Herpes Zoster Clinical Presentation
- Author: Camila K Janniger, MD; Chief Editor: Dirk M Elston, MD more...
Herpes zoster may begin with a systemic response (eg, fever, anorexia, and lassitude), though symptoms frequently are mild and may not be associated by either patient or physician with the classic manifestations of the condition.
Symptoms typically include prodromal sensory phenomena along 1 or more skin dermatomes lasting 1-10 days (average, 48 hours), which usually are noted as pain or, less commonly, itching or paresthesias. Prodromal pain typically is described as muscle or toothachelike in origin but may simulate headache, iritis, pleurisy, brachial neuritis, cardiac pain, appendicitis or other intra-abdominal disease, or sciatica. This simulation can result in incorrect tentative diagnoses; however, the dermatomal distribution usually helps clarify the diagnosis.
The prodromal interval of pain prior to onset of cutaneous findings has been believed to represent spread of varicella-zoster virus (VZV) particles along sensory nerves; however, approximately 10% of patients report the simultaneous onset of pain and rash.
After the onset of prodromal symptoms, the following signs and symptoms occur:
Patchy erythema, occasionally accompanied by induration, in the dermatomal area of involvement
Regional lymphadenopathy, either at this stage or subsequently
Grouped herpetiform vesicles developing on the erythematous base (the classic finding)
Pain in the dermatomal area of involvement may remain the same as in prodrome or may change in character and intensity with the onset of other symptoms; many patients describe the pain as burning, throbbing, or stabbing in nature; it may be severe, mild, constant, rare, or felt as another sensation such as pruritus; the involved area may be tender to palpation 
Vesicular involution – Vesicles initially are clear but eventually cloud, rupture, crust, and involute, a process that may be greatly accelerated by treatment
After vesicular involution, slow resolution of the remaining erythematous plaques, typically without visible sequelae – Note, however, that scarring can occur if deeper epidermal and dermal layers have been compromised by excoriation, secondary infection, or other complications
Unfortunately, resolution of the associated pain does not always accompany resolution of erythema and vesiculation. Postherpetic neuralgia (PHN), which usually is confined to the area of original dermatomal involvement, can persist for weeks, months, or years and is often severe.
The reason why some patients with zoster experience PHN and others do not is not fully understood, but it is clear that patients who are older (> 60 years), particularly those who are debilitated or arteriosclerotic, are affected far more frequently than younger patients are. In addition, PHN is observed more frequently after cases of herpes zoster ophthalmicus (HZO) and in instances of upper-body dermatomal involvement.
Other less common postherpetic sequelae include hyperesthesia or, more rarely, hypoesthesia or anesthesia in the area of involvement.
Herpes zoster oticus (Ramsay Hunt syndrome) may produce an acute jugular foramen syndrome. It is characterized by acute-onset dysphagia and dysphonia, often accompanied or preceded by cranial, cervical, or pharyngeal pain. Herpetic vesicles on the skin or mucosa may or may not occur, may be noted late after onset, or may go undetected.
Classic physical findings of herpes zoster include painful grouped herpetiform vesicles on an erythematous base confined to the cutaneous surface innervated by a sensory nerve (see the first image below). Typically, the condition affects a single dermatome, most commonly a thoracic dermatome, on one side of the body (see the second, third, and fourth images below). Regional lymphadenopathy may be present.
After a prodromal illness, erythematous macules and papules appear (see the image below) and progress to vesicles within 1 day. The vesicles eventually cloud, rupture, crust, and involute. Patients may experience pain and sensory loss in the distribution of the rash. Motor weakness, especially in lumbar and cervical radicular distributions, is often present but unrecognized and represents viral activity beyond the sensory root. Because the weakness often is not diagnosed accurately, the incidence and prevalence are uncertain.
Note that zoster may present in multiple dermatomes and possibly bilaterally (ie, zoster multiplex). The frequency of multiple, disseminated, and visceral zoster is increased in the immunocompromised population. Occasionally, patients experience paresthesias and pain in a dermatomal distribution without a rash (ie, zoster sine herpete).
Many clinical variations are possible. The following is a summary of the more important variations.
Herpes zoster ophthalmicus
HZO results from viral invasion of the Gasserian ganglion and accounts for 10-15% of zoster cases. In addition to the classic symptoms and lesions of herpes zoster, common manifestations of HZO include conjunctivitis, scleritis, episcleritis, keratitis iridocyclitis, Argyll-Robertson pupil, glaucoma, retinitis, choroiditis, optic neuritis, optic atrophy, retrobulbar neuritis, exophthalmos, lid retraction, ptosis, and extraocular muscle palsies.
HZO develops when cranial nerve (CN) V (ie, the trigeminal nerve) is involved in viral reactivation. For unknown reasons, involvement of the ophthalmic branch of this nerve (V1) is 5 times as common as involvement of the maxillary branch (V2) or the mandibular branch (V3). HZO is easily recognized on the basis of vesicular and erythematous involvement of the CN V1 dermatome, ipsilateral forehead, and upper eyelid (see the image below). When lesions are found in the CN V1 dermatome, a slit-lamp examination is done to identify corneal findings.
Ipsilateral preauricular and, occasionally, submaxillary nodal involvement is a common prodromal event in HZO and often is valued equivalently with pain, vesiculation, and erythema in establishing a diagnosis. Prodromal lymphadenopathy should not be confused with the later reactive adenopathy caused by secondary infection of vesicles. Headaches, nausea, and vomiting also are common prodromal symptoms.
Signs of meningeal irritation may be present; therefore, meningitis must be excluded. CN V1 (with ciliary ganglion) sends branches to the tentorium (the recurrent nerve of Arnold), as well as to CN III, CN VI, and occasionally CN IV. This may account for the frequency of meningeal signs and the occasional CN III and CN VI nerve palsies associated with HZO.
