What are the symptoms of oral shingles. How is herpes zoster in the mouth diagnosed. What treatments are available for shingles affecting the oral cavity. Can oral shingles be mistaken for other dental conditions. How can early detection of oral shingles improve patient outcomes.

What is Herpes Zoster Mouth?

Herpes zoster mouth, also known as oral shingles, is a manifestation of the varicella-zoster virus (VZV) reactivation in the oral cavity. This condition occurs when the dormant virus, which causes chickenpox in its initial infection, becomes active again later in life. When it affects the trigeminal nerve, particularly the maxillary branch (V2), it can lead to symptoms in and around the mouth.

Understanding oral shingles is crucial for both patients and healthcare providers, as its early symptoms can often be mistaken for other dental conditions, potentially leading to delayed diagnosis and treatment.

Key Characteristics of Oral Shingles

• Caused by reactivation of the varicella-zoster virus
• Typically affects one side of the face or mouth
• Can cause pain, tingling, and burning sensations before visible symptoms appear
• May present with blisters or ulcerations in the oral cavity
• Can be accompanied by facial swelling and skin changes

Recognizing the Symptoms of Herpes Zoster in the Mouth

Identifying oral shingles can be challenging, especially in its early stages. The symptoms often evolve over time and may initially mimic other dental or oral conditions. Being aware of the progression and unique characteristics of oral shingles can aid in prompt diagnosis and treatment.

Early Warning Signs

What are the initial symptoms of oral shingles? Early signs may include:

• Localized pain or discomfort in the mouth or face
• Tingling or burning sensations
• Sensitivity to touch in the affected area
• Toothache-like pain that doesn’t seem to have a dental cause

These symptoms may precede any visible signs by several days, making early diagnosis challenging.

Visible Symptoms

As the condition progresses, more noticeable symptoms may develop:

• Redness or swelling of the oral mucosa
• White or yellowish ulcerations, typically on one side of the mouth
• Blisters or vesicles on the palate, gums, or other oral tissues
• Facial swelling, potentially extending to the eyelids
• Skin rash near the mouth or on the face (in some cases)

Diagnostic Challenges and Importance of Oral Examination

Diagnosing oral shingles can be tricky, especially when it presents with atypical symptoms. Why is a thorough oral examination crucial for identifying herpes zoster in the mouth?

A comprehensive oral inspection can reveal telltale signs that might otherwise be overlooked. In the case study mentioned, the patient initially presented with facial swelling and a history of toothache, which could have been mistaken for a bacterial infection following dental work. However, a careful intraoral examination uncovered white erosions on the left hard palate, clearly demarcated at the midline – a characteristic sign of herpes zoster affecting the maxillary nerve.

Potential Misdiagnoses

Oral shingles can be mistaken for several other conditions, including:

• Dental abscess or infection
• Trigeminal neuralgia
• Temporomandibular joint (TMJ) disorders
• Oral candidiasis
• Aphthous ulcers

This highlights the importance of considering herpes zoster as a differential diagnosis in cases of unexplained oral pain or lesions, especially in older adults or immunocompromised individuals.

Diagnostic Methods for Confirming Oral Shingles

How can healthcare providers definitively diagnose herpes zoster in the mouth? While clinical presentation is often indicative, several diagnostic tools can help confirm the diagnosis:

1. Viral Culture: Swabbing the affected area to isolate the virus
2. PCR Testing: Detecting viral DNA in fluid from blisters or blood
3. Tzanck Smear: Microscopic examination of cells from a lesion
4. Antibody Testing: Checking for elevated levels of varicella-zoster virus antibodies in the blood

In the case study, the patient’s serum level of varicella-zoster virus-specific IgG was significantly elevated at 1240 (reference range <2), confirming the diagnosis of herpes zoster reactivation.

Treatment Approaches for Oral Shingles

Once diagnosed, prompt treatment of oral shingles is crucial to manage symptoms and prevent complications. What are the primary treatment options for herpes zoster affecting the mouth?

Antiviral Medications

The cornerstone of treatment is antiviral therapy, which can help shorten the duration of the outbreak and reduce the severity of symptoms. Common antiviral medications include:

• Acyclovir
• Valacyclovir
• Famciclovir

In the case study, the patient received intravenous acyclovir for one week, which helped resolve the acute symptoms.

Pain Management

Pain control is an essential aspect of oral shingles treatment. Options may include:

• Over-the-counter pain relievers (e.g., acetaminophen, ibuprofen)
• Prescription pain medications for severe cases
• Topical anesthetics for localized relief

Supportive Care

Additional measures to support healing and comfort may include:

• Oral rinses to soothe inflamed tissues
• Soft or liquid diet to minimize discomfort while eating
• Cold or warm compresses for pain relief

Complications and Long-term Effects of Oral Shingles

While many cases of oral shingles resolve without significant long-term effects, some patients may experience complications. What are the potential long-term consequences of herpes zoster in the mouth?

Postherpetic Neuralgia

One of the most common and troublesome complications is postherpetic neuralgia (PHN), a condition characterized by persistent pain in the affected area even after the rash has healed. In the case study, the patient developed PHN, experiencing a burning sensation on the left side of his face and hard palate.

PHN can significantly impact quality of life and may require ongoing pain management strategies, including:

• Anticonvulsant medications (e.g., gabapentin, pregabalin)
• Tricyclic antidepressants
• Topical lidocaine or capsaicin patches
• Nerve blocks or other interventional pain procedures

Other Potential Complications

Additional complications of oral shingles may include:

• Secondary bacterial infections of the lesions
• Scarring of oral tissues
• Tooth sensitivity or damage if nerves supplying the teeth are affected
• Taste disturbances
• In rare cases, spread of the infection to other cranial nerves

Prevention and Risk Factors for Oral Shingles

Understanding the risk factors for herpes zoster and taking preventive measures can help reduce the incidence of oral shingles. What factors increase the likelihood of developing this condition, and how can it be prevented?

Risk Factors

Several factors may increase an individual’s risk of developing herpes zoster, including:

• Age: The risk increases significantly after 50 years
• Weakened immune system due to illness or medications
• History of chickenpox, especially if contracted at a young age
• Chronic stress or physical trauma
• Certain medical conditions, such as cancer or HIV/AIDS

Preventive Measures

While it’s not always possible to prevent shingles, certain steps can reduce the risk or severity of outbreaks:

1. Vaccination: The shingles vaccine is recommended for adults over 50 and can significantly reduce the risk of developing herpes zoster or its complications
2. Stress management: Practicing stress-reduction techniques may help support immune function
3. Maintaining overall health: A balanced diet, regular exercise, and adequate sleep can support immune system strength
4. Prompt treatment of any immune-compromising conditions

The Role of Dental Professionals in Identifying Oral Shingles

Dental professionals play a crucial role in the early detection and management of oral shingles. How can dentists and dental hygienists contribute to better outcomes for patients with herpes zoster in the mouth?

Importance of Vigilance

Dentists and dental hygienists are often the first healthcare providers to examine a patient’s oral cavity. Their vigilance in recognizing unusual oral lesions or unexplained pain can lead to earlier diagnosis and treatment of oral shingles. This is particularly important given that the prodromal stage of herpes zoster can mimic other dental conditions, such as odontogenic pain.

Key Responsibilities of Dental Professionals

• Thorough oral examinations, paying attention to unilateral lesions or pain
• Consideration of herpes zoster in differential diagnoses, especially for older or immunocompromised patients
• Prompt referral to appropriate medical professionals when oral shingles is suspected
• Education of patients about the signs and symptoms of oral shingles
• Collaboration with medical colleagues in the management of oral shingles cases

By maintaining a high index of suspicion and conducting careful examinations, dental professionals can significantly contribute to the early detection and management of oral shingles, potentially reducing the risk of complications like postherpetic neuralgia.

Future Directions in Oral Shingles Research and Management

As our understanding of herpes zoster continues to evolve, what are the potential future developments in the diagnosis, treatment, and prevention of oral shingles?

