Herpes zoster differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; L. Katie Morrison, MD; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. [2] João André Alves Silva, M.D. [3]

Overview

Diagnosis of Herpes zoster might not be possible in the absence of a rash (i.e., before rash or in cases of zoster without rash). It is sometimes confused with herpes simplex, and, occasionally, with impetigo, contact dermatitis, folliculitis, scabies, insect bites, papular urticaria, candidal infection, dermatitis herpetiformis, and drug eruptions.

Differentiating Herpes Zoster from other Diseases

For rash:

Disease Findings
Atopic dermatitis
Pyoderma gangrenosum
*Herpes simplex
Contact dermatitis
Folliculitis
Scabies
[Papule|Papular]] urticaria
Candidal infection
Drug eruptions
Kawasaki disease
Measles
'[Rubella]]
Atypical Measles
Monkeypox
Coxsackievirus
Acne
, *Syphilis
Molluscum contagiosum
Mononucleosis
Toxic erythema
Rat-bite fever
Parvovirus B19 Cytomegalovirus Scarlet fever Rickettsialpox Varicella-zoster virus, Meningococcemia Rocky Mountain spotted fever [[Impetigo
Stevens-Johnson syndrome
Rocky Mountain spotted fever
Impetigo'
  • Atopic dermatitis - The skin of a patient with atopic dermatitis reacts abnormally and easily to irritants, food, and environmental allergens and becomes red, flaky and very itchy. It also becomes vulnerable to surface infections caused by bacteria. The skin on the flexural surfaces of the joints (for example inner sides of elbows and knees) are most commonly affected regions in people.
  • Herpes simplex - Primary orofacial herpes / Herpes simplex type 1 presents itself as multiple, round, superficial oral ulcers [1] Adults with non-typical presentation are more difficult to diagnose. However, prodromal symptoms that occur before the appearance of herpetic lesions helps to differentiate HSV from other conditions with similar symptoms like allergic stomatitis. Genital herpes can be more difficult to diagnose than oral herpes since most genital herpes/HSV-2-infected persons have no classical signs and symptoms.[1]. They present with blisters and ulcers in genital area that are similar to orofacial herpes. Herpes infection can recur even after successful initial treatment. The first episode is usually longer (two to four weeks) more painful and severe than the subsequent/recurrent episodes.
  • Contact dermatitis - skin reaction resulting from exposure to allergens (allergic contact dermatitis) or irritants (irritant contact dermatitis).Phototoxic dermatitis occurs when the allergen or irritant is activated by sunlight. Contact dermatitis is a localized rash or irritation of the skin caused by contact with a foreign substance. Only the superficial regions of the skin are affected in contact dermatitis.
  • Papular urticaria - skin condition, commonly caused by an allergic reaction, that is characterized by raised red skin welts. It is also known as nettle rash or uredo. Welts from hives can appear anywhere on the body, including the face, lips, tongue, throat, and ears. Welts may vary in size from about 5 mm (0.2 inches) in diameter to the size of a dinner plate; they typically itch severely, sting, or burn, and often have a pale border. Urticaria is generally caused by direct contact with an allergenic substance, or an immune response to food or some other allergen, but can also appear for other reasons, notably emotional stress. The rash can be triggered by quite innocent events, such as mere rubbing or exposure to cold.
  • Dermatitis herpetiformis - systemic condition, usually extremely itchy. In many people the vesicles or papules appear on pressure points, such as the elbows, knees, back and buttocks. It may also present as a patch of red skin with little water blisters scattered about. The unpredictable skin rash may appear or be exacerbated by any irritation such as dry skin, scratching or clothing that is rough or scratchy. The fact that the rash is most prevalent at pressure points may be why the symptoms sometimes appear to be symmetrical.
  • Monkeypox - presentation is similar to smallpox, although it is often a milder form, with fever, headache, myalgia, back pain, swollen lymph nodes, a general feeling of discomfort, and exhaustion. Within 1 to 3 days (sometimes longer) after the appearance of fever, the patient develops a papular rash, often first on the face. The lesions usually develop through several stages before crusting and falling off.
  • Coxsackievirus - the most commonly caused disease is the Coxsackie A disease, presenting as hand, foot and mouth disease. It may be asymptomatic or cause mild symptoms, or it may produce fever and painful blisters in the mouth (herpangina), on the palms and fingers of the hand, or on the soles of the feet. There can also be blisters in the throat or above the tonsils. Adults can also be affected. The rash, which can appear several days after high temperature and painful sore throat, can be itchy and painful, especially on the hands/fingers and bottom of feet.
  • Molluscum contagiosum - lesions are commonly flesh-colored, dome-shaped, and pearly in appearance. They are often 1-5 millimeters in diameter, with a dimpled center. Generally not painful, but they may itch or become irritated. Picking or scratching the lesions may lead to further infection or scarring. In about 10% of the cases, eczema develops around the lesions. They may occasionally be complicated by secondary bacterial infections.
  • Parvovirus B19 - the rash of fifth disease is typically described as "slapped cheeks," with erythema across the cheeks and sparing the nasolabial folds, forehead, and mouth.
  • Stevens-Johnson syndrome - symptoms may include fever, sore throat and fatigue. Commonly presents ulcers and other lesions in the mucous membranes, almost always in the mouth and lips but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. Conjunctivitis of the eyes occurs in about 30% of children. A rash of round lesions about an inch across, may arise on the face, trunk, arms and legs, and soles of the feet, but usually not on the scalp.
  • Varicella-zoster virus - commonly starts as a painful rash on one side of the face or body. The rash forms blisters that typically scab over in 7-10 days and clears up within 2-4 weeks.
  • Chickenpox - commonly starts with conjunctival and catarrhal symptoms and then characteristic spots appearing in two or three waves, mainly on the body and head, rather than the hands, becoming itchy raw pox (small open sores which heal mostly without scarring). Touching the fluid from a chickenpox blister can also spread the disease.
  • Impetigo - commonly presents with pimple-like lesions surrounded by erythematous skin. Lesions are pustules, filled with pus, which then break down over 4-6 days and form a thick crust. It's often associated with insect bites, cuts, and other forms of trauma to the skin.

For pain symptoms depending on the location:

Herpes zoster can be more difficult to diagnose in children, younger adults, and immunocompromised persons who are more likely to have atypical presentations.

References

  1. 1.0 1.1 Fatahzadeh M, Schwartz RA (2007). "Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management". J. Am. Acad. Dermatol. 57 (5): 737–63, quiz 764–6. doi:10.1016/j.jaad.2007.06.027. PMID 17939933.
  2. Walsh TJ, Dixon DM (1996). "Deep Mycoses". In Baron S et al eds. Baron's Medical Microbiology (via NCBI Bookshelf) (4th ed. ed.). Univ of Texas Medical Branch. ISBN 0-9631172-1-1.
  3. 3.0 3.1 3.2 MedlinePlus Encyclopedia Vaginal yeast infection
  4. 4.0 4.1 Fidel PL (2002). "Immunity to Candida". Oral Dis. 8: 69–75. PMID 12164664.
  5. Pappas PG (2006). "Invasive candidiasis". Infect. Dis. Clin. North Am. 20 (3): 485–506. doi:10.1016/j.idc.2006.07.004. PMID 16984866.

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