Aggressive treatment and follow-up monitoring are required for HZO because of the possibility of eye involvement, which occurs in about 50% of HZO patients. Traditionally, nasociliary branch involvement, characterized by vesicles at the tip of the nose, has indicated that eye involvement is present or imminent (the Hutchinson rule). This rule is now being disputed, with some experts claiming that eye and nasociliary branch involvement can be present without such vesiculation. In our experience, eye lesions are rare in the absence of distal nose lesions.
In the absence of prompt detection and treatment, eye involvement poses a risk to vision. The presence of orbital edema is an ophthalmologic emergency, and patients must be referred immediately for specialized ophthalmic evaluation and treatment. Iritis, iridocyclitis, glaucoma, and corneal tissue ulcerations are possible in these cases. Involvement of the area below the palpebral fissure alone, without upper eyelid or nasal involvement, is considered less likely to result in ocular complications, in that the superior maxillary nerve innervates the lower eyelid.
Postherpetic complications are more common in HZO than in other manifestations of zoster. In particular, PHN is observed in well over 50% of patients with HZO and can be severe and long-lasting. Scarring also is more common, probably as a result of severe destructive inflammation.
As noted (see above), palsy of CN III and, occasionally, of CN IV and CN VI may occur. Rarely, simultaneous involvement of other CNs has been reported. The most common such event is CN VII involvement, which may produce facial palsy.
Svozilkova et al reported 1 case of varicella-caused retinal necrosis after ocular trauma.
Herpes zoster of maxillary branch of CN V
Involvement of CN V2 is localized to the ipsilateral cheek, the lower eyelid, the side of the nose, the upper eyelid, the upper teeth, the mucous membrane of the nose, the nasopharynx, the tonsils, and the roof of the mouth. At times, only the oral mucous membrane is involved, and there are no cutaneous manifestations. Early preeruptive herpetic pain can simulate a severe toothache and result in unnecessary oral surgery or dental treatment.
Herpes zoster of mandibular branch of CN V
Areas of CN V3 involvement include the side of the head, the external ear and external auditory canal, the lower lip, and a portion of the oral mucosa. As when other branches of CN V are involved, prodromal pain in affected areas can result in incorrect diagnoses.
Herpes zoster oticus
Herpes zoster oticus (also termed geniculate zoster, zoster auris, Ramsay Hunt syndrome, or Hunt syndrome) may develop if the geniculate ganglion is involved. This condition is considered rare but more likely is just rarely recognized. It often is mistaken for eczema, Ménière disease, Bell palsy, stroke, and abscess of the ear.
Classically, herpes zoster oticus begins with otalgia and herpetiform vesicles in the external ear canal or on the tympanic membrane, with or without features of facial paralysis resulting from facial nerve (CN VII) involvement, auditory symptoms (eg, deafness), and vestibular symptoms in variable combinations. The syndrome also may result from zoster originating from CN IX or CN X; the external ear has complex innervation that includes branches of several CNs (CN V, CN VII, CN IX, and CN X), as well as vertebral nerve C2 and possibly C3.
Glossopharyngeal and vagal herpes zoster
Glossopharyngeal zoster (herpes pharyngis) and vagal zoster (herpes laryngis) involve the jugular and petrosal ganglia, which are adjacent and often involved in some combination; however, individual involvement of both ganglia has been observed. Painful vesicular rash typically involves the palate, posterior tongue, epiglottis, tonsillar pillars, and, occasionally, the external ear. A unilateral distribution can distinguish this variation of zoster from herpes simplex and herpangina.
Herpes occipitocollaris (vertebral nerves C2 and C3 involvement)
Herpes occipiticollaris involves the posterior scalp, the nuchal area, portions of the ear, and portions of the lower mandible and anterior neck (see the image below). Vertebral nerves C2 and C3 often are involved together. Branches of these 2 vertebral nerves communicate with CN VII and CN X, sometimes causing symptoms related to these cranial nerves as well.
Nuchal or scalp involvement occasionally is confused with folliculitis, furunculosis, cellulitis, erysipelas, or acne keloidalis nuchae. The painful prodrome can result in confusion and misdiagnosis until the classic vesicular rash appears.
Herpes zoster encephalomyelitis
Herpes zoster encephalomyelitis may give rise to localized mild leptomeningitis in the region of neurologic involvement. This is more common than is generally recognized and often results in pleocytosis in the cerebrospinal fluid (CSF). Leptomeningitis most likely occurs when CNs (especially CN V) are involved because of the presence of the recurrent nerve of Arnold, which branches from CN V1 to the tentorium. For this reason, meningeal symptoms (eg, headache, changes in sensorium, fever, and neck stiffness) are most common with HZO.
Rarely, symptoms of meningoencephalitis may be significant; at times, they may be severe enough to cause death. Westenend and Hoppenbrouwers reported fatal hemorrhagic encephalitis in an otherwise healthy woman. Zoster encephalomyelitis may be mistaken for acute poliomyelitis. The spread of VZV to the central nervous system (CNS) also may occur during suppression of host resistance by neoplasms, by cytotoxic drugs, and, possibly, by radiation therapy.
Herpes zoster myelitis
That VZV can produce encephalomyelitis is well documented. More rarely, the myelitis lesion predominates or is the sole feature. The clinical picture is one of acute onset of paraplegia resulting from a diffuse involvement of the spinal cord. The picture is that associated with acute transverse myelopathy.
