Geriatric MedicineTier 1Disease (DEADMAN)

Ulcers - shingles

Description

Herpes zoster considered specifically as a cause of skin breakdown/ulceration mimicking or complicating other leg/skin ulcers in geriatric practice
Dermatomal vesicular eruption progresses to crusting; ulceration occurs with secondary bacterial infection, excoriation, or in the immunocompromised (necrotic/haemorrhagic lesions)

Epidemiology

As per herpes zoster generally - incidence and severity rise steeply with age; see dedicated herpes zoster note for full epidemiology

Aetiopathogenesis

VZV reactivation -> vesicular rash -> lesions rupture, crust, occasionally erode/ulcerate
Ulceration more likely with: scratching/excoriation, secondary bacterial superinfection, immunosuppression (necrotic, deep, slow-healing lesions), or disseminated disease

Diagnosis

Dermatomal distribution is the key discriminator from vascular/pressure/neuropathic ulcers - unilateral, follows a nerve root, preceded by neuralgic pain
Vesicular stage usually recognisable before ulceration - history of preceding rash pattern is diagnostic
Swab/PCR if atypical, non-healing, or diagnosis unclear (e.g. presents late as an unexplained ulcerated patch)
Consider immunosuppression workup if severe, disseminated, or recurrent

Management

Antivirals (valaciclovir/famciclovir; IV aciclovir if disseminated/immunocompromised) - as per herpes zoster note
Ulcerated lesions - standard wound care (non-adherent dressing, monitor for secondary bacterial infection - swab and treat if cellulitis develops)
Analgesia - neuropathic pain often precedes and outlasts the skin lesion
Avoid misclassifying as venous/pressure ulcer and applying compression/off-loading alone without antiviral therapy

Associations

Immunosuppression - malignancy, chemotherapy, high-dose steroids
Postherpetic neuralgia
Secondary bacterial cellulitis of the ulcerated area

Natural history & complications

Uncomplicated lesions heal within 2-4 weeks without scarring if treated early
Delayed antiviral therapy or secondary infection prolongs healing and increases scarring/PHN risk
Recurrent or non-healing ulcerated zoster - investigate for underlying immunosuppression

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