Advanced Diagnostic Tools

Research is ongoing to develop more rapid and accurate diagnostic methods for herpes zoster. These may include:

• Point-of-care testing for immediate viral detection in dental offices
• Advanced imaging techniques to visualize nerve involvement before visible symptoms appear
• Genetic markers to identify individuals at higher risk of developing shingles

Novel Treatment Approaches

Emerging therapies for oral shingles may focus on:

• More potent and targeted antiviral medications
• Immunomodulatory therapies to boost the body’s response to the virus
• Advanced pain management techniques for prevention and treatment of postherpetic neuralgia
• Regenerative therapies to address nerve damage caused by the virus

Enhanced Prevention Strategies

Future preventive measures may include:

• Development of more effective and longer-lasting vaccines
• Personalized vaccination schedules based on individual risk factors
• Targeted interventions for high-risk populations, such as cancer patients or older adults

As research progresses, the management of oral shingles is likely to become more precise and effective, potentially reducing the incidence and impact of this challenging condition. Dental and medical professionals will need to stay informed about these advancements to provide optimal care for their patients.

Oral shingles | BMJ Case Reports

Description 

A previously healthy 70-year-old man who underwent dental treatment for left maxillary toothache 1 week previously presented to us with facial swelling. He had experienced facial tenderness along with a tingling sensation in his mouth for several days. Physical examination revealed puffy skin on the left side of his face, reaching his left lid margin, without apparent vesicular rash. There was no facial paralysis. We initially suspected a bacterial soft tissue infection induced by the preceding dental procedure. However, intraoral inspection uncovered white erosion produced at the left hard palate clearly separated at the midline (figure 1). Specific antibodies for human herpes virus were negative, while the serum level of varicella-zoster virus specific IgG level was highly elevated at 1240 (enzyme immunoassay; reference range, <2). Accordingly, we diagnosed the patient with reactivation of herpes zoster involving the maxillary nerve (V2) dermatome of the left trigeminal nerve. The symptoms subsided following intravenous administration of acyclovir for 1 week; however, postherpetic neuralgia remained, causing a left-sided burning sensation on his face and hard palate.

Figure 1

Mirror image of the hard palate. Ulceration accompanying yellowish plaque covering the oral mucous membrane of the left side of the palate was observed.

Oral shingles pose diagnostic challenges among dentists because the prodromal stage of the disease can precede an emergence of mucosal or dermatological manifestations possibly by several days.1 Toothache, which the patient experienced at the beginning, could be an initial presentation of oral shingles in this case. Actually, previous cases referred to the potential of herpes zoster reactivation mimicking odontogenic pain.2 3 Delay in the appropriate treatment as a direct consequence of delayed diagnosis could be responsible for the development of postherpetic neuralgia as a sequela. This case highlights the importance of prudent intraoral examination and watchful waiting in diagnosing oral shingles.

Learning points

• Reactivation of herpes zoster involving the trigeminal nerve may mimic odontogenic pain during the prodromal stage of the disease.

• Careful intraoral inspection can lead to an early diagnosis of oral shingles.

Herpes zoster. Shingles | DermNet NZ

Author: Hon A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand, 1997. Updated October 2015.

What is herpes zoster?

Herpes zoster is a localised, blistering and painful rash caused by reactivation of varicella-zoster virus (VZV). Herpes zoster is also called shingles.

VZV is also called herpesvirus 3 and is a member of the Herpesvirales order of double-stranded DNA viruses.

Herpes zoster

Who gets herpes zoster?

Anyone who has had varicella (chickenpox) may subsequently develop herpes zoster. Zoster can occur in childhood but is much more common in adults, especially older people. People with various kinds of cancer have a 40% increased risk of developing zoster. People who have had zoster rarely get it again; the chance of getting a second episode is about 1%.

Herpes zoster often affects people with weak immunity.

What causes herpes zoster?

After primary infection—varicella—VZV remains dormant in dorsal root ganglia nerve cells in the spine for years before it is reactivated and migrates down sensory nerves to the skin to cause herpes zoster.

It is not clear why herpes zoster affects a particular nerve fibre. Triggering factors are sometimes recognised, such as:

• Pressure on the nerve roots
• Radiotherapy at the level of the affected nerve root
• Spinal surgery
• An infection
• An injury (not necessarily to the spine)
• Contact with someone with varicella or herpes zoster

What are the clinical features of herpes zoster?

Herpes zoster is characterised by dermatomal distribution, that is the blisters are confined to the cutaneous distribution of one or two adjacent sensory nerves. This is usually unilateral, with a sharp cut-off at the anterior and posterior midlines.

The clinical presentation of herpes zoster depends on the age and health of the patient and which dermatome is affected.

The first sign of herpes zoster is usually localised pain without tenderness or any visible skin change. It may be severe, relating to one or more sensory nerves. The pain may be just in one spot, or it may spread out. The patient may feel quite unwell with fever and headache. The lymph nodes draining the affected area are often enlarged and tender.

Within one to three days of the onset of pain, a blistering rash appears in the painful area of skin. It starts as a crop of red papules. New lesions continue to erupt for several days within the distribution of the affected nerve, each blistering or becoming pustular then crusting over.

The chest (thoracic), neck (cervical), forehead (ophthalmic) and lumbar/sacral sensory nerve supply regions are most commonly affected at all ages. The frequency of ophthalmic herpes zoster increases with age. Herpes zoster occasionally causes blisters inside the mouth or ears, and can also affect the genital area. Sometimes there is pain without rash—herpes zoster “sine eruptione”—or rash without pain, most often in children.

Pain and general symptoms subside gradually as the eruption disappears. In uncomplicated cases, recovery is complete within 2–3 weeks in children and young adults, and within 3–4 weeks in older patients.

Herpes zoster

See more images of herpes zoster.

What are the complications of herpes zoster?

• Involvement of several dermatomes, or sometimes, bilateral eruptions in unique dermatomes
• Eye complications when the ophthalmic division of the fifth cranial nerve is involved
• Deep blisters that take weeks to heal followed by scarring
• Muscle weakness in about one in 20 patients. Facial nerve palsy is the most common result (see Ramsay Hunt syndrome). There is a 50% chance of complete recovery, but some improvement can be expected in nearly all cases
• Infection of internal organs, including the gastrointestinal tract, lungs, and brain (encephalitis)

Herpes zoster is infectious to people who have not previously had chickenpox.

Herpes zoster in the early months of pregnancy can harm the fetus, but luckily this is rare. Shingles in late pregnancy can cause chickenpox in the fetus or newborn. Herpes zoster may then develop as an infant.

Post-herpetic neuralgia

Post-herpetic neuralgia is defined as persistence or recurrence of pain in the same area, more than a month after the onset of herpes zoster. It becomes increasingly common with age, affecting about a third of patients over 40. It is particularly likely if there is facial infection. Post-herpetic neuralgia may be a continuous burning sensation with increased sensitivity in the affected areas or spasmodic shooting pain. The overlying skin is often numb or exquisitely sensitive to touch. Sometimes, instead of pain, the neuralgia results in a persistent itch (neuropathic pruritus).

What is the treatment of herpes zoster?

Prevention of herpes zoster

Because the risk of serious complications from herpes zoster is more likely in older people, those aged over 60 years might consider the zoster vaccine, which can reduce the incidence of herpes zoster by half. In people who do get herpes zoster despite being vaccinated, the symptoms are usually less severe, and post-herpetic neuralgia is less likely to develop. In New Zealand, the zoster vaccine will be funded from 1 April 2018 for people aged between 66 and 80 years old.

Herpes zoster vaccination is contraindicated in immunosuppressed patients due to the risk of it causing disseminated herpes zoster infection.

General measures

• Rest and pain relief
• Protective ointment applied to the rash, such as petroleum jelly.
• Oral antibiotics for secondary infection

Specific measures

Antiviral treatment can reduce pain and the duration of symptoms if started within one to three days after the onset of herpes zoster. Aciclovir 800 mg 5 times daily for seven days is most often prescribed. Valaciclovir and famciclovir are also useful. The efficacy of prescribing systemic steroids is unproven.

Post-herpetic neuralgia 

Nonsteroidal anti-inflammatories and opioids are generally unhelpful.

Rare Occurrence of Herpes Zoster of Trigeminal Nerve following Extraction of Tooth

Herpes Zoster also known as Shingles is an acute viral infection which is an extremely painful and incapacitating ailment. It results from the reactivation of the varicella zoster virus. The triggering factors for the onset of an attack of Herpes Zoster include some form of immunosuppression. The diagnosis of Herpes Zoster can be made on proper medical history and a thorough clinical examination. Here is the report of a male patient affected by Herpes Zoster infection which followed after extraction of a lower first molar.

1. Introduction

Herpes Zoster is a painful acute infectious viral disease caused due to the inflammation of dorsal root ganglia or extramedullary cranial nerve ganglia, leading to vesicular eruptions of the skin or mucous membrane in an area supplied by the affected nerve. The most commonly affected dermatomes are the thoracic (45%), cervical (23%), and trigeminal (15%) [1, 2].

