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Updated: Apr 27 2023

Herpes Zoster (Shingles)

Images map.jpg papules plaques.jpg blisters bullae.jpg ophthalmicus.jpg corneal ulceration.jpg
  • Snapshot
    • A 45-year-old woman presents to the emergency room for a rash on her face. She reports that this rash started as a small flat red rash yesterday but progressed to a very painful rash. She also reports some blurry vision in her right eye. She has a past medical history of lupus and is on long-term steroids. On physical exam, she has an extensive vesicular rash on the right side of her face involving her nose and eyes. She is admitted into the hospital for antiviral therapy, and ophthalmology is consulted.
  • Introduction
    • Classification
      • varicella-zoster virus (VZV)
        • an enveloped, linear double-stranded DNA virus
        • also known as human herpesvirus-3
        • transmitted via
          • respiratory secretions
          • direct contact with skin lesions
        • causes chickenpox, herpes zoster (shingles), encephalitis, meningitis, and pneumonia
    • Prevention
      • herpes zoster
        • recombinant vaccine
          • adults > 50 years of age
        • live vaccine
          • adults > 60 years of age
  • Epidemiology
    • Demographics
      • herpes zoster in elderly population
      • encephalitis and pneumonia in the immunocompromised
      • men > women
    • Risk factors
      • immunosuppression
      • advanced age
      • previous infection with VZV
    • Pathogenesis
      • the virus infects T-cells
      • the virus is often latent in the dorsal root ganglia or trigeminal ganglia
      • reactivation of the latent virus causes herpes zoster
        • often precipitated by immunocompromise or stress
  • Presentation
    • Symptoms
      • preceded by prodrome of itchiness or tingling
      • painful rash
    • Physical exam
      • painful unilateral vesicular/pustular skin eruption along a single dermatome
        • does not cross midline
      • may involve the eye
        • herpes zoster opthalmicus
        • distribution of cranial nerve V
      • may involve the ear
        • Ramsay-Hunt syndrome or herpes zoster oticus
        • distribution of cranial nerve VII
  • Studies
    • Labs
      • Tzanck smear
        • multinucleated giant cells
      • polymerase chain reaction
      • direct fluorescent antibody staining
    • Making the diagnosis
      • most cases are clinically diagnosed
      • in atypical cases, laboratory examination may be useful
  • Differential
    • Herpes simplex virus
      • distinguishing factor
        • typically does not present in a dermatomal fashion
    • Contact dermatitis
      • distinguishing factor
        • typically is more itchy than painful
  • Treatment
    • Management approach
      • for herpes zoster, antivirals are first-line therapy
    • Medical
      • oral antivirals
        • indications
          • all patients with shingles
        • drugs
          • valacyclovir
          • famciclovir
          • acyclovir
      • intravenous antivirals
        • indication
          • patients with visceral or central nervous system disease
        • drugs
          • acyclovir
      • analgesics
        • indication
          • all patients
        • drugs
          • do not give aspirin for risk of Reye syndrome
  • Complications
    • Disseminated disease
      • in immunocompromised patients
      • often involves the viscera
    • Post-herpetic neuralgia
      • incidence
        • very common
    • Fetal complications
      • blindness
      • scarring
      • limb hypoplasia
    • Vision loss, corneal anesthesia, and keratitis from herpes zoster opthalmicus
  • Prognosis
    • Complete healing may take more > 1 month
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