Spinal cord involvement becomes apparent within 2-3 weeks of the initial rash, with myelopathic findings (usually bilateral) on examination. The disease may progress for 3 weeks, though a few cases of progression for as long as 6 months have been reported in patients with AIDS. Recurrent zoster myelitis is rare, though one case has been reported of a previously healthy young woman who developed recurrent myelopathy at the same spinal level. The condition resolved fully with intravenous (IV) acyclovir treatment.
Disseminated herpes zoster
Disseminated herpes zoster is usually defined as a generalized eruption of more than 10-12 extradermatomal vesicles occurring 7-14 days after the onset of classic dermatomal herpes zoster. Typically, it is clinically indistinguishable from varicella (chickenpox). Dissemination occurs in approximately 2% of zoster cases in the general population but has been observed in as many as 35% of patients who are hospitalized or immunocompromised.
Dissemination often is an indication of depressed cell-mediated immunity caused by various underlying clinical situations, including malignancies, radiation therapy, cancer chemotherapy, organ transplants, and long-term use of systemic corticosteroids (short-term use of low-to-moderate doses of corticosteroids does not increase the incidence of dissemination). Patients in whom zoster has disseminated must be observed carefully for the development of pneumonitis and encephalitis, which can be life-threatening.
Unilateral herpes zoster involving multiple dermatomes
Involvement of more than 1 dermatomal distribution in unilateral zoster is rare and usually is considered a harbinger of significant compromise of the immune system caused by AIDS, malignancy, chemotherapy, and other factors. Involvement of 2 dermatomes may be referred to as zoster duplex, and involvement of 3 or more may be referred to as zoster multiplex.
Bilateral herpes zoster
On rare occasions, herpes zoster manifests bilaterally. Bilateral presentations should always raise concern for disseminated disease (and immunocompromise) or for alternate diagnosis, specifically for herpes simplex.
In cases of bilateral zoster, it is not unusual for 1 or 2 adjacent dermatomes to be involved. Unlike examples of multiple dermatomal involvement in unilateral disease (see above), involvement in adjacent dermatomes is not typically a sign of underlying disease (eg, malignancy).
Recurrent herpes zoster
Recurrences of herpes zoster, though rare, are not unheard of and have not been shown to represent any specific event. Most reputed cases of recurrent zoster involve other entities, usually herpes simplex in a linear distribution.
Herpes zoster involving urinary bladder
Rarely, zoster involving the dermatomes of the buttock area (vertebral nerves L1, L2, S2, S3, S4) may be associated with vesicles in the bladder, which can cause severe dysuria and urinary frequency. This picture is easily mistaken for that of cystitis. If vesicles rupture in the bladder, hematuria (another common symptom of cystitis) may occur. Transient bladder paralysis resulting from zoster involving the gluteal and sacral regions and lumbar sympathetic segments has been reported, and acute urinary retention is possible if a motor component exists.
Herpes zoster involving other internal structures
Vesicular involvement has been reported in bronchi, pleural spaces, and the gastrointestinal (GI) tract. Zoster pneumonia also has been reported. Such involvement frequently is found in individuals with significantly compromised immune systems. Pain in these areas, like pain on the cutaneous surface, may be referred and does not necessarily indicate the presence of vesicles.
Herpes zoster with motor complications
Although VZV typically invades only sensory nerves (for unknown reasons), viral particles occasionally cross over to the anterior horn of the involved ganglion and cause motor symptoms. These symptoms range from weakness to total paralysis, depending on how many roots of the involved nerve plexus are affected. Whereas most motor involvement (like most sensory involvement) is self-limited, partial or complete paresis can persist indefinitely, particularly when cranial (CN V or VII), phrenic, and extremity nerves are affected.
Paresis may be seen in extraocular muscles, any area of facial innervation, and anywhere along the spinal cord, including the phrenic nerve. Paresis most commonly is observed when muscles of an arm or leg are involved; however, this may be because it is detected most easily at those locations.
Fabian et al reported a patient who had a left upper arm monoplegia after zoster multiplex involving C4, C5, and C6 nerves. The authors believed that the brachial plexus inflammation was an extension of a dorsal ganglionitis. They found that the motor neuropathy was an inflammatory demyelinating process.
Truncal motor involvement may be more common than generally is believed, because both physician and patient easily may overlook a small area of muscle weakness of the central trunk. Paralysis of abdominal musculature can cause a hernial bulge.
Zoster sine herpete
Some cases of VZV reactivation result in a condition known as zoster sine herpete. Patients experience pain and weakness in a dermatomal distribution, and a tender, erythematous, unilateral patch or plaque is apparent, but there are no visible signs of cutaneous vesicles. Like typical herpes zoster (shingles), zoster sine herpete tends to be preceded by dysesthesias.
This condition presents a diagnostic dilemma; however, VZV DNA may be detected by polymerase chain reaction (PCR) assay of oropharyngeal swabs in patients with zoster peripheral facial palsy. Because such studies are not routine, the true incidence and prevalence are unknown. Furuta et al found that VZV could be demonstrated in 8-25% of patients with acute peripheral facial palsy without cutaneous vesicles.
Although herpes zoster is rarely, if ever, fatal in itself, it may be considered a contributing factor to death in some individuals who are severely debilitated. Westenend and Hoppenbrouwers reported fatal hemorrhagic encephalitis in an otherwise healthy female. The condition has numerous potential nonfatal complications, as follows.
PHN is the most common complication of herpes zoster, affecting as many as 50% of patients older than 60 years. It may develop as a continuation of the pain that accompanies acute zoster, or it may develop after apparent resolution of the initial zoster reactivation. The pain may last for months to years. The underlying pathophysiology of PHN may involve peripheral nerve damage or continued viral activity.
Herpes zoster involving CN V1 (ie, HZO) may be associated with conjunctivitis, keratitis, corneal ulceration, iridocyclitis, glaucoma, and decreased visual acuity or blindness. With ocular involvement, long-term antiviral treatment may be required.