The primary infection of varicella zoster virus (VZV) is the chicken pox and, due to the characteristic of latency of the herpes group of viruses, VZV gets reactivated to cause Herpes Zoster infection in later age.

The incidence of latent Herpes Zoster increases 5–10-fold after the age of 80 years [3].

2. Case Report

A male patient of 49 years reported to the Department of Oral Medicine and Radiology, C.S.I. College of Dental Sciences and Research, with the chief complaint of pain and ulceration on left side of face and mouth for four days. Patient gave the history of extraction of the tooth 5 days ago after which multiple vesicles formed on the left side of the face and inside the mouth which made him uncomfortable while ingesting food. He had visited a dentist who diagnosed the condition as angioedema and prescribed antihistamines for three days but they did not alleviate any of the symptoms and the pain and ulcerations worsened. He did not have any relevant medical history. He is not a smoker but occasionally consumes alcohol.

On examination, unilateral multiple vesicles with few of them ulcerated were found on the left side of the face and facial asymmetry due to diffuse swelling which extended superiorly to the upper eyelid was evident (Figure 1). On intraoral examination, unilateral multiple ulcerations were evident on the left side of hard and soft palate which did not cross the mid line (Figure 2).

Ulcerations were also evident on left buccal mucosa and alveolar mucosa in relation to 36 (Figure 3). The ulcers were covered with slough and bleeding on slightest provocation was evident. The ulcers were extremely tender on palpation.

Patient was subjected to few investigations to rule out any immunocompromised status. The hemogram and serum glucose levels were within normal limits. ELISA for HIV was negative. Patient was referred to a general physician for hydration and ophthalmic evaluation. A dose of antivirals and steroids which included Valacyclovir 1000 mg 3 times a day and Prednisolone 20 mg 3 times a day and topical acyclovir for 1 week was prescribed.

The patient responded to antivirals and steroids well within a week and showed considerable healing. Patient was evaluated every week and steroids were tapered over four weeks and stopped. Gradual healing was observed in phases (Figures 4(a) and 4(b)).

By fourth week the patient was seen only with scars on the left side of face (Figures 5 and 6).

Systemic steroids could have prevented complications as it has been 3 months and the patient is apparently healthy at present.

3. Discussion

Herpes Zoster has an estimated life time incidence of 10–20% and gets reactivated with some form of immunosuppression. Herpes Zoster infection is common in elder persons, HIV-positive individuals, and patients affected by malignant blood dyscrasias or malignant tumours or undergoing immune suppressive therapy and radiotherapy [4].

The most noted point of our case report was that there was no previous history of any herpetic simplex infection in childhood or recurrent herpes labialis in later stage. It is believed that the patient could have contracted chicken pox early in his life as the incidence of chicken pox in a tropical country like India is very high. Also the unilateral distribution of the erosions and the lesions pertaining only to the oral and maxillofacial region with involvement of ophthalmic, maxillary, and mandibular division of trigeminal nerve is suggestive of Herpes Zoster rather than a herpes simplex infection. The infection was triggered by a traumatic extraction of left mandibular lower first molar. El Hayderi et al. postulated that HSV reactivation occurs during surgical procedures involving trigeminal nerve in 50% of patients and an anaesthetic block may irritate the nerve leading to reactivation and recrudescence of herpes lesion [5]. Two cases of Herpes Oticus and a similar case of Herpes Zoster after extraction of tooth have been reported [6, 7]. This case was reported to the department with a delay as he had previously consulted a local dentist, who was unable to diagnose the condition, and the patient was treated with antihistamines.

Involvement of the second and third branches of the trigeminal nerve results in vesicular lesions in oral cavity. The vesicular lesions develop 2–4 days after prodromal period of fever, weakness, fatigue, and stiffness of the neck [8]. Our patient did not have any typical prodromal symptoms. Characteristic signs of oral HZ are the presence of unilateral vesicles that break rapidly, leaving small ulcers. On skin and lips, vesicle ruptures can result in erosions covered by pseudomembranes and haemorrhagic crusts which were also seen in our patient. By the end of second or third week the crusts and pseudomembranes disappear with eventual healing of the vesicular lesions [3, 9]. A frequent complication of HZ infection is development of postherpetic neuralgia (PHN) within one to three months of healing of VZ lesions and is characterised by pain, paresthesia, hypoesthesia, or allodynia and can persist for months and years. This patient was followed up for up to six months and did not develop postherpetic neuralgia.

The duration of healing of Herpes Zoster lesions and the severity of pain associated with the disease have been shown to be considerably less with prompt administration of antiviral agents. However these benefits have been found in patients who received antiviral agents within 72 hours after the onset of the rash [4]. But our patient reported to us only after 5 days of having eruptions due to misdiagnosis. Even after prescription of antivirals and steroids, a delayed healing was noted.

4. Conclusion

The early diagnosis of Herpes Zoster and prompt treatment can avoid further complications. Herpes infection following extractions has been reported very rarely. Herpes Zoster infection must also be considered as one of the complications after extraction. The patients must be asked to report to the dentist if there is any symptoms of the disease after extraction. The patient should be under medication and periodically reviewed. Misdiagnosis should be avoided as far as possible unlike this case where herpes infection was misdiagnosed as allergy.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

Copyright

Copyright © 2015 A. Winnifred Christy et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Oral Herpes Zoster – JETem

History of present illness:

A 65-year-old man presented to the emergency department with a chief complaint of progressively worsening oral pain for three days. The patient had previously seen his dentist three days prior when the pain began and no lesions or source of pain could be identified. Over the past 24 hours, the patient noticed the development of painful lesions in his mouth. He reported decreased intake of solids and liquids due to pain. He denied a history of past rashes or any other lesions on his body.

Significant findings:

Physical exam findings revealed vesicular lesions on the lip, hard and soft palates which did not cross the midline. The lesions appeared in the distribution of the maxillary branch (V2) of the trigeminal nerve, consistent with herpes zoster.

Discussion:

Herpes zoster, commonly known as shingles, is a frequent reason for patients to present to the emergency department or clinic. The prodrome typically involves pain and tingling before the eruption of grouped vesicles in a dermatomal distribution and can be accompanied by fever, headache and malaise. It is estimated that 30% of Americans will experience at least one episode of herpes zoster in their lifetime. While the disease is typically not life-threatening, it can cause significant morbidity.¹

Herpes zoster is due to reactivation of the varicella zoster virus, which causes chicken pox and remains dormant in the dorsal root ganglion. The incidence of the disease increases with age, with the majority of cases presenting after the age of 50.²  Risk factors include increasing age, hospitalization, co-morbid conditions and cutaneous or mucosal trauma. One study found that those with craniofacial herpes zoster were twenty-five times as likely to have had facial trauma in the week prior compared to controls.³

Diagnosis is often clinical, requiring no additional lab tests or imaging. A Tzanck smear may be performed to identify multinucleated giant cells. The differential diagnosis for oral lesions includes herpes zoster, primary syphilis, aphthous stomatitis and thermal burns.⁴  Further diagnostic testing, such as direct fluorescent antibody testing, polymerase chain reaction (PCR) and viral culture may aid in the diagnosis but are frequently not used in the clinical setting.

The treatment of herpes zoster is antiretrovirals and pain control. If the lesions are identified within 72 hours, strong evidence exists for the use of acyclovir or one of its derivatives to reduce pain, promote healing, and prevent new lesion formation.⁵  Acyclovir requires more frequent dosing due to poor gastrointestinal absorption compared to valacyclovir. Studies have also shown a modest improvement in the resolution of symptoms and prevention of post-herpetic neuralgia with the use of valacyclovir.⁶  Non-steroidal anti-inflammatories are often adequate for pain control. Early studies found a small benefit with the addition of corticosteroids in preventing post-herpetic neuralgia, but a recent meta-analysis found no difference in the occurrence of postherpetic neuralgia in patients receiving corticosteroids.⁷

Transmission is by direct contact with lesions. Patients with oral lesions should be instructed to avoid oral contact with others including kissing and sharing of food or beverage. Patients should be expressly advised to avoid immunocompromised or pregnant contacts. The virus is no longer transmissible once the lesions are crusted over.⁸Patients should be instructed to follow up with their primary care provider and dermatology if the eruption is severe and to return to the ED if they have any visual changes or spreading of lesions.

The patient was treated with intramuscular ketorolac and given a prescription forvalacyclovir. The patient was referred to the dermatology clinic but on review of records did not seek follow up care.

