Herpes Zoster 

  • Author: Joseph S Eastern, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: May 11, 2011
 

Background

Zoster is a common, predominantly dermal, and neurologic disorder caused by the varicella-zoster virus (VZV), a virus morphologically and antigenically identical to the virus causing varicella (chickenpox). Difference in clinical manifestations between varicella and zoster apparently depends on the immune status of individual patients; those with no prior immunologic exposure to varicella virus, most commonly children, develop the clinical syndrome of varicella, while those with circulating varicella antibodies develop a localized recrudescence, zoster.

Zoster probably results most often from a failure of the immune system to contain latent varicella-zoster virus replication. Whether other factors such as radiation, physical trauma, certain medications, other infections, or stress also can trigger zoster has not been determined with certainty. Nor is it entirely clear why circulating varicella antibodies and cell-mediated immune mechanisms do not prevent recurrent overt disease, as is common with most other viral illnesses.

An inverse correlation appears to exist between the capacity of a host to mount a cellular immune response and the incidence of zoster. However, many patients with zoster apparently have normal immune systems. In these patients, zoster is postulated to occur when varicella-zoster virus antibody titers and cellular immunity drop to levels at which they no longer are completely effective in preventing viral invasion. Evidence for this hypothesis includes the observation that pediatricians, who presumably are reexposed to the varicella virus routinely and thus maintain high levels of immunity to varicella-zoster virus, seldom develop zoster.

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Pathophysiology

Zoster most commonly manifests in 1 or more posterior spinal ganglia or cranial sensory ganglia, presumably because viral particles have been preserved within these ganglia in a dormant state since the original episode of varicella. This results in pain and characteristic cutaneous findings (see History) along the corresponding sensory dermatomes of the involved ganglia. Less often, involvement of anterior and posterior horn cells, leptomeninges, and peripheral nerves is observed, with consequent muscle weakness or palsy, pleocytosis of spinal fluid, and/or sensory loss. Rarely, myelitis, meningitis, encephalitis, or visceral involvement may occur.

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Epidemiology

Frequency

United States

The incidence of zoster is estimated at 2-3 cases per 1000 per year (approximately 750,000 cases per year). Actual incidence may be significantly higher since many relatively mild cases do not come to the attention of health care workers and remain undiagnosed. Generally, approximately 10-20% of the US population eventually develops 1 or more cases of zoster. The incidence in individuals who are immunocompromised or in elderly persons is much higher, probably close to 50%.

International

Internationally, the incidence of zoster has not been well studied, but probably it is in the same range of 2-3 cases per 1000 persons per year.

Mortality/Morbidity

Zoster is rarely, if ever, fatal, although in individuals who are severely debilitated, zoster may be considered a contributing factor to death.

Morbidity usually is confined to pain within the affected dermatome, which can be severe and can persist well beyond the duration of active disease (postherpetic neuralgia [PHN]). Eye involvement (zoster ophthalmicus) can cause temporarily or permanently decreased visual acuity or blindness. Complications such as secondary infection and meningeal or visceral involvement can produce further morbidity in the form of infections and scarring.

Race

Blacks are reported to have a significantly lower risk of developing zoster than whites; however, zoster has been reported as an early manifestation of HIV infection in young Africans.

Sex

No sex predilection is reported for varicella-zoster virus reactivation.

Age

Almost 50% of individuals who live beyond age 80 years can expect to develop zoster. Zoster is rare in children and young adults, with the exception of younger patients with AIDS, lymphoma, other malignancies, and other immune deficiencies, and patients who are recipients of bone marrow and kidney transplants. In addition, patients with these associated factors are at greater risk of developing zoster regardless of age.

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Contributor Information and Disclosures
Author

Joseph S Eastern, MD  Clinical Assistant Professor, Department of Internal Medicine, Section of Dermatology, University of Medicine and Dentistry of New Jersey

Joseph S Eastern, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, International Society for Dermatologic Surgery, and Medical Society of New Jersey

Disclosure: Abbott Honoraria Speaking and teaching; Amgen Honoraria Speaking and teaching; Aqua Honoraria Consulting; Stiefel Honoraria Speaking and teaching; Medicis Honoraria Speaking and teaching; Quinnova Honoraria Consulting; Graceway Speaking and teaching; Abbott Grant/research funds Clinical Research; Amgen Grant/research funds Clinical Research

Specialty Editor Board

Franklin Flowers, MD  Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, Affiliate Associate Professor of Pediatrics and Pathology, University of Florida College of Medicine

Franklin Flowers, MD, is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Paul Krusinski, MD  Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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