Complications of herpes zoster oticus (Ramsay Hunt syndrome)—that is, zoster involving CN V, CN IX, and CN X)—may include peripheral facial nerve weakness and deafness. This condition may also produce an acute jugular foramen syndrome.
Herpes zoster may be associated with a secondary bacterial infection at the site of the rash (typically streptococcal or staphylococcal). Necrotizing fasciitis is a possible and devastating complication.
Meningoencephalitis secondary to herpes zoster is more likely to be seen in immunocompromised patients than in immunocompetent patients. Other CNS complications may include myelitis, cranial nerve palsies, and granulomatous angiitis. Granulomatous angiitis may result in the development of a cerebrovascular accident.
Disseminated zoster may be seen in immunocompromised patients. In such cases, hematogenous spread may result in the involvement of multiple dermatomes.
Visceral involvement can also occur. Hong and Elgart have reported GI complications.
VZV is being investigated for its possible role in least some cases of chronic fatigue syndrome.
In children, VZV infection may produce a facial palsy ; it may also result in zoster sine herpete, doing so more frequently in children than adults. Ramsay Hunt syndrome (herpes zoster oticus) tends to be found more often in school-aged children, whereas zoster sine herpete is more likely to be found in preschool children.
Childhood varicella zoster virus infections have been linked with an increased risk of arterial ischemic stroke and may precipitate a childhood arterial ischemic stroke.[62, 63]
[Guideline] Dworkin RH, Johnson RW, Breuer J, Gnann JW, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. 2007 Jan 1. 44 Suppl 1:S1-26. [Medline].
Blein C, Gavazzi G, Paccalin M, Baptiste C, Berrut G, Vainchtock A. Burden of herpes zoster: the direct and comorbidity costs of herpes zoster events in hospitalized patients over 50 years in France. BMC Infect Dis. 2015 Aug 19. 15 (1):350. [Medline].
Goh CL, Khoo L. A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic. Int J Dermatol. 1997 Sep. 36(9):667-72. [Medline].
Pasqualucci A, Pasqualucci V, Galla F, De Angelis V, et al. Prevention of post-herpetic neuralgia: acyclovir and prednisolone versus epidural local anesthetic and methylprednisolone. Acta Anaesthesiol Scand. 2000 Sep. 44(8):910-8. [Medline].
Kost RG, Straus SE. Postherpetic neuralgia--pathogenesis, treatment, and prevention. N Engl J Med. 1996 Jul 4. 335(1):32-42. [Medline].
Zareba G. Pregabalin: a new agent for the treatment of neuropathic pain. Drugs Today (Barc). 2005 Aug. 41(8):509-16. [Medline].
Irving G, Jensen M, Cramer M, Wu J, Chiang YK, Tark M, et al. Efficacy and tolerability of gastric-retentive gabapentin for the treatment of postherpetic neuralgia: results of a double-blind, randomized, placebo-controlled clinical trial. Clin J Pain. 2009 Mar-Apr. 25(3):185-92. [Medline].
Lopez-Belmonte JL, Cisterna R, Gil de Miguel A, Guilmet C, Bianic F, Uhart M. The use of Zostavax in Spain: the economic case for vaccination of individuals aged 50 years and older. J Med Econ. 2016 Jan 25. 1-29. [Medline].
Ongkosuwito JV, Feron EJ, van Doornik CE, Van der Lelij A, Hoyng CB, La Heij EC, et al. Analysis of immunoregulatory cytokines in ocular fluid samples from patients with uveitis. Invest Ophthalmol Vis Sci. 1998 Dec. 39(13):2659-65. [Medline].
Kumano Y, Manabe J, Hamamoto M, Kawano Y, Minagawa H, Fukumaki Y, et al. Detection of varicella-zoster virus genome having a PstI site in the ocular sample from a patient with acute retinal necrosis. Ophthalmic Res. 1995. 27(5):310-6. [Medline].
Karlin JD. Herpes zoster ophthalmicus: the virus strikes back. Ann Ophthalmol. 1993 Jun. 25(6):208-15. [Medline].
Jemsek J, Greenberg SB, Taber L, Harvey D, Gershon A, Couch RB. Herpes zoster-associated encephalitis: clinicopathologic report of 12 cases and review of the literature. Medicine (Baltimore). 1983 Mar. 62(2):81-97. [Medline].
Pevenstein SR, Williams RK, McChesney D, Mont EK, Smialek JE, Straus SE. Quantitation of latent varicella-zoster virus and herpes simplex virus genomes in human trigeminal ganglia. J Virol. 1999 Dec. 73(12):10514-8. [Medline]. [Full Text].
Pavan-Langston D. Herpes zoster ophthalmicus. Neurology. 1995 Dec. 45(12 Suppl 8):S50-1. [Medline].
Wung PK, Holbrook JT, Hoffman GS, Tibbs AK, Specks U, et al. Herpes zoster in immunocompromised patients: incidence, timing, and risk factors. Am J Med. 2005 Dec. 118(12):1416. [Medline].
Norman J, Politz D. Shingles (varicella zoster) outbreaks in patients with hyperparathyroidism and their relationship to hypercalcemia. Clin Infect Dis. 2008 May 1. 46(9):1452-4. [Medline].
Chronister CL. Review of external ocular disease associated with aids and HIV infection. Optom Vis Sci. 1996 Apr. 73(4):225-30. [Medline].
Foster RE, Petersen MR, Neuss MN, Osher RH. Progressive outer retinal necrosis syndrome in a lymphoma patient with good visual outcome. Am J Ophthalmol. 2001 Jul. 132(1):117-20. [Medline].
