HISTORY. Generally, patients will describe a history of itching, numbness, tingling, tenderness, and pain in the affected area for 1 to 2 days before skin lesions develop. The rash begins as maculopapules (discolored patches on the skin mixed with elevated red pimples) that rapidly develop into crops of vesicles (blisters) on an erythematous (diffuse redness) base. New lesions continue to appear for 3 to 5 days as the older lesions ulcerate and crust. Malaise, low-grade fever, and adenopathy may accompany the rash. The patient will report a history of chickenpox.

PHYSICAL EXAMINATION. Observe the rash, noting the color, temperature, and appearance of lesions and their location and distribution over the body. Note lesion grouping and identify the type. The involved skin may reveal redness, warmth, swelling, vesicles, or crusted areas. This area is generally tender to touch. Determine if lesions are present in the patient's mouth.

The appearance of the lesions changes over time. The initial maculopapules and blisters may evolve in 10 days to scabbed dry blisters and in 2 weeks to small, red nodular skin lesions spread around the area of the dermatome. The patient usually experiences intermittent or continuous pain for up to 4 weeks, although, in rare situations, intractable neurological pain may persist for years.

PSYCHOSOCIAL. Assess the patient's ability to cope with a sudden, unexpected illness that is generally very painful. Assess the amount of pain and degree of relief obtained. Some patients with facial palsy or visible skin lesions may have an altered body image that may cause anxiety.

Diagnostic Highlights

Abnormality with

Test Normal Result Condition Explanation

Viral culture Negative culture Positive for herpes zoster Demonstrates presence of viruses in an active lesion; cultures are most accurate in first several days of ulceration

Other Tests: Tzanck smear (obtained from lesions but cannot differentiate between herpes zoster and herpes simplex), direct immunofluorescence assay (can distinguish herpes zoster from herpes simplex), monoclonal antibody tests.

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