Topics:

Oral lesions, herpes zoster, shingles.

References:

1. Yawn BP, Saddier P, Wollan PC, St Sauver JL, Kurland MJ, Sy LS. A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc. 2007;82(11):1341-1349.
2. Schmader K. Herpes zoster in older adults. Clin Infect Dis. 2001;32(10):1481-1486.
3. Zhang JX, Joesoef RM, Bialek S, Wang C, Harpaz R. Association of physical trauma with risk of herpes zoster among medicare beneficiaries in the United States. J Infect Dis. 2013;207(6):1007-1011. doi: 10.1093/infdis/jis937.
4. Hairston BR, Bruce AJ, Rogers RS III. Viral diseases of the oral mucosa. Dermatol Clin. 2003;21(1):17–32.
5. Wood MJ, Kay R, Dworkin RH, Soong SJ, Whitley RJ. Oral acyclovir therapy accelerates pain resolution in patients with herpes zoster: a meta-analysis of placebo-controlled trials. Clin Infect Dis.1996;22(2):341-347.
6. Beutner KR, Friedman DJ, Forszpaniak C, Andersen PL, Wood MJ. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother. 1995;39(7):1546-1553.
7. Han Y, Zhang J, Chen J, He L, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2013;(3):CD005582. doi: 10.1002/14651858.CD005582.pub4.
8. Centers for Disease Control and Prevention. Shingles (Herpes Zoster). CDC.gov.https://www.cdc.gov/shingles/about/transmission.html. Accessed 24 July 2018.

Herpes Zoster Oticus

Herpes zoster oticus, also called Ramsay Hunt Syndrome or Ramsay Hunt Syndrome type II, is a common complication of shingles. Shingles is an infection caused by the varicella-zoster virus, which is the virus that causes chickenpox. Shingles occurs in people who have had chickenpox and represents a reactivation of the dormant varicella-zoster virus. Herpes zoster oticus, which is caused by the spread of the varicella-zoster virus to facial nerves, is characterized by intense ear pain, a rash around the ear, mouth, face, neck, and scalp, and paralysis of facial nerves. Other symptoms may include hearing loss, vertigo (abnormal sensation of movement), and tinnitus (abnormal sounds). Taste loss in the tongue and dry mouth and eyes may also occur.

Treatment

Some cases of herpes zoster oticus do not require treatment. When treatment is needed, medications such as antiviral drugs or corticosteroids may be prescribed. Vertigo may be treated with the drug diazepam

Prognosis

Generally, the prognosis of herpes zoster oticus is good. However, in some cases, hearing loss may be permanent. Vertigo may last for days or weeks. Facial paralysis may be temporary or permanent.

Research

The NINDS supports research on shingles and shingles-related conditions. Current studies focus on the relationship between the persistence of neurotropic viruses and development of neurological diseases including herpes simplex and varicella-zoster viruses.

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Organizations

National Institute on Deafness and
Other Communication Disorders (NIDCD)

National Institutes of Health, DHHS
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Bethesda, MD 20892-2320
[email protected]
http://www.nidcd.nih.gov
Tel: Bethesda

National Organization for Rare Disorders (NORD)
Federation of voluntary health organizations dedicated to helping people with rare “orphan” diseases and assisting the organizations that serve them. Committed to the identification, treatment, and cure of rare disorders through programs of education, advocacy, research, and service.

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Danbury, CT 06810
[email protected]
http://www.rarediseases.org
Tel: Danbury
Fax: 203-798-2291

Office of Rare Diseases

National Institutes of Health, DHHS
6100 Executive Blvd., 3B01, MSC 7518
Bethesda, MD 20892-7518
http://rarediseases.info.nih.gov
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Shingles (Herpes Zoster) | Symptoms, Causes and Treatments

What is shingles?

Dr Sarah Jarvis MBE

What are the symptoms of shingles?

Symptoms occur in the area of skin that is supplied by the affected nerve fibres. The usual symptoms are pain and a rash. Occasionally, two or three nerves next to each other are affected.

Very rarely, shingles can cause more widespread infection, or can affect both sides of the body, but this is usually only in people with a weakened immune system.

The most commonly involved nerves are those supplying the skin on the chest or tummy (abdomen). The upper face (including an eye) is also a common site.

The pain is a localised band of pain. It can be anywhere on your body, depending on which nerve is affected. The pain can range from mild to severe. You may have a constant dull, burning, or gnawing pain. In addition, or instead, you may have sharp and stabbing pains that come and go. The affected area of skin is usually tender.

The rash typically appears 2-3 days after the pain begins. Red blotches appear that quickly develop into itchy fluid-filled blisters. The rash looks like chickenpox but only appears on the band of skin supplied by the affected nerve. New blisters may appear for up to a week. The soft tissues under and around the rash may become swollen for a while due to inflammation caused by the virus. The blisters then dry up, form scabs and gradually fade away. Slight scarring may occur where the blisters have been. The picture shows a scabbing rash (a few days old) of a fairly bad bout of shingles. In this person, it has affected a nerve and the skin that the nerve supplies, on the left side of the abdomen.

Signs of shingles

Shingles Day 2

Shingles Day 6

Images above by Mariegriffiths via Wikimedia Commons

An episode of shingles usually lasts 2-4 weeks. In some cases there is a rash but no pain. Rarely, there is no rash but just a band of pain.

You may also feel you have a high temperature (feel feverish) and feel unwell for a few days.

What is shingles?

Shingles is a painful, blistery rash in one specific area of your body. Most of us get chickenpox in our lives, usually when we are children. Shingles is a reactivation of that chickenpox virus but only in one nerve root. So instead of getting spots all over your body, as you do when you have chickenpox, you get them just in one area of your body.

It is almost always just on one side of your body, although it may go right around from front to back, following the skin the nerve affects. The affected skin hurts, and it may start to hurt before the rash appears, and may keep hurting for some time after the rash has gone. You may feel generally off-colour and not yourself.

Is shingles contagious?

You can catch chickenpox from someone with shingles if you have not had chickenpox before. But most adults and older children have already had chickenpox and so are immune from catching chickenpox again. You cannot get shingles from someone who has shingles.

The shingles rash is contagious (for someone else to catch chickenpox) until all the blisters (vesicles) have scabbed and are dry. If the blisters are covered with a dressing, it is unlikely that the virus will pass on to others. This is because the virus is passed on by direct contact with the blisters. If you have a job, you can return to work once the blisters have dried up, or earlier if you keep the rash covered and feel well enough. Similarly children with shingles can go to school if the rash is covered by clothes and the children do not feel unwell.

Pregnant women who have not had chickenpox should avoid people with shingles. See the separate leaflet called Chickenpox Contact in Pregnancy for more details. Also, if you have a poor immune system (immunosuppression), you should avoid people with shingles. (See below for a list of people who have a poor immune system.) These general rules are to be on the safe side, as it is direct contact with the rash that usually passes on the virus.

Can other people catch it?

This one is confusing! You can catch chickenpox from other people, but you can’t catch shingles from other people. You only get shingles from a reactivation of your own chickenpox infection in the past.

So if you have shingles, and you come into contact with somebody else, they cannot ‘catch’ your shingles. But if they have never had chickenpox, it is possible that they could catch chickenpox from you. (And if you had chickenpox, and came into contact with somebody else who had never had chickenpox, they could catch chickenpox. But they couldn’t ‘catch’ shingles from your chickenpox.)

To put it another way, no, you don’t ‘catch’ shingles. It comes from a virus hiding out in your own body, not from someone else. But if you have shingles, you may be infectious, as it is possible for people to catch chickenpox from you.

Only people who have never had chickenpox are likely to be at risk of catching chickenpox from your shingles. People who have had chickenpox should be immune from catching it again. If the rash is in a covered area of skin, the risk of anyone with whom you are not in close contact catching chickenpox is very low.

How common is it?

Shingles is an infection of a nerve and the area of skin supplied by the nerve. It is caused by a virus called the varicella-zoster virus. It is the same virus that causes chickenpox. Anyone who has had chickenpox in the past may develop shingles. Shingles is sometimes called herpes zoster. (Note: this is very different to genital herpes which is caused by a different virus called herpes simplex.)

About 1 in 4 people have shingles at some time in their lives. It can occur at any age but it is most common in older adults (over the age of 50 years). After the age of 50, it becomes increasingly more common as you get older. It is uncommon to have shingles more than once but some people do have it more than once.