Hodge WG, Seiff SR, Margolis TP. Ocular opportunistic infection incidences among patients who are HIV positive compared to patients who are HIV negative. Ophthalmology. 1998 May. 105(5):895-900. [Medline].
Kezuka T. Immune deviation and ocular infections with varicella zoster virus. Ocul Immunol Inflamm. 2004 Mar. 12(1):17-24. [Medline].
Margolis TP, Milner MS, Shama A, Hodge W, Seiff S. Herpes zoster ophthalmicus in patients with human immunodeficiency virus infection. Am J Ophthalmol. 1998 Mar. 125(3):285-91. [Medline].
Peck R, Gimple SK, Gregory DW, Youree B. Progressive outer retinal necrosis in a 73-year-old man: treatment with valganciclovir. AIDS. 2003 May 2. 17(7):1110-1. [Medline].
Purdy KW, Heckenlively JR, Church JA, Keller MA. Progressive outer retinal necrosis caused by varicella-zoster virus in children with acquired immunodeficiency syndrome. Pediatr Infect Dis J. 2003 Apr. 22(4):384-6. [Medline].
Rao NA. Acquired immunodeficiency syndrome and its ocular complications. Indian J Ophthalmol. 1994 Jun. 42(2):51-63. [Medline].
Walton RC, Reed KL. Herpes zoster ophthalmicus following bone marrow transplantation in children. Bone Marrow Transplant. 1999 Jun. 23(12):1317-20. [Medline].
Yau TH, Butrus SI. Presumed bilateral herpes zoster ophthalmicus in an AIDS patient: a case report. Cornea. 1996 Nov. 15(6):633-4. [Medline].
Bert RJ, Samawareerwa R, Melhem ER. CNS MR and CT findings associated with a clinical presentation of herpetic acute retinal necrosis and herpetic retrobulbar optic neuritis: five HIV-infected and one non-infected patients. AJNR Am J Neuroradiol. 2004 Nov-Dec. 25(10):1722-9. [Medline].
Gariano RF, Berreen JP, Cooney EL. Progressive outer retinal necrosis and acute retinal necrosis in fellow eyes of a patient with acquired immunodeficiency syndrome. Am J Ophthalmol. 2001 Sep. 132(3):421-3. [Medline].
Neves RA, Rodriguez A, Power WJ, Muccioli C, Lane L, Belfort R Jr, et al. Herpes zoster peripheral ulcerative keratitis in patients with the acquired immunodeficiency syndrome. Cornea. 1996 Sep. 15(5):446-50. [Medline].
Fernandes NF, Malliah R, Stitik TP, Rozdeba P, Lambert WC, Schwartz RA. Herpes zoster following intra-articular corticosteroid injection. Acta Dermatovenerol Alp Panonica Adriat. 2009 Mar. 18(1):28-30. [Medline].
Benz MS, Glaser JS, Davis JL. Progressive outer retinal necrosis in immunocompetent patients treated initially for optic neuropathy with systemic corticosteroids. Am J Ophthalmol. 2003 Apr. 135(4):551-3. [Medline].
Strangfeld A, Listing J, Herzer P, Liebhaber A, Rockwitz K, Richter C, et al. Risk of herpes zoster in patients with rheumatoid arthritis treated with anti-TNF-alpha agents. JAMA. 2009 Feb 18. 301(7):737-44. [Medline].
Sharma A, Makrandi S, Modi M, Sharma A, Marfatia Y. Immune reconstitution inflammatory syndrome. Indian J Dermatol Venereol Leprol. 2008 Nov-Dec. 74(6):619-21. [Medline].
Reuters Health. Increased Risk of Herpes Zoster With IBD, Study Confirms. Available at http://www.medscape.com/viewarticle/776280. Accessed: February 21, 2013.
Long MD, Martin C, Sandler RS, Kappelman MD. Increased risk of herpes zoster among 108 604 patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2013 Feb. 37(4):420-9. [Medline].
Nouri K, Ricotti CA Jr, Bouzari N, Chen H, Ahn E, Bach A. The incidence of recurrent herpes simplex and herpes zoster infection during treatment with arsenic trioxide. J Drugs Dermatol. 2006 Feb. 5(2):182-5. [Medline].
Korber A, Franckson T, Grabbe S, Dissemond J. Ambilateral reactivation of herpes zoster V2 following cataract operation of both eyes. J Eur Acad Dermatol Venereol. 2007 May. 21(5):712-3. [Medline].
Forbes HJ, Bhaskaran K, Thomas SL, Smeeth L, Clayton T, Langan SM. Quantification of risk factors for herpes zoster: population based case-control study. BMJ. 2014. 348:g2911. [Full Text].
Marin M, Meissner HC, Seward JF. Varicella prevention in the United States: a review of successes and challenges. Pediatrics. 2008 Sep. 122(3):e744-51. [Medline].
Whitley RJ. Varicella-Zoster Virus. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practices of Infectious Diseases. 7th ed. New York, NY: Churchill Livingstone; 2010:1963-69.
Gnann JW Jr, Whitley RJ. Clinical practice. Herpes zoster. N Engl J Med. 2002 Aug 1. 347(5):340-6. [Medline].
Schmader K, George LK, Burchett BM, Pieper CF. Racial and psychosocial risk factors for herpes zoster in the elderly. J Infect Dis. 1998 Nov. 178 Suppl 1:S67-70. [Medline].
Araújo LQ, Macintyre CR, Vujacich C. Epidemiology and burden of herpes zoster and post-herpetic neuralgia in Australia, Asia and South America. Herpes. 2007 Sep. 14 Suppl 2:40-4. [Medline].
