From the Guidelines
The most appropriate next step in management is an ophthalmologic examination (E). This patient presents with a painful, itchy rash with vesicles on the right side of his forehead, which is highly suggestive of herpes zoster (shingles) affecting the ophthalmic division of the trigeminal nerve. When zoster involves the ophthalmic branch, there is significant risk of ocular complications including keratitis, uveitis, and potentially vision-threatening conditions, as noted in the guidelines for the diagnosis and management of skin and soft tissue infections 1. An urgent ophthalmologic examination is necessary to assess for eye involvement, which would require specific treatment. While antiviral therapy should be initiated promptly, the ophthalmologic evaluation is critical to determine if additional treatments are needed to prevent ocular complications. The distribution along a dermatome, the progression from red bumps to fluid-filled vesicles, and the unilateral presentation are classic for herpes zoster, which represents reactivation of latent varicella-zoster virus, as described in the practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america 1.
Some key points to consider in this case include:
- The patient's occupation as a nurse's aide in a local hospital may increase his risk of exposure to varicella-zoster virus, but this does not change the immediate need for an ophthalmologic examination.
- The patient's symptoms and presentation are consistent with herpes zoster, which has a significant risk of ocular complications if left untreated or if treatment is delayed.
- Antiviral therapy, such as oral acyclovir, famciclovir, or valacyclovir, may be beneficial for this patient, but the priority is to assess for ocular involvement and prevent potential vision-threatening complications, as recommended in the guidelines 1.
- Corticosteroids, antihistamines, cultures, or immunoglobulin measurements are not the priority in this case where ocular involvement must be ruled out immediately.
Given the potential for serious ocular complications, an ophthalmologic examination is the most critical next step in management, and it should be performed urgently to assess for eye involvement and guide further treatment.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Diagnosis and Management
The patient's symptoms, including a painful, itchy rash over the right side of his forehead that progressed to blisters productive of yellowish fluid, are suggestive of herpes zoster. The following are key points to consider in the management of this condition:
- Herpes zoster is caused by the varicella zoster virus (VZV) and can lead to complications such as postherpetic neuralgia 2, 3, 4, 5.
- Antiviral medications, such as valaciclovir, are effective in reducing the duration and severity of herpes zoster-associated pain and postherpetic neuralgia 2, 3, 4, 5.
- Valaciclovir has been shown to be at least as effective as aciclovir in controlling the symptoms of acute herpes zoster and is better tolerated due to its improved bioavailability 2, 4.
- The recommended regimen for valaciclovir in the treatment of herpes zoster is 1000 mg three times daily for 7 days 2, 4.
Next Steps in Management
Based on the patient's symptoms and the evidence from the studies, the most appropriate next step in management would be:
- To start the patient on antiviral medication, such as valaciclovir, as soon as possible after symptoms appear 2, 3, 4, 5.
- To consider an ophthalmologic examination to rule out any ocular complications, such as zoster ophthalmicus, especially since the rash is located on the forehead 2, 3.
- The following options are not the most appropriate next steps in management:
- Administration of oral corticosteroids (option A) may not be necessary in this case, as antiviral medication is the primary treatment for herpes zoster.
- Application of topical antihistamines (option B) may not be effective in reducing the symptoms of herpes zoster.
- Culture of the lesions (option C) may not be necessary, as the diagnosis of herpes zoster can be made clinically.
- Measurement of serum immunoglobulin concentration (option D) is not relevant to the management of herpes zoster.