Causes of shingles

Most people have chickenpox at some stage (usually as a child). The virus does not completely go after you have chickenpox. Some virus particles remain inactive in the nerve roots next to your spinal cord. They do no harm there and cause no symptoms. For reasons that are not clear, the virus may begin to multiply again (reactivate). This is often years later. The reactivated virus travels along the nerve to the skin to cause shingles.

In most cases, an episode of shingles occurs for no apparent reason. Sometimes a period of stress or illness seems to trigger it. A slight ageing of the immune system may account for it being more common in older people. (The immune system keeps the virus inactive and prevents it from multiplying. A slight weakening of the immune system in older people may account for the virus reactivating and multiplying to cause shingles.)

The risk of getting shingles increases in people with a poor immune system (immunosuppression). For example, shingles commonly occurs in younger people who have HIV/AIDS or whose immune system is suppressed with treatment such as steroids or chemotherapy.

Shingles treatment options

Two main aims of treating shingles are:

• To ease any pain and discomfort during the episode of shingles.
• To prevent, as much as possible, complications from developing.

General measures

Loose-fitting cotton clothes are best to reduce irritating the affected area of skin. Pain may be eased by cooling the affected area with ice cubes (wrapped in a plastic bag), wet dressings, or a cool bath. A non-adherent dressing that covers the rash when it is blistered and raw may help to reduce pain caused by contact with clothing. Simple creams (emollients) may be helpful if the rash is itchy. Calamine lotion can help to cool the skin and reduce mild itchiness.

Painkillers for shingles

Painkillers – for example, paracetamol, or paracetamol combined with codeine (such as co-codamol), or anti-inflammatory painkillers (such as ibuprofen) – may give some relief. Strong painkillers (such as oxycodone and tramadol) may be needed in some cases.

Some painkillers are particularly useful for nerve pain. If the pain during an episode of shingles is severe, or if you develop postherpetic neuralgia (PHN), you may be advised to take:

If an antidepressant or anticonvulsant is advised, you should take it regularly as prescribed. It may take up to two or more weeks for it to become fully effective to ease pain. In addition to easing pain during an episode of shingles, they may also help to prevent PHN. See the separate leaflet called Postherpetic Neuralgia for more information.

Antiviral medicines for shingles

Antiviral medicines used to treat shingles include aciclovir, famciclovir and valaciclovir. An antiviral medicine does not kill the virus but works by stopping the virus from multiplying. So, it may limit the severity of symptoms of the shingles episode.

An antiviral medicine is most useful when started in the early stages of shingles (within 72 hours of the rash appearing). However, in some cases your doctor may still advise you have an antiviral medicine even if the rash is more than 72 hours old – particularly in elderly people with severe shingles, or if shingles affects an eye.

Antiviral medicines are not advised routinely for everybody with shingles. As a general rule, the following groups of people who develop shingles will normally be advised to take an antiviral medicine:

• If you are over the age of 50. The older you are, the more risk there is of severe shingles or complications developing and the more likely you are to benefit from treatment.
• If you are of any age and have any of the following:
  • Shingles that affects the eye or ear.
  • A poorly functioning immune system (immunosuppression – see later for who is included).
  • Shingles that affects any parts of the body apart from the trunk (that is, shingles affecting an arm, leg, neck, or genital area).
  • Moderate or severe pain.
  • Moderate or severe rash.

If prescribed, a course of an antiviral medicine normally lasts seven days.

Steroid medication for shingles

Steroids help to reduce swelling (inflammation). A short course of steroid tablets (prednisolone) may be considered in addition to antiviral medication. This may help to reduce pain and speed healing of the rash. However, the use of steroids in shingles is controversial. Your doctor will advise you. Steroids do not prevent PHN.

Are there any tests for shingles?

Tests are not usually done for shingles. The rash can be recognised by its typical pattern and symptoms.

Should I see a doctor?

It is usually worth seeing a doctor to be certain about the diagnosis and to see if you need treatment or not. Ideally you should see a doctor as soon as possible after the rash appears.

The rash of shingles can be very painful. So even if the doctor doesn’t think you need an anti-shingles medicine, they may be able to give you stronger painkillers than those you can buy over the counter from the chemist.

What if I have shingles and a poor immune system?

If you have a poor immune system (immunosuppression) and develop shingles then see your doctor straightaway. You will normally be given antiviral medication whatever your age and will be monitored for complications. People with a poor immune system include:

• People taking high-dose steroids. (This means adults taking 40 mg prednisolone (steroid tablets) per day for more than one week in the previous three months. Or, children who have taken steroids within the previous three months, equivalent to prednisolone 2 mg/kg per day for at least one week, or 1 mg/kg per day for one month.)
• People on lower doses of steroids in combination with other immunosuppressant medicines.
• People taking anti-arthritis medications which can affect the bone marrow.
• People being treated with chemotherapy or generalised radiotherapy, or who have had these treatments within the previous six months.
• People who have had an organ transplant and are on immunosuppressive treatment.
• People who have had a bone marrow transplant and who are still immunosuppressed.
• People with an impaired immune system.
• People who are immunosuppressed with HIV infection.

What complications are there from shingles?

Most people do not have any complications. Those that sometimes occur include the following.

Postherpetic neuralgia (PHN)

This is the most common complication. It is where the nerve pain (neuralgia) of shingles persists after the rash has gone. See the separate leaflet called Postherpetic Neuralgia for more details.

Skin infection

Sometimes the rash becomes infected with germs (bacteria). The surrounding skin then becomes red and tender. If this occurs you may need a course of medicines called antibiotics.

Eye problems

Shingles of the eye can cause inflammation of the front of the eye. In severe cases it can lead to inflammation of the whole of the eye which may cause loss of vision. 

Weakness

Sometimes the nerve affected is a motor nerve (ones which control muscles) and not a usual sensory nerve (ones for touch). This may result in a weakness (palsy) of the muscles that are supplied by the nerve.

Various other rare complications

Examples are infection of the brain by the varicella-zoster virus, or spread of the virus throughout the body. These are very serious but rare. People with a poor immune system (immunosuppression) who develop shingles have a higher than normal risk of developing rare or serious complications. (For example, people with HIV/AIDS, people on chemotherapy, etc.)

Is there a shingles vaccine?

In the UK there is a shingles vaccine immunisation programme for people aged 70 years to protect against herpes zoster. There is also a catch-up programme which offers the vaccine to anyone aged between 70 and 79 years who has previously missed out on immunisation. The vaccine is licensed for people aged over 50 years, and if you are not eligible for the vaccine on the NHS, your pharmacist may be able to provide the vaccine as a private (paid for) service.

The chickenpox vaccine is not routinely given to children in the UK but is offered to people who are in close contact with someone who is particularly vulnerable to chickenpox or its complications – eg, people with a weakened immune system.

Herpes Zoster Diagnosis, Testing, Lab Methods

Clinical Diagnosis

The signs and symptoms of herpes zoster are usually distinctive enough to make an accurate clinical diagnosis once the rash has appeared. However, 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). Herpes zoster is sometimes confused with herpes simplex, and, occasionally, with impetigo, contact dermatitis, folliculitis, scabies, insect bites, papular urticaria, candidal infection, dermatitis herpetiformitis, and drug eruptions. Herpes zoster can be more difficult to diagnose in children, younger adults, and people with compromised immune systems who are more likely to have atypical presentations.

Laboratory Testing

PCR is the most useful test

Laboratory testing may be useful in cases with less typical clinical presentations, such as in people with suppressed immune systems who may have disseminated herpes zoster (defined as appearance of lesions outside the primary or adjacent dermatomes). Polymerase chain reaction (PCR) is the most useful test for confirming cases of suspected zoster sine herpete (herpes zoster-type pain that occurs without a rash).

PCR can be used to detect VZV DNA rapidly and sensitively, and is now widely available. The ideal samples are swabs of unroofed vesicular lesions and scabs from crusted lesions; you may also detect viral DNA in saliva during acute disease, but salvia samples are less reliable for herpes zoster than they are for varicella. Biopsy samples are also useful test samples in cases of disseminated disease. It is also possible to use PCR to distinguish between wild-type and vaccine strains of VZV.

Other Tests

Direct fluorescent antibody (DFA) and Tzanck smear are not recommended due to limited sensitivity. These methods have a rapid turnaround time, but DFA is substantially less sensitive than PCR, and Tzanck is not specific for VZV. Moreover, real-time PCR protocols can be completed within one day.