Ultsch B, Köster I, Reinhold T, Siedler A, Krause G, Icks A, et al. Epidemiology and cost of herpes zoster and postherpetic neuralgia in Germany. Eur J Health Econ. 2012 Dec 28. [Medline].
Nagasako EM, Johnson RW, Griffin DR, Elpern DJ, Dworkin RH. Geographic and racial aspects of herpes zoster. J Med Virol. 2003. 70 Suppl 1:S20-3. [Medline].
Schmader K. Herpes zoster in older adults. Clin Infect Dis. 2001 May 15. 32(10):1481-6. [Medline].
Ertunç V, Dane S, Karakuzu A, Deniz O. Higher herpes zoster infection frequency in right-handed patients and more frequent appearance in the left body side of females. Acta Derm Venereol. 1997 May. 77(3):245. [Medline].
Tseng HF, Smith N, Marcy SM, Sy LS, Chao CR, Jacobsen SJ. Risk factors of herpes zoster among children immunized with varicella vaccine: results from a nested case-control study. Pediatr Infect Dis J. 2010 Mar. 29(3):205-8. [Medline].
Ono N, Sakabe A, Nakajima M. [Herpes zoster oticus-associated jugular foramen syndrome]. Brain Nerve. 2010 Jan. 62(1):81-4. [Medline].
Edgerton G. Herpes zoster ophthalmicus: a review of the literature. Arch Ophthalmol. 1945;34:40-62; 114-53.
Galil K, Choo PW, Donahue JG, Platt R. The sequelae of herpes zoster. Arch Intern Med. 1997 Jun 9. 157(11):1209-13. [Medline].
Svozílková P, Ríhová E, Diblík P, Kuthan P, Kovarík Z, Kalvodová B. Varicella zoster virus acute retinal necrosis following eye contusion: case report. Virol J. 2005 Aug 31. 2:77. [Medline]. [Full Text].
Westenend PJ, Hoppenbrouwers WJ. [Fatal varicella-zoster encephalitis; a rare complication of herpes zoster]. Ned Tijdschr Geneeskd. 1998 Mar 21. 142(12):654-7. [Medline].
Fabian VA, Wood B, Crowley P, Kakulas BA. Herpes zoster brachial plexus neuritis. Clin Neuropathol. 1997 Mar-Apr. 16(2):61-4. [Medline].
Furuta Y, Fukuda S, Suzuki S, Takasu T, Inuyama Y, Nagashima K. Detection of varicella-zoster virus DNA in patients with acute peripheral facial palsy by the polymerase chain reaction, and its use for early diagnosis of zoster sine herpete. J Med Virol. 1997 Jul. 52(3):316-9. [Medline].
Hong JJ, Elgart ML. Gastrointestinal complications of dermatomal herpes zoster successfully treated with famciclovir and lactulose. J Am Acad Dermatol. 1998 Feb. 38(2 Pt 1):279-80. [Medline].
Cresswell F, Eadie J, Longley N, Macallan D. Severe Guillain-Barré syndrome following primary infection with varicella zoster virus in an adult. Int J Infect Dis. 2010 Feb. 14(2):e161-3. [Medline].
Shapiro JS. Does varicella-zoster virus infection of the peripheral ganglia cause Chronic Fatigue Syndrome?. Med Hypotheses. 2009 Nov. 73(5):728-34. [Medline].
Ogita S, Terada K, Niizuma T, Kosaka Y, Kataoka N. Characteristics of facial nerve palsy during childhood in Japan: frequency of varicella-zoster virus association. Pediatr Int. 2006 Jun. 48(3):245-9. [Medline].
Elkind MS, Hills NK, Glaser CA, Lo WD, Amlie-Lefond C, Dlamini N, et al. Herpesvirus Infections and Childhood Arterial Ischemic Stroke: Results of the VIPS Study. Circulation. 2016 Jan 26. [Medline].
Grose C. Biological Plausibility of a Link Between Arterial Ischemic Stroke and Infection with Varicella-Zoster Virus or Herpes Simplex Virus. Circulation. 2016 Jan 26. [Medline].
Koh MJ, Seah PP, Teo RY. Zosteriform herpes simplex. Singapore Med J. 2008 Feb. 49(2):e59-60. [Medline].
Patel GA, Siperstein RD, Ragi G, Schwartz RA. Zosteriform lymphangioma circumscriptum. Acta Dermatovenerol Alp Panonica Adriat. 2009 Dec. 18(4):179-82. [Medline].
Ozcan A, Senol M, Saglam H, Seyhan M, Durmaz R, Aktas E, et al. Comparison of the Tzanck test and polymerase chain reaction in the diagnosis of cutaneous herpes simplex and varicella zoster virus infections. Int J Dermatol. 2007 Nov. 46(11):1177-9. [Medline].
Kalpoe JS, Kroes AC, Verkerk S, Claas EC, Barge RM, Beersma MF. Clinical relevance of quantitative varicella-zoster virus (VZV) DNA detection in plasma after stem cell transplantation. Bone Marrow Transplant. 2006 Jul. 38(1):41-6. [Medline].
Böer A, Herder N, Blödorn-Schlicht N, Falk T. Herpes incognito most commonly is herpes zoster and its histopathologic pattern is distinctive!. Am J Dermatopathol. 2006 Apr. 28(2):181-6. [Medline].
Homsy J, Katabira E, Kabatesi D, Mubiru F e. Evaluating herbal medicine for the management of Herpes zoster in human immunodeficiency virus-infected patients in Kampala, Uganda. J Altern Complement Med. 1999 Dec. 5(6):553-65. [Medline].
Eaglstein WH, Katz R, Brown JA. The effects of early corticosteroid therapy on the skin eruption and pain of herpes zoster. JAMA. 1970 Mar 9. 211(10):1681-3. [Medline].
