Herpes Zoster Treatment & Management
- Author: Camila K Janniger, MD; Chief Editor: Dirk M Elston, MD more...
Episodes of herpes zoster are generally self-limited and resolve without intervention; they tend to be more benign and mild in children than in adults. An enormous number and variety of therapeutic approaches have been proposed over the years, most of which are probably ineffective. Some effective therapies for herpes zoster do exist, however, and these can reduce the extent and duration of symptoms, and possibly the risk of chronic sequelae (eg, postherpetic neuralgia [PHN]) as well.
Therapeutic choices generally depend on the host’s immune state and on the presentation of zoster. Conservative therapy includes nonsteroidal anti-inflammatory drugs (NSAIDs); wet dressings with 5% aluminum acetate (Burow solution), applied for 30-60 minutes 4-6 times daily; and