Serologic methods have limited use for laboratory confirmation of herpes zoster, and should only be used when suitable specimens for PCR testing are not available. Patients with herpes zoster may mount a transient IgM response and would be expected to mount a memory IgG response. However, a positive IgM ELISA result could indicate primary VZV infection, re-infection, or re-activation. Primary infection can be distinguished from reactivation or reinfection with VZV IgG avidity testing. High avidity IgG in the context of VZV IgM is indicative of a remote infection; low avidity IgG indicates a primary infection. Measuring acute and convalescent sera also has limited value, since it is difficult to detect an increase in IgG for laboratory diagnosis of herpes zoster.

In people with compromised immune systems, it may be difficult to distinguish between varicella and disseminated herpes zoster by physical examination or serological testing. In these instances, to help with diagnosis, consider if the patient has a history of VZV exposure or of a rash that began with a dermatomal pattern, along with results of VZV antibody testing during or before the time of rash.

90,000 Shingles (herpes Zoster). Oral manifestations> Clinical protocols MH RK

Treatment goals:

elimination of the inflammatory process and an increase in the period of remission.

Treatment tactics: [4,5,7,8,9,10,12] treatment is carried out on an outpatient basis.
The volume of treatment is determined by the form of the disease, the size of the focus, the speed of development of the process.

Drug-free treatment: [4,5,7,10] Mode III.Table number 15.

Drug treatment: [4,5,7,8,9,10,12]

Outpatient drug treatment:

Local drug therapy:

Pain medications:
1. Lidocaine hydrochloride , 1% for applications on the oral mucosa before meals until the pain subsides.
In case of intolerance:
2. Procaine, 5mg / ml, 0.5%, for applications on the oral mucosa, for the purpose of anesthesia before eating and processing lesion elements until pain subsides.

Antiseptics:
3. Chlorhexidine bigluconate, 0.05%, for oral cavity treatment 3 times a day for 10 days.

Antiviral drugs (choose one of them):
4. Acyclovir, 5%, for applications on the mucous membrane 3-4 times a day for 7-14 days, depending on the severity.
5. Penciclovir, 1%, for application to the affected area every 2 hours (about 8 times / day), course for 4 days Interferon, 2 ml, dissolve in 2 ml of warm water in the form of applications 5-6 times a day within 7-14 days, depending on the severity.

Epithelial preparations:
6. Tocopherol acetate, 30%, in the form of applications on the oral mucosa, 3 times a day until complete epithelization of the lesion elements.

General drug therapy:
Non-steroidal anti-inflammatory drugs (choose one of them):
1. Paracetamol, 500 mg, orally, 1 tablet 3 times a day, up to a maximum of 5-7 days.
2. Ibuprofen, 200mg, 1 tablet 3 times a day, maximum daily dose 2.4g, maximum no more than 5 days.
Antiviral drugs (choose one of them):
3. Acyclovir, 200mg, orally, 1 tablet 5 times a day for 7-14 days, depending on the severity.

Other treatments: no.

Surgical intervention: no.

Indicators of treatment effectiveness:
satisfactory condition, stable remission.

Preparations (active ingredients) used in the treatment

How to deal with the herpes virus – Russian newspaper

95% of all mankind is susceptible to herpes.

And at the same time, the knowledge of this disease in most people is minimal. What do you need to know about adversity in order to avoid health problems?

Colds from nerves

It is called “fever”, “cold”, usually unaware that itchy and painful blisters on the lips and skin are caused by a special virus.

A cold can really be one of the causes of an exacerbation of the disease. But only indirectly, since a person who has a cold decreases immunity.But in the same way, herpes is activated by stress, nervous and physical fatigue, exacerbation of chronic diseases. And it can also be triggered by the bright sun, alcohol intake, hormonal surges.

Herpes appears as a rash on the skin and mucous membranes. But don’t take it lightly. The virus can cause complicated diseases, for example, herpetic stomatitis, sore throat, etc., which require serious treatment. Genital herpes, for example, significantly increases the risk of cervical cancer in women and prostate cancer in men.

Dangerous Kisses

Herpes is easy to get infected: it is transmitted by airborne droplets (when coughing, sneezing), contact (when kissing, sharing utensils, lipstick) and through the genital tract.

Very often the herpes virus enters the body in early childhood, at 3-4 years old, and in some cases it is possible to infect the child from the mother while still in the womb.

In the active phase of the disease, the likelihood of infection increases. But sometimes the virus is secreted from the saliva of those who suffer from herpes, and outside of relapses of the disease.

If hygiene rules are not followed, you can increase the number of foci of the disease yourself: the virus is spread by hands and takes root on the skin, where there are scratches, microtrauma. So, a virus from a focus on the lips or on the finger can be brought into the eyes, genitals.

In order not to spread herpes throughout the body and not infect your loved ones, follow these simple rules:

1 Do not touch the herpes with your hands, even if it is unbearably itchy. If you do touch, wash your hands thoroughly, even if you have applied antiviral cream.

2 Do not touch your eyes with your hands during the period when a herpes rash appears. This is especially true for women who regularly wear makeup.

3 Do not use saliva to moisten contact lenses. The virus can move into the eyes.

4 Do not kiss during an exacerbation of the disease, especially with children, do not use someone else’s lipstick and do not lend your own to anyone, do not share the same cigarette with a friend.

5 Do not try to remove blisters or scabs.So the infection gets additional opportunities to move to other parts of the body.

6 Do not leave the virus on things. For example, after visiting the toilet, you need to disinfect the toilet seat (the virus lives on plastic for up to 4 hours).

7 Do not wear tight clothing – poor air circulation slows down the healing of the skin.

Sleeping enemy

Once settled in the body, the harmful herpes virus remains with a person for life.It “slumbers” in the cells of the nervous system, but from time to time it wakes up and enters the bloodstream.

It is believed that if herpes bothers no more than 4 times a year, then the infected person has no serious cause for concern. You just need to be able to relieve exacerbations, observe the rules of antiherpetic safety and take a set of preventive measures to “lull” the virus.

But if exacerbations occur with “enviable” regularity, if rashes appear not only on the nose and lips, but also on other, and very extensive, areas of the body, it is imperative to conduct an immunological examination by a doctor.

True, there is currently no means for a complete cure for the herpes virus. But there are antiviral medications that can significantly reduce the chances of ulcers and blistering rashes.

Daily therapy can also negate the possibility of transmission from an infected person to their sexual partner.

Vitamins are better than iodine

Moxibustion with iodine or brilliant green is often used to combat herpes. But this does not in any way affect the herpes virus and its activity.But burns of the mucous membrane may appear, where the virus will multiply even more actively. It is best to gently lubricate the rash with an alcohol-free antiseptic. You must first lubricate the area around the redness and only then the sore itself, and you must use only a cotton swab.

After all, the concentration of viruses in the wound is very high, and it is easy to transfer the infection to other areas of the skin with your fingers.

During an exacerbation, herpes is treated with special antiviral drugs, for example, acyclovir, which prevents the virus from multiplying.

In case of frequent relapses, drugs that stimulate the immune system and fortifying agents are used.

Vitamins C and group B in the early stages of the disease lead to the disappearance of symptoms.

Vitamin E helps to reduce pain and accelerate the healing of ulcers. It is applied in the form of an oil solution to the affected areas for 15 minutes. After half an hour, the pain subsides.

Folk recipes recommend the following:

to reduce itching, apply ice (for 10 minutes), repeating the procedure after three hours;

rub oil from chamomile or medicinal lavender;

apply a cotton swab moistened with valocordin to the reddened area for a few minutes.

BTW

With herpes, you need to follow a certain diet: there are more foods with a high content of the essential amino acid – lysine, dairy products, meat, eggs, soybeans, potatoes, wheat germ, lentils.

Harmful for patients with herpes are foods in which the content of another amino acid – arginine is high. These are peanuts, chocolate, raisins, some cereals.

The balance between dishes with a high content of amino acids and natural alkalis is also important.The former include meat dishes, the latter – dishes made from fruits, vegetables, and legumes. An imbalance will instantly lead to a relapse, so every acidic dish must be seized with an alkaline one.

Treatment for Shingles in the Mouth

Oral shingles, also known as oral shingles, is a less common manifestation of herpes zoster, but can cause a painful flare-up of blisters in the mouth.

Shingles, a disease caused by reactivation of the varicella-zoster virus, is usually treated with antiviral drugs to reduce the duration and severity of the outbreak.When treating shingles in the mouth, pain relievers, local anesthetics, and soothing mouthwashes can also help relieve pain.

It is estimated that between 20% and 30% of the general population will develop shingles at some point in their lives2. Early diagnosis and treatment can help reduce the risk of long-term nerve damage and other complications.

