What is the diagnosis for left upper extremity pain with crusted lesions?

Assessment and Management of Left Upper Extremity Pain with Crusted Lesions

The most appropriate problem list entry for "left upper extremity pain with crusted lesions" should be "Herpes zoster infection (shingles) of the left upper extremity." 1

Diagnostic Considerations

• Crusted lesions with pain in a dermatomal distribution strongly suggest herpes zoster (shingles), particularly when the pain preceded the development of lesions 1, 2
• The clinical presentation of pain with crusted lesions in the upper extremity is characteristic of the healing phase of herpes zoster infection 1
• Differential diagnosis should include:
  • Herpes simplex virus infection (typically more localized) 1
  • Contact dermatitis with secondary infection (typically more diffuse) 1
  • Impetigo (usually more honey-colored crusts) 1
  • Molluscum contagiosum (typically painless, umbilicated lesions) 1

Clinical Assessment

• Evaluate the distribution pattern of lesions - herpes zoster typically follows a dermatomal pattern along a single nerve root 2
• Assess the stage of lesions - crusted lesions indicate a healing phase of herpes zoster 1
• Document the severity and character of pain (burning, shooting, lancinating) which may indicate postherpetic neuralgia 2
• Determine if there are any signs of secondary bacterial infection (increasing erythema, purulence, warmth) 1
• Check for systemic symptoms such as fever or malaise which may be present in acute herpes zoster 1

Imaging Considerations

• Imaging is generally not required for diagnosis of cutaneous herpes zoster 1
• If there is concern for deeper involvement or complications:
  • MRI would be the preferred imaging modality to evaluate for any associated soft tissue or nerve involvement 3
  • Ultrasound may be useful to evaluate for any associated soft tissue abnormalities 3

Management Approach

• For active herpes zoster with crusted lesions:

  • Systemic antiviral therapy (acyclovir, valacyclovir, or famciclovir) should be considered if within 72 hours of rash onset 1
  • Pain management with appropriate analgesics (NSAIDs, acetaminophen, or if severe, short-term opioids) 3
  • Topical treatments may include calamine lotion or lidocaine patches for localized pain relief 4

• For post-herpetic neuralgia:

  • First-line: gabapentin or pregabalin 2
  • Second-line: tricyclic antidepressants (amitriptyline, nortriptyline) 4
  • Topical lidocaine 5% patch or capsaicin cream for localized pain 4

Return to Activities/Sports Considerations

• For athletes or those participating in contact sports:
  • No return to practice or competition until:
    • All lesions are healed with well-adherent scabs 1
    • No new vesicles for at least 72 hours 1
    • No moist lesions present 1
    • Completion of at least 5 days of appropriate systemic antiviral therapy 1
  • Covered active lesions are not permitted during practice or competition 1

Prevention of Complications

• Monitor for development of postherpetic neuralgia, especially in older patients 2
• Consider early pain management strategies to reduce risk of chronic pain 4
• For recurrent herpes zoster, prophylactic antiviral therapy may be considered 1
• Avoid contact with immunocompromised individuals, pregnant women, and newborns until lesions are completely crusted 1

Documentation Tips

• Document the specific distribution of lesions (dermatomal pattern)
• Note the stage of lesions (crusted indicates healing phase)
• Describe pain characteristics and intensity
• Record any functional limitations caused by pain
• Document response to treatments