Jean, 63 years old, Facial rash
Written with the participation of FDVF (Future Dermatologists and Venereologists of France) interns.
Related topics
- Other
- 63-year-old male
- Facial rash against a background of inflammation
- Vesicles, pustules, meliceric crusts
- Progressing for 5 days, sudden onset
- No pruritus, but pain and a burning sensation
- Intraoral lesions
- Impairment of quality of life: hard to eat!
- Pristinamycin 48 hrs: no improvement
- Healthy family and friends
- No animals at home
- No particular family history
Quiz
7 respondents
Question of 1
What is your diagnosis? (only one correct response)
Shingles
Shingles
It is indeed shingles.
Let’s rule out differential diagnoses:
- Acute, sudden and rapidly spreading: not suggestive of a cutaneous tumoural disease.
- No tumoural appearance
- Vesicular primary lesion
- Inflammatory background
- Meliceric crusts
- Metameric pattern +++: key factor in the diagnosis (≠acute impetiginised eczema)
- No oedema and diffuse pronounced erythema, no increase in local skin temperature, no fever: no arguments in favour of erysipelas BUT possible progression if secondary infection is not treated.
Ulcerated basal cell carcinoma
Wrong answer!
It was shingles.
Let’s rule out differential diagnoses:
- Acute, sudden and rapidly spreading: not suggestive of a cutaneous tumoural disease.
- No tumoural appearance
- Vesicular primary lesion
- Inflammatory background
- Meliceric crusts
- Metameric pattern +++: key factor in the diagnosis (≠acute impetiginised eczema)
- No oedema and diffuse pronounced erythema, no increase in local skin temperature, no fever: no arguments in favour of erysipelas BUT possible progression if secondary infection is not treated.
Acute impetiginised eczema
Wrong answer!
It was shingles.
Let’s rule out differential diagnoses:
- Acute, sudden and rapidly spreading: not suggestive of a cutaneous tumoural disease.
- No tumoural appearance
- Vesicular primary lesion
- Inflammatory background
- Meliceric crusts
- Metameric pattern +++: key factor in the diagnosis (≠acute impetiginised eczema)
- No oedema and diffuse pronounced erythema, no increase in local skin temperature, no fever: no arguments in favour of erysipelas BUT possible progression if secondary infection is not treated.
Erysipelas
Wrong answer!
It was shingles.
Let’s rule out differential diagnoses:
- Acute, sudden and rapidly spreading: not suggestive of a cutaneous tumoural disease.
- No tumoural appearance
- Vesicular primary lesion
- Inflammatory background
- Meliceric crusts
- Metameric pattern +++: key factor in the diagnosis (≠acute impetiginised eczema)
- No oedema and diffuse pronounced erythema, no increase in local skin temperature, no fever: no arguments in favour of erysipelas BUT possible progression if secondary infection is not treated.
- Context: Non-immunocompromised male in his sixties
- Primary lesions:
- Vesicles, grouped in clusters
- Pustules
- Erythematous inflammatory background
- Secondary lesions:
- Meliceric crusts = secondary infection
- Erosions on the oral mucosa
- Location/Pattern:
- Key factor in the diagnosis +++
- Face: skin AND oral mucosa
- Unilateral metameric pattern, along the V2 nerve
- Associated signs:
- Pain: neuropathic; often starts before the eruption
- No pruritus
- No fever but adenopathy may be found in the drainage region
- When faced with a painful, vesicular, unilateral and metameric dermatosis, evoke the diagnosis of shingles
- Facial shingles: investigate mucosal involvement (oral: V2, ocular: V1)
- HIV serology: testing recommended in at-risk subjects
Antiviral treatment (oral valaciclovir or famciclovir, intravenous aciclovir):
- Immunocompetent patients over the age of 50 within 72 hours following the onset of the rash (prevention of postherpetic pain)
- Ocular shingles
- Immunocompromised patients
Systematic local care:
- Cleansing of the lesions with water and mild soap
- Repair cream: after the secondary infection, to promote healing
Systematic symptomatic treatment:
- Grade I or II analgesics
- +/-amitriptyline
Treating the secondary infection:
- Antibiotic therapy: amoxicillin-clavulanic acid, pristinamycin, macrolide
- Local antisepsis
Treating postherpetic pain:
- Grade II or III analgesics
- Lidocaine plaster
- Analgesic psychotropic agents (amitriptyline, carbamazepine, gabapentin, pregabalin, etc.)
Preventive treatment = vaccination:
- Recommended for adults aged 65 to 74
- Reduces the incidence and severity of shingles and postherpetic pain
Parent education:
- Vaccination: prevention
- Hygiene: cleanse the lesions on a daily basis and disinfect to limit infectious complications
- Do not touch or pick at the lesions
- Initiate antiviral treatment as soon as possible
- Suitable nutrition in the event of oral mucosal involvement:
- cold, puréed/semi-solid foods
- small, frequent meals
- local anaesthetics on mucosal lesions before meals
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