Symptoms

Shingles is a viral syndrome caused by the reactivation of the same virus called the varicella zoster virus (VZV), which causes chickenpox.

Once you are infected with VZV, the virus will remain dormant in nerve tissues adjacent to the spinal cord (called dorsal root ganglia) and along the trigeminal nerve of the face (called trigeminal ganglion) .3

When reactivation occurs, the outbreak will be limited to the affected nerve branch called the dermatome. The vast majority of cases will be unilateral (that is, limited to one side of the body) 3.

In oral herpes zoster, VZV reactivation occurs along a branch of the trigeminal nerve: the mandibular nerve serving the mandible or the maxillary nerve serving the upper jaw.

Symptoms of oral herpes develop in different stages, known as the prodromal phase, the acute phase of the rash, and the chronic phase.

Prodromal phase

The prodromal (pre-eruptive) phase of herpes zoster is the period immediately preceding the appearance of blisters. It can last 48 hours or more, causing nonspecific symptoms that are often difficult to recognize as shingles, including: 1

• Abnormal skin sensations or pain on one side of the jaw, mouth or face

• Headaches

• Photosensitivity (photophobia)

These symptoms are often mistaken for toothache.

Acute eruptive phase

The acute stage is characterized by the rapid formation of blisters on the mucous membranes of the upper or lower part of the mouth. Blisters begin as tiny bumps, usually dense clusters, that quickly turn into painful blisters. The affected area will be clearly marked on one side or the other of the face.

If the rash occurs along the mandibular nerve, it can affect the tongue or the gums of the lower teeth. If this occurs along the maxillary nerve, blisters can form on the palate and gums of the upper teeth.

In addition to the inside of the mouth, blisters often form on the face, either around the cheeks or on one side of the jaw.

Shingles can easily rupture and lead to ulcer-like ulcers that coalesce into larger ulcers. During the acute phase of the rash, symptoms may include: 5

• Burning, shooting or throbbing pain, often severe

• Oral tenderness

• Difficulty chewing

• Altered taste

• Loss of appetite

Unlike shingles on skin, which can crust and dry out after blistering, the moist environment in the mouth prevents blisters from drying out.

Instead, ruptured blisters can form moist sores that are slow to heal and are vulnerable to bacterial infection (including herpetic gingivostomatitis) .6 If not treated properly, the infection can lead to severe periodontitis (gum disease), osteonecrosis (bone death), and tooth loss 5

The acute phase of the rash can last from two to four weeks and is the period during which the virus is most infectious.

Chronic phase

The chronic phase is the period during which the blisters largely heal, but the pain may continue.Pain, called postherpetic neuralgia, can be chronic or recurrent and may include: 3

• Dull, throbbing pain

• Burning, tingling or itching (paresthesia)

• Shooting, shock pain

The types of sensations vary and may worsen when the jaw moves (for example, when chewing).

Postherpetic neuralgia may be short-lived and gradually resolve over weeks or months.With severe nerve damage, the pain can last much longer and even become permanent and disabling.

Between 10% and 18% of people over 60 years of age with shingles will develop postherpetic neuralgia, the risk of which increases with age.7 Typically, less than 2% of people under 60 years of age with shingles develop postherpetic neuralgia.

Causes

Shingles occurs only in people who have had chickenpox.When a person gets chickenpox, the immune system is able to destroy the virus in all but isolated nerve clusters called ganglia. If the immune system is intact, it can keep the virus dormant (dormant) for decades.

Shingles is a disorder of the body’s immune defenses, during which the virus can spontaneously reactivate and cause disease. The reasons for reactivation are many and include:

• Aging (characterized by a progressive decline in immune function)

• Acute or chronic illness

• Psychological stress

• Immunosuppressive treatments

• Decreased immunity or late HIV2 Older age is perhaps the biggest risk factor for shingles.While the lifetime risk ranges between 20% and 30%, the risk increases dramatically after age 50. By age 85, the lifetime risk is at least 50% .2 90,019

  However, shingles can affect people under 50, and there is often no rhyme or reason why some people get sick and others don’t.

  This is especially true for oral shingles. Some studies show that men are 70% more likely to get shingles than women, although it’s unclear why.

  According to the Centers for Disease Control and Prevention (CDC), about 1 million people in the United States suffer from shingles each year.

  Diagnostics

  Shingles can often be diagnosed by physical examination and a person’s medical history. The appearance of accumulated blisters on one side of the mouth, combined with severe pain and prodromal symptoms, is often sufficient for a diagnosis. This is especially true if the person is older and has no history of mouth ulcers.

  However, oral herpes can be mistaken for other conditions, including: 9

  • Intraoral herpes simplex type 1 (more often associated with herpes)
  • Intraoral herpes simplex type 2 (more often associated with genital herpes)
  • Primary syphilis

  What are the characteristics of

  • Recurrent lichen 292000 mouth ulcers from other mouth ulcers, such as a one-sided lesion, dense accumulation of tiny blisters, severity of pain, and jagged edges of open ulcers.9 With that said, herpes simplex can also occasionally cause multiple open sores with jagged edges and significant pain.

    If there is any doubt about the cause, a swab from the ulcers can be sent to a laboratory for evaluation using a polymerase chain reaction (PCR) test. This is a test that strengthens the DNA in a sample of body fluids to pinpoint the viral cause.

    There are also blood tests that can detect antibodies to the hepatitis virus.They can look for IgM antibodies that are present at the initial infection with VZV and again if it is activated again (but not while the virus is dormant). Or, they may look for increasing levels of IgG antibodies that develop after the initial VZV infection or immunization, but will increase when the virus is reactivated.

    Care

    Early treatment of shingles is key to reducing the severity and duration of an outbreak.Compared to oral herpes, oral herpes zoster is treated much more aggressively due to the risk of postherpetic neuralgia and other complications.

    Antiviral therapy

    Shingles is primarily treated with antiviral drugs. Ideally, therapy should be started within 72 hours of an outbreak with one of three oral antiviral drugs: Zovirax (acyclovir), Valtrex (valacyclovir), and Famvir (famciclovir). There is little benefit from therapy after 72 hours.

    The dose and duration of use depend on the type of preparation: 2

    Zovirax is considered by many to be the first-line drug for shingles, but Valtrex and Famvir have shown similar efficacy with simpler dosing regimens.

    Several studies have shown that Valtrex is able to relieve shingles pain even faster than Zovirax.

    Adjunctive therapy

    In addition to antiviral drugs, there are other drugs that support the treatment of shingles.This is called adjuvant therapy.

    Among these, oral corticosteroids such as prednisone are sometimes prescribed to reduce inflammation and aid healing. They are usually considered only if the pain is severe and are never used on their own without antiviral drugs.

    Oral herpes zoster is also commonly treated with analgesics and other pain relievers depending on the severity of the mouth pain. This can be over-the-counter pain relievers or stronger prescription medications.

    Local oral anesthetics can also be applied to ulcers for short-term pain relief. This includes over-the-counter drugs and prescription drugs such as xylocaine gel (2% lidocaine hydrochloride).

    Home care

    You can do other things at home to help heal shingles and reduce the risk of complications.

    Alcohol-free antibacterial mouthwashes can not only reduce the risk of bacterial infection, but also relieve mouth pain.These include over-the-counter mouthwashes that contain benzydamine hydrochloride, such as Oral-B Special Care for mouth ulcers.12 Those that contain menthol (such as Listerine) also appear to help.13

    In addition to oral care, a soft mechanical diet and smoking cessation can help relieve pain and speed healing14. Good oral hygiene further reduces the risk of secondary bacterial infection.

    Forecast

    It can take up to five weeks for shingles outbreaks to completely disappear.With early initiation of antiviral therapy and appropriate supportive care, recovery times can be significantly reduced15.

    Without treatment, the time between blistering and crusting and healing is 7 to 10 days. If antiviral drugs are started within 72 hours of an outbreak, the time can be reduced to 2 days. In addition, the severity and duration of the outbreak can be reduced11.

    For example, studies have shown that early initiation of Valtrex can shorten the duration of shingles pain by 13 days compared with no treatment.

    Although antiviral drugs can significantly reduce the severity and duration of a shingles outbreak, there is little evidence that they can reduce the likelihood of postherpetic neuralgia. Age (rather than treatment) appears to be the most influential risk factor in this regard2.

    A 2014 review published in the Cochrane Database of Systematic Reviews concluded with a high degree of confidence that Zovirax did not significantly affect the risk of postherpetic neuralgia in people with herpes zoster.

