staphylococcal Scalded Skin Syndrome (SSSS)

• Clinical Presentation:
  • Patient has impaired general state: abrupt onset of irritability and fever
  • Macular erythema starts on the face (periorificial) and folds
  • Sensitive skin, generalized rash, Nikolsky sign (+) (skin peels off with friction)
  • Wrinkled skin, 24-48 hours: flaccid bullae detach, large erosive areas with moisture that dries → thin crust, desquamation (in folds) 3-5 days
  • Includes hands and feet, crusts and fissures (radiating) around the mouth
  • Pathology: Necrosis of keratinocytes

SSSS Treatment

• Primary Goal: Eradicate the infectious focus
• Treatment:
  • Intravenous antibiotics (cloxacillin, vancomycin if MRSA)
  • Skin and electrolyte management
  • Diagnosis and management of carriers (mupirocin nasal)

SSSS Differential Diagnosis

• Scarlet fever
• Kawasaki disease
• Staphylococcal toxic shock syndrome
• Toxic Epidermal Necrolysis (TEN) (due to medications)

Folliculitis

• Superficial Folliculitis:
  • Involves the distal portion of the hair follicle
  • Papules or pustules 1-4 mm in diameter on an erythematous base, pruritic
• Deep Folliculitis:
  • Involves the deeper portion of the hair follicle
  • Erythematous, tender papules of larger size with central pustules
  • Can extend to surrounding tissue → furuncle
• Differential Diagnosis:
  • Acne
  • Pilonidal cyst
  • Sycosis

Folliculitis Treatment

• Reduce Predisposing Factors:
  • Hygiene
  • Medications (e.g., corticosteroids)
• Local Measures:
  • Washing with antibacterial soaps (triclosan or chlorhexidine 1%)
• Topical Antibiotics:
  • Mupirocin 2%, fusidic acid for 7-10 days
• Oral Antibiotics:
  • Flucloxacillin → for extensive, resistant, or recurrent cases

Abscess, Furuncle, Carbuncle

• Abscess: Located in any area, whereas furuncle involves hair follicle, and carbuncle is a cluster of furuncles.
• Furuncle:
  • Occurs more frequently in adolescents and young adults, due to S. aureus
  • More frequent in areas of friction, face, neck (nape), armpits, buttocks, thighs and perineum
  • Predisposing factors: S. aureus carriage, diabetes mellitus (DM), obesity, immunosuppression, tight clothing, hyperhidrosis, poor hygiene
• Carbuncle:
  • Involves subcutaneous tissue, firm swelling with openings that drain pus on the surface
  • More commonly found in the nape, back, and thighs.
  • Symptoms: Fever, pain
  • Complications: Scarring
  • More common in: Diabetics

Abscess, Furuncle, Carbuncle Treatment

• Local Management:
  • Local heat and drainage
• Systemic Antibiotics:
  • Cloxacillin or flucloxacillin
  • First-generation cephalosporin
  • Amoxicillin-clavulanate
  • Penicillin allergy: macrolide or clindamycin

Ecthyma

• Clinical Presentation:
  • Ulcerative form of non-bullous impetigo, involvement of epidermis and dermis
  • More frequently seen on the lower extremities (dorsum of the feet and anterior legs)
  • Few lesions
• Treatment:
  • Mild cases: topical macrolides or clindamycin
  • Severe or facial cases: IV antibiotics
    • Penicillin sodium (2-4 million units every 6 hours) + cloxacillin (1 g every 6 hours) OR
    • First-generation cephalosporin (cefazolin 1-2 g every 8 hours) OR
    • If responds well after 72 hours: cefadroxil (1 g every 12 hours) orally
  • Penicillin allergy: lincomycin IV and then orally
  • Chronic ulcer associated with Ecthyma: Cover for anaerobes and gram-
    • Metronidazole + ciprofloxacin
  • Recurrences:
    • Benzathine penicillin (1.2 million units monthly) for 6 months or erythromycin (250 mg every 12 hours) for 3 months

Erysipelas

• Clinical Presentation:

  • Infection of the dermis and superficial lymphatic plexus (more superficial than cellulitis)
  • Caused by S. pyogenes (usually group A beta-hemolytic streptococcus)

• Risk Factors:

  • Age (more common in elderly)
  • Underlying medical conditions (diabetes, alcoholism, malnutrition)
  • Impaired immune system
  • Skin trauma (cuts, scratches, insect bites)
  • Recent surgery or invasive procedures
  • Lymphedema

• Clinical Presentation:

  • Well-demarcated, raised, erythematous plaque
  • Tenderness and pain
  • Edema
  • Often involves the face, lower legs, and arms

• Treatment:

  • Penicillin V (250-500 mg orally four times a day)
  • Patients with penicillin allergy: cephalexin (250-500 mg by mouth four times a day)
  • For severe cases: intravenous penicillin or ceftriaxone
  • The duration of treatment is typically 10 days.

Erysipelas Complications

• Cellulitis
• Lymphangitis
• Sepsis
• Brain abscess (rare)

Skin Infections: Summary of Organisms

• Impetigo vulgaris: Staphylococcus aureus (most common) and Streptococcus pyogenes.
• Bullous impetigo: Staphylococcus aureus.
• Ecthyma: Streptococcus pyogenes, but Staphylococcus aureus can also be involved.
• Erysipelas: Streptococcus pyogenes.

Este cuestionario aborda os factores de risco, tratamento e prevención do herpes zoster, así como a identificación de síntomas e a importancia de refíos a especialistas. É fundamental entender como tratar e minimizar os riscos asociados a esta condición para mellorar a calidade de vida dos pacientes.