Vesicular and Crusted Lesions on an Erythematous Plaque in an 88-Year-Old Female Patient
- 1. Department of Dermatology, Ciudad Real General University Hospital, 13005 Ciudad Real, Spain
An 88-year-old woman, with no medical history of interest, came to the emergency department with fever and painful swelling of the right cheek for two days.On examination, she presented an inflammatory plaque with raised borders, affecting the right nasal ala, cheek and lower eyelid on the same side (Figure 1). On the inflammatory plaque there were vesicular lesions, other hemorrhagic and meliceric crusty lesions in the territory of innervation of the maxillary branch of the trigeminal nerve (V2 territory), which did not exceed the midline, but with involvement of the nasal tip (V1 territory). She reported ocular pain and difficulty in opening the eye due to palpebral edema. Laboratory tests revealed leukocytosis and increased acute phase reactants. In view of the involvement of the nasal tip, known as Hutchinson’s sign, the ophthalmology department was consulted and ruled out corneal involvement, which can occur when herpes-zoster affects the V1 territory erysipelas, with virological confirmation of herpes zoster virus by polymerase chain reaction test. Intravenous treatment was prescribed with Acyclovir 500mg every 8 hours and amoxicillinclavulanic acid 1g/200mg every 8 hours, both for one week.
Herpes zoster is a disease consisting of a painful rash formed by vesicles on an erythematous base, usually distributed along metameric lines with respect to the midline, due to reactivation of the varicella-zoster virus. Primary infection with this virus gives rise to the well-known varicella . The diagnostic test of choice is the Polymerase chain reaction (PCR), taking a sample of the vesicles .
Although the most frequent complication of herpes zoster is bacterial superinfection, the involvement of some nerve territories can be associated with more severe involvement, as is the example of facial nerve involvement giving rise to ramsay-hunt syndrome, clinically suspected by vesicles in the auricular concha, or the involvement of the ophthalmic branch of the trigeminal nerve, clinically suspected by vesicles in thenasal tip, known as Hutchinson’s sign. Some authors consider that the search for this sign should extend along the nasociliary dermatome, including ala, dorsum, nasal root and inner canthus of the eye . The sight of vesicles in these areas should alert us of these affectations.
The clinical diagnosis was herpes zoster with associated
Figure 1: Vesicles and meliceric crusts over an erythematous plaque extending from the right cheek to the temple of the patient. Note presence of nasal tip involvement
Treatment consists of analgesia and oral antiviral treatment, except in selected cases, such as immunosuppressed patients, where intravenous acyclovir is the treatment of choice. Antiherpetic treatment accelerates the healing of vesicles and prevents the appearance of postherpetic neuralgia. In case of associated erysipelas, systemic treatment with antibiotics and disinfection of the crusts are necessary. Prevention is based on the use of a recombinant zoster vaccine, which reduces the incidence of herpes zoster by about 90% and is preferred to the live attenuated herpes zoster vaccine [2,4].
Alwattar-Ceballos O, Moro-Bolado F, Martínez-Montalvo L, Sánchez-Mateos JSL (2023) Vesicular and Crusted Lesions on an Erythematous Plaque in an 88-Year-Old Female Patient. JSM Clin Case Rep 11(2): 1214