Jean, 63 years old, Facial rash

Written with the participation of FDVF (Future Dermatologists and Venereologists of France) interns.

12 respondents

Question of 1

True

Shingles

It is indeed shingles.

Let’s rule out differential diagnoses:

Acute, sudden and rapidly spreading: not suggestive of a cutaneous tumoural disease.
No tumoural appearance
Vesicular primary lesion
Inflammatory background
Meliceric crusts
Metameric pattern +++: key factor in the diagnosis (≠ acute impetiginised eczema)
No oedema and diffuse pronounced erythema, no increase in local skin temperature, no fever: no arguments in favour of erysipelas BUT possible progression if secondary infection is not treated.

Wrong answer!

It was shingles.

Let’s rule out differential diagnoses:

Acute, sudden and rapidly spreading: not suggestive of a cutaneous tumoural disease.
No tumoural appearance
Vesicular primary lesion
Inflammatory background
Meliceric crusts
Metameric pattern +++: key factor in the diagnosis (≠ acute impetiginised eczema)
No oedema and diffuse pronounced erythema, no increase in local skin temperature, no fever: no arguments in favour of erysipelas BUT possible progression if secondary infection is not treated.

Wrong answer!

It was shingles.

Let’s rule out differential diagnoses:

Acute, sudden and rapidly spreading: not suggestive of a cutaneous tumoural disease.
No tumoural appearance
Vesicular primary lesion
Inflammatory background
Meliceric crusts
Metameric pattern +++: key factor in the diagnosis (≠ acute impetiginised eczema)
No oedema and diffuse pronounced erythema, no increase in local skin temperature, no fever: no arguments in favour of erysipelas BUT possible progression if secondary infection is not treated.

Wrong answer!

It was shingles.

Let’s rule out differential diagnoses:

Acute, sudden and rapidly spreading: not suggestive of a cutaneous tumoural disease.
No tumoural appearance
Vesicular primary lesion
Inflammatory background
Meliceric crusts
Metameric pattern +++: key factor in the diagnosis (≠ acute impetiginised eczema)
No oedema and diffuse pronounced erythema, no increase in local skin temperature, no fever: no arguments in favour of erysipelas BUT possible progression if secondary infection is not treated.

Context: Non-immunocompromised male in his sixties
Primary lesions:
- Vesicles, grouped in clusters
- Pustules
- Erythematous inflammatory background
Secondary lesions:
- Meliceric crusts = secondary infection
- Erosions on the oral mucosa
Location/Pattern:
- Key factor in the diagnosis +++
- Face: skin AND oral mucosa
- Unilateral metameric pattern, along the V2 nerve
Associated signs:
- Pain: neuropathic; often starts before the eruption
- No pruritus
- No fever but adenopathy may be found in the drainage region

When faced with a painful, vesicular, unilateral and metameric dermatosis, evoke the diagnosis of shingles
Facial shingles: investigate mucosal involvement (oral: V2, ocular: V1)
HIV serology: testing recommended in at-risk subjects

Antiviral treatment (oral valaciclovir or famciclovir, intravenous aciclovir):

Immunocompetent patients over the age of 50 within 72 hours following the onset of the rash (prevention of postherpetic pain)
Ocular shingles
Immunocompromised patients

Systematic local care:

Systematic symptomatic treatment:

Treating the secondary infection:

Treating postherpetic pain:

Grade II or III analgesics
Lidocaine plaster
Analgesic psychotropic agents (amitriptyline, carbamazepine, gabapentin, pregabalin, etc.)

Preventive treatment = vaccination:

Vaccination: prevention
Hygiene: cleanse the lesions on a daily basis and disinfect to limit infectious complications
Do not touch or pick at the lesions
Initiate antiviral treatment as soon as possible
Suitable nutrition in the event of oral mucosal involvement:
cold, puréed/semi-solid foods
small, frequent meals
local anaesthetics on mucosal lesions before meals