Whitley RJ, Weiss H, Gnann JW Jr, Tyring S, Mertz GJ et al. Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Ann Intern Med. 1996 Sep 1. 125(5):376-83. [Medline].
Wood MJ, Shukla S, Fiddian AP, Crooks RJ. Treatment of acute herpes zoster: effect of early (< 48 h) versus late (48-72 h) therapy with acyclovir and valaciclovir on prolonged pain. J Infect Dis. 1998 Nov. 178 Suppl 1:S81-4. [Medline].
van Wijck AJ, Opstelten W, Moons KG, van Essen GA, Stolker RJ, Kalkman CJ, et al. The PINE study of epidural steroids and local anaesthetics to prevent postherpetic neuralgia: a randomised controlled trial. Lancet. 2006 Jan 21. 367(9506):219-24. [Medline].
Berry JD, Petersen KL. A single dose of gabapentin reduces acute pain and allodynia in patients with herpes zoster. Neurology. 2005 Aug 9. 65(3):444-7. [Medline].
Dworkin RH, Barbano RL, Tyring SK, Betts RF, et al. A randomized, placebo-controlled trial of oxycodone and of gabapentin for acute pain in herpes zoster. Pain. 2009 Apr. 142(3):209-17. [Medline].
Lin PL, Fan SZ, Huang CH, Huang HH, Tsai MC, Lin CJ, et al. Analgesic effect of lidocaine patch 5% in the treatment of acute herpes zoster: a double-blind and vehicle-controlled study. Reg Anesth Pain Med. 2008 Jul-Aug. 33(4):320-5. [Medline].
De Benedittis G, Lorenzetti A. Topical aspirin/diethyl ether mixture versus indomethacin and diclofenac/diethyl ether mixtures for acute herpetic neuralgia and postherpetic neuralgia: a double-blind crossover placebo-controlled study. Pain. 1996 Apr. 65(1):45-51. [Medline].
Semel D, Murphy TK, Zlateva G, Cheung R, Emir B. Evaluation of the safety and efficacy of pregabalin in older patients with neuropathic pain: results from a pooled analysis of 11 clinical studies. BMC Fam Pract. 2010 Nov 5. 11:85. [Medline]. [Full Text].
Huff JC, Bean B, Balfour HH Jr, Laskin OL, Connor JD, Corey L, et al. Therapy of herpes zoster with oral acyclovir. Am J Med. 1988 Aug 29. 85(2A):84-9. [Medline].
Degreef H. Famciclovir, a new oral antiherpes drug: results of the first controlled clinical study demonstrating its efficacy and safety in the treatment of uncomplicated herpes zoster in immunocompetent patients. Int J Antimicrob Agents. 1994. 4(4):241-6. [Medline].
Tyring S, Barbarash RA, Nahlik JE, Cunningham A, Marley J, Heng M, et al. Famciclovir for the treatment of acute herpes zoster: effects on acute disease and postherpetic neuralgia. A randomized, double-blind, placebo-controlled trial. Collaborative Famciclovir Herpes Zoster Study Group. Ann Intern Med. 1995 Jul 15. 123(2):89-96. [Medline].
Beutner KR, Friedman DJ, Forszpaniak C, Andersen PL, Wood MJ. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother. 1995 Jul. 39(7):1546-53. [Medline]. [Full Text].
Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med. 1994 Mar 31. 330(13):896-900. [Medline].
Kumar V, Krone K, Mathieu A. Neuraxial and sympathetic blocks in herpes zoster and postherpetic neuralgia: an appraisal of current evidence. Reg Anesth Pain Med. 2004 Sep-Oct. 29(5):454-61. [Medline].
Ahmed HE, Craig WF, White PF, Ghoname ES, Hamza MA, Gajraj NM, et al. Percutaneous electrical nerve stimulation: an alternative to antiviral drugs for acute herpes zoster. Anesth Analg. 1998 Oct. 87(4):911-4. [Medline].
Strasfeld L, Chou S. Antiviral drug resistance: mechanisms and clinical implications. Infect Dis Clin North Am. 2010 Sep. 24(3):809-33. [Medline].
Decroix J, Partsch H, Gonzalez R, Mobacken H, Goh CL, Walsh L, et al. Factors influencing pain outcome in herpes zoster: an observational study with valaciclovir. Valaciclovir International Zoster Assessment Group (VIZA). J Eur Acad Dermatol Venereol. 2000 Jan. 14(1):23-33. [Medline].
Kurokawa I, Kumano K, Murakawa K. Clinical correlates of prolonged pain in Japanese patients with acute herpes zoster. J Int Med Res. 2002 Jan-Feb. 30(1):56-65. [Medline].
Kubeyinje EP. Cost-benefit of oral acyclovir in the treatment of herpes zoster. Int J Dermatol. 1997 Jun. 36(6):457-9. [Medline].
Ahmed AM, Brantley JS, Madkan V, Mendoza N, Tyring SK. Managing herpes zoster in immunocompromised patients. Herpes. 2007 Sep. 14(2):32-6. [Medline].
Balfour HH Jr, Bean B, et al. Acyclovir halts progression of herpes zoster in immunocompromised patients. N Engl J Med. 1983 Jun 16. 308(24):1448-53. [Medline].
Colin J, Prisant O, Cochener B, Lescale O, Rolland B, Hoang-Xuan T. Comparison of the efficacy and safety of valaciclovir and acyclovir for the treatment of herpes zoster ophthalmicus. Ophthalmology. 2000 Aug. 107(8):1507-11. [Medline].
Dworkin RH, Schmader KE. Treatment and prevention of postherpetic neuralgia. Clin Infect Dis. 2003 Apr 1. 36(7):877-82. [Medline].
