NU-623 Herzing University – A 35-year-old woman presents to the walk-in clinic with an erythemic rash along her left lateral rib area, somewhat under her breast, which she describes as “very painful.”

A 35-year-old woman presents to the walk-in clinic with an erythemic rash along her left lateral rib area, somewhat under her breast, which she describes as “very painful.” You note it has a few vesicles developing. The woman has a 6-month-old infant who is breastfeeding and three other children over 3 years of age, all of whom the parents have chosen not to vaccinate against common childhood illnesses. The woman describes recent stress related to providing 24-hour care in her home to her mother, who is seriously ill. The woman is seeking treatment for the painful rash.

1. Which conditions should be included in your list of differentials?
2. What additional information should be gathered to make the diagnosis?
3. Which condition is the woman likely experiencing?
4. What treatment plan should you prescribe for the woman?  Provide full prescription details.
5. Based on the likely diagnosis, what are your concerns about the other members of the family?
6. What patient teaching should you include?

Please be sure to validate your opinions and ideas with citations and references in APA format.

ANSWER

“Herpes Zoster in a Breastfeeding Mother: Diagnosis, Treatment, and Family Concerns”

Herpes zoster (shingles): The presentation of an erythemic rash with vesicles along a dermatome, particularly in an adult, suggests the possibility of herpes zoster. The characteristic severe pain is also indicative of this condition. The patient’s age, the presence of vesicles, and the unilateral distribution are all consistent with herpes zoster.

Contact dermatitis: If the rash is localized and confined to the area under the breast, contact dermatitis may be considered as a potential cause. This could be a result of an allergic reaction to clothing, laundry detergent, or other irritants.

Tinea corporis (ringworm): Another possible consideration is tinea corporis, commonly known as ringworm. This fungal infection can present as an erythemic rash with a circular or ring-like appearance (Yee, 2023). It may also be accompanied by itching and discomfort.

Additional information

To make a definitive diagnosis, it would be important to gather more information through history-taking and a physical examination. The following details could be relevant:

Detailed description of the rash: Inquire about the exact location, size, shape, and progression of the rash, as well as the presence of any associated symptoms such as itching or pain.

Past medical history: Explore the patient’s medical history, including any previous occurrences of similar rashes or episodes of herpes zoster. Any known allergies or previous skin conditions should also be noted.

Immunization history: Determine the immunization status of the patient and her children, as this information can help identify potential infectious causes.

Exposure history: Ask about recent exposures to irritants, new soaps, detergents, or any changes in clothing materials that could contribute to contact dermatitis.

Stress and caregiving factors: Understand the patient’s stress levels, particularly related to the 24-hour care she is providing to her ill mother. Stress can affect the immune system and potentially contribute to the development of certain conditions.

Likely diagnosis

Based on the presentation of an erythemic rash along a dermatome with vesicles and severe pain, the most likely diagnosis in this case is herpes zoster, also known as shingles.

Treatment plan

The treatment for herpes zoster aims to alleviate pain, promote healing, and prevent complications. The following prescription details can be considered:

Antiviral medication: Prescribe oral antiviral medication such as acyclovir, valacyclovir, or famciclovir. These medications can help reduce the severity and duration of the outbreak if initiated within 72 hours of rash onset (Gnann, 2007). The specific dosage and duration will depend on the chosen medication and the patient’s individual factors. Provide instructions on how to take the medication and any potential side effects to watch for.

Pain management: Recommend over-the-counter pain relievers such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) to help manage the pain associated with shingles. Advise the patient to follow the recommended dosage instructions and any precautions regarding the use of these medications.

Topical treatment: Consider prescribing a topical cream or ointment containing a numbing agent such as lidocaine to provide local pain relief.

Wound care: Advise the patient to keep the affected area clean and dry. Recommend gentle cleansing with mild soap and water, followed by the application of a sterile dressing or non-stick bandage if needed to prevent secondary infection.

Concerns about other family members

Given that the patient’s children have not been vaccinated against common childhood illnesses, there may be an increased risk of transmission of certain infectious diseases to them. Herpes zoster, in particular, can be contagious if direct contact is made with the rash or vesicles. It is essential to educate the patient about the potential risks and advise her to take precautions to prevent transmission to her children.

Patient teaching

Transmission prevention: Emphasize the importance of avoiding direct contact with the rash and vesicles, especially for the infant who is breastfeeding. Instruct the patient to wash her hands thoroughly after touching the affected area and to avoid sharing towels, clothing, or personal items.

Vaccination: Discuss the benefits of childhood vaccinations with the patient, highlighting the protection they can provide against common infectious diseases. Encourage her to reconsider her decision and consult with a healthcare provider about vaccinating her children.

Pain management: Provide instructions on how to manage pain at home using over-the-counter pain relievers and topical creams (Milani, 2023). Advise the patient to follow the recommended dosage and any precautions associated with these medications.

Self-care measures: Educate the patient about the importance of keeping the affected area clean and dry to promote healing and prevent infection. Emphasize the use of gentle cleansers and non-stick bandages, if necessary.

Follow-up: Advise the patient to schedule a follow-up appointment to monitor the progress of the rash and evaluate the need for any further treatment or interventions.

By providing comprehensive patient education, you can empower the patient to take appropriate measures to manage her condition and minimize the risk of transmission to her family members.

References

Gnann, J. W., Jr. (2007). Antiviral therapy of varicella-zoster virus infections. Human Herpesviruses – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK47401/ 

Milani, D. a. Q. (2023, February 28). Pain Management Medications. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK560692/ 

Yee, G. (2023, April 16). Tinea Corporis. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK544360/