    Prevention

    Shingles can be prevented with a DNA vaccine known as Shingrix. Approved for use by the US Food and Drug Administration (FDA) in 2017, Shingrix is ​​recommended for all adults over 50.

    This includes people who have previously been vaccinated with Zostavax (an earlier generation live vaccine, voluntarily discontinued in 2020) or who have previously had shingles18.

    When used as directed, Shingrix two-dose vaccine can reduce the risk of shingles by 91.3% .19

    Word from Verywell

    Oral herpes zoster has its own special problems, different from the “traditional” shingles on the skin.Because symptoms can be mistaken for other conditions, especially in the early stages, you may inadvertently miss out on treatment if you wait for more obvious signs to appear.

    Since it is important to start antiviral therapy within 72 hours of an outbreak, do not hesitate to see your doctor if painful blisters develop in your mouth. If your PCP cannot see you right away, consider seeking emergency medical attention or telemedicine services so that you can access treatment as soon as possible.

    Treatment of herpes in St. Petersburg: reviews and contacts of clinics

    Dermatologists of St. Petersburg – latest reviews

    I made an appointment with Andrey Vladimirovich. Everything went perfectly. At the reception, the doctor examined and consulted.The doctor explained everything correctly and easily, told. The specialist gave a referral for tests and appointed a second appointment.

    Catherine,

    12 November 2021

    Professional, polite doctor, I liked it.The reception went well. Olga Valerievna took a complete history, studied the previous test results and prescribed the necessary treatment for me. I was satisfied. I would recommend this specialist to my friends, if necessary.

    Darya,

    12 November 2021

    I liked everything, everything was fine.The doctor explained everything to me about my problem, conducted an examination, a survey, carried out all the necessary procedures. And as a result, he prescribed the initial treatment. Petr Andreevich is attentive, sociable, tactful, excellent specialist, leaves a good impression.

    Alexey,

    05 November 2021

    The doctor is good.At the appointment, Natalya Borisovna carefully looked at everything, prescribed tests and the proposed treatment. Spent enough time. Would apply again.

    Anna,

    04 November 2021

    Chupryaeva Ekaterina Aleksandrovna I really liked it.She is responsive. All clear. I am satisfied with the service.
    She made an initial examination. Then she recommended the medications that should be taken and removed the papillomas from the eye.
    If necessary, I will definitely contact you. Adequate time was given at the reception. Very pleased with the reception.

    Helena,

    03 November 2021

    I was satisfied with the quality of the appointment, a good doctor.Alexander Mikhailovich is polite and friendly. At the reception, he held a consultation, prescribed tests. The doctor gave me enough time.

    Alexander,

    October 31, 2021

    The doctor is friendly and helpful.I liked everything. She comprehensively approached the problem and did not prescribe anything superfluous. The reception lasted 50 minutes and I had enough time. I received information on how to proceed further in this situation. I would recommend this specialist to my friends.

    Hope,

    October 20, 2021

    The initial appointment went well.Polite, pleasant specialist. There was a feeling that the doctor treated me in a friendly way. I liked everything. We talked with Sofya Markovna about my problem. And the doctor prescribed a plan of action. I believe that these recommendations have already begun to help me. Therefore, I will go back to see this specialist. I recommend it to my friends.

    Oksana,

    September 15, 2021

    The doctor is wonderful, she told me everything in detail about my problem.As a result, she prescribed all the necessary medications, and without unnecessary overpayments. She has a very good approach to the patient, everything goes quickly and efficiently. If necessary, I will still refer to this particular doctor.

    Alexandra,

    02 September 2021

    A friendly and competent doctor.At the reception, she answered all my questions, removed all fears and prescribed treatment for the child.

    Natalia,

    04 March 2021

    Show 10 reviews of 4,707 90,000 Wind Kiss. Herpes, causes and how not to get infected

    Kiss of the wind.Herpes, causes and how not to get infected

    Wind Kiss

    What you need to know about herpes?

    With the herpes virus, which has manifested itself as a “cold on the lips”, most people go directly to the pharmacy, bypassing the consultation of a doctor. However, the disease is not as harmless as it seems. The virus has a devastating effect on the immune system. We suggest getting to know the uninvited guest better so that his visits do not darken our life.
    Where is the multifaceted virus hiding?
    Herpes simplex virus type I – affects the face (lips, mouth, nose, nasolabial triangle, ears and cheeks), lives in the cranial cavity, in the trigeminal ganglion.
    Type II – genital. Located in the sacral plexus. He cannot get independently from the head into the genitals. It is transmitted sexually or through direct contact (for example, touching the affected area on the lips with your hands and then touching the genitals).
    Type III – chickenpox.Most often affects babies. If you did not have chickenpox in childhood, then be careful: the virus is sleeping in the body and, with a decrease in immunity, it can come out in the form of herpes zoster.
    What causes herpes?
    – decreased immunity;
    – skin damage;
    – hormonal changes in the body.
    How to be treated and not get infected?
    Complex treatment is prescribed by a doctor. But there are recommendations that will help you quickly cope with the disease and prevent it.

    1. Do not touch the rash with your hands, be sure to wash your hands after accidental touching.
    2. Practice good hygiene: use only your own dishes, towels, cosmetics.
    3. Refrain from kissing with strangers and questionable relationships.
    4. Avoid hypothermia, maintain immunity.
    5. Take vitamins A, C, E, zinc and selenium , drink plenty of fluids.
    6. Use ointments and lip balms based on acyclovir .
    7. Take Antivirals and Probiotics .
    8. Eliminate coffee, chocolate, flour products.

    Herpes zoster and its manifestation in the mouth (all about the disease)

    Herpes zoster or herpes zoster or also called herpes zoster is caused by a specific virus varicella zoster. Clinically, two forms of the disease are distinguished – herpes zoster and chickenpox – chickenpox. People get chickenpox when they first come into contact with the virus.Shingles occurs exclusively in patients who have previously had chickenpox and have specific antibodies. The onset of the disease is preceded by the activation of a latent virus or secondary external infection.

    Both adults and children suffer from shingles to the same extent, but among adults it is more often people of old age. Ways of transmission of infection with this type of lichen is contact or airborne droplets. Some seasonality is characteristic – the frequency of the disease increases in winter and autumn.

    Characterized by febrile phenomena, inflammation of the ganglia of the intervertebral and cranial nerves, erythematous – vesicular rash on the skin, mucous membranes along the affected nerves.

    Symptoms of the disease on the oral mucosa arise as a result of damage to the Gasser’s node – herpetic ganglionitis occurs, as well as inflammation of the trigeminal nerve. In parallel, the corresponding skin areas are affected. Separately, the oral mucosa is rarely affected.

    The incubation period lasts about 7-14 days.After this, characteristic symptoms appear – a sharp headache, chills, an increase in body temperature up to 39 °. In rare cases, intoxication can be mild. Together with general somatic symptoms or a little later, neuralgic pains of a burning, paroxysmal nature occur, clearly along the affected nerves, the pain radiates to the teeth, aggravated by various stimuli.

    Usually after 2-4 days, sometimes later, vesicles with a diameter of 1 to 6 mm are formed on the skin.Together with the vesicles, many vesicles appear on the skin in the oral cavity, while the mucous membrane is highly hyperemic and edematous. Vesicular eruptions easily burst and erosions form in their place, which are covered with fibrinous plaque. A lesion is characteristic only on one side, skin lesions with a rash in the innervation area.

    The formation of regional lymphadenitis is characteristic. On the skin, bubbles form crusts, after peeling occurs, pigmentation of the skin remains in their place.This is all characteristic of the vesicular form of herpes zoster, which is most often found in clinical practice. According to the contents of these vesicles, the hemorrhagic form of lichen is also distinguished – if there is blood in the vesicles and a gangrenous form – in the presence of decay elements in the vesicles.

    The duration of the course of herpes zoster is about 2-3 weeks. The prognosis is most often favorable. Although there can be various complications – neuralgia, hyperesthesia, trophic disorders in the affected areas, which can last for months or even years.

    In humans, the disease forms a stable long-term immunity, but relapses are also possible.

    For diagnostics, in addition to external examination, complaints, a general blood test is used, a study of bubbles for the presence of a virus, scrapings from the erosive bottom.

    It is necessary to differentiate herpes zoster from herpetic stomatitis in the acute period, pulpitis, pemphigus, from rashes with allergies. A very important sign is the exclusivity of the defeat on the one hand.