Whitley RJ, Volpi A, McKendrick M, Wijck Av, Oaklander AL. Management of herpes zoster and post-herpetic neuralgia now and in the future. J Clin Virol. 2010 May. 48 Suppl 1:S20-8. [Medline].
Wu CL, Raja SN. An update on the treatment of postherpetic neuralgia. J Pain. 2008 Jan. 9(1 Suppl 1):S19-30. [Medline].
Rauck RL, Irving GA, Wallace MS, Vanhove GF, Sweeney M. Once-Daily Gastroretentive Gabapentin for Postherpetic Neuralgia: Integrated Efficacy, Time to Onset of Pain Relief and Safety Analyses of Data From Two Phase 3 Multicenter, Randomized, Double-Blind, Placebo-Controlled Studies. J Pain Symptom Manage. 2012 Nov 10. [Medline].
Khaliq W, Alam S, Puri N. Topical lidocaine for the treatment of postherpetic neuralgia. Cochrane Database Syst Rev. 2007 Apr 18. CD004846. [Medline].
Gelb LD. Preventing herpes zoster through vaccination. Ophthalmology. 2008 Feb. 115(2 Suppl):S35-8. [Medline].
Kotani N, Kushikata T, Hashimoto H, Kimura F, Muraoka M, Yodono M, et al. Intrathecal methylprednisolone for intractable postherpetic neuralgia. N Engl J Med. 2000 Nov 23. 343(21):1514-9. [Medline].
Paster Z, Morris CM. Treatment of the localized pain of postherpetic neuralgia. Postgrad Med. 2010 Jan. 122(1):91-107. [Medline].
Pavan-Langston D. Herpes zoster antivirals and pain management. Ophthalmology. 2008 Feb. 115(2 Suppl):S13-20. [Medline].
Douglas MW, Johnson RW, Cunningham AL. Tolerability of treatments for postherpetic neuralgia. Drug Saf. 2004. 27(15):1217-33. [Medline].
Evans RW, Lee AG. Herpes zoster ophthalmicus, ophthalmoplegia, and trauma. Headache. 2004 Mar. 44(3):286-8. [Medline].
Oxman MN, Levin MJ, Johnson GR, Schmader KE, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005 Jun 2. 352(22):2271-84. [Medline].
Oxman MN. Zoster vaccine: current status and future prospects. Clin Infect Dis. 2010 Jul 15. 51(2):197-213. [Medline].
Civen R, Chaves SS, Jumaan A, Wu H, Mascola L, Gargiullo P, et al. The incidence and clinical characteristics of herpes zoster among children and adolescents after implementation of varicella vaccination. Pediatr Infect Dis J. 2009 Nov. 28(11):954-9. [Medline].
Sanford M, Keating GM. Zoster vaccine (Zostavax): a review of its use in preventing herpes zoster and postherpetic neuralgia in older adults. Drugs Aging. 2010 Feb 1. 27(2):159-76. [Medline].
Caple J. Varicella-zoster virus vaccine: a review of its use in the prevention of herpes zoster in older adults. Drugs Today (Barc). 2006 Apr. 42(4):249-54. [Medline].
van Hoek AJ, Gay N, Melegaro A, Opstelten W, Edmunds WJ. Estimating the cost-effectiveness of vaccination against herpes zoster in England and Wales. Vaccine. 2009 Feb 25. 27(9):1454-67. [Medline].
[Guideline] Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008 Jun 6. 57:1-30; quiz CE2-4. [Medline].
Schmader K, Levin M, Gnann J, McNeil S, Vesikari T, et al. Efficacy, immunogenicity, safety, and tolerability of zoster vaccine (ZV) in subjects 50 to 59 years of age (Poster/Abstract). Infectious Diseases Society of America. The 48th Annual Meeting of the Infectious Diseases Society of America. 10-21-2010;Vancouver, British Columbia, Canada:Ref Type: Abstract: 3363.
Schmader KE, Oxman MN, Levin MJ, Johnson G, et al. Persistence of the efficacy of zoster vaccine in the shingles prevention study and the short-term persistence substudy. Clin Infect Dis. 2012 Nov 15. 55(10):1320-8. [Medline].
Marin M, Güris D, Chaves SS, Schmid S, Seward JF. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007 Jun 22. 56:1-40. [Medline].
[Guideline] Fashner J, Bell AL. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2011 Jun 15. 83 (12):1432-7. [Medline].
[Guideline] Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014 Jul 15. 59 (2):147-59. [Medline].
[Guideline] Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014 Feb. 58 (3):309-18. [Medline].
[Guideline] Dubinsky RM, Kabbani H, El-Chami Z, Boutwell C, Ali H, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004 Sep 28. 63 (6):959-65. [Medline].
[Guideline] Attal N, Cruccu G, Baron R, Haanpää M, Hansson P, Jensen TS, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol. 2010 Sep. 17 (9):1113-e88. [Medline].
[Guideline] Centers for Disease Control and Prevention (CDC). Update on herpes zoster vaccine: licensure for persons aged 50 through 59 years. MMWR Morb Mortal Wkly Rep. 2011 Nov 11. 60 (44):1528. [Medline].
[Guideline] Hales CM, Harpaz R, Ortega-Sanchez I, Bialek SR, Centers for Disease Control and Prevention (CDC). Update on recommendations for use of herpes zoster vaccine. MMWR Morb Mortal Wkly Rep. 2014 Aug 22. 63 (33):729-31. [Medline].
Lee EG, Lee HJ, Hyun DJ, Min K, Kim DH, Yoon MS. Efficacy of low dose gabapentin in acute herpes zoster for preventing postherpetic neuralgia: a prospective controlled study. Dermatol Ther. 2016 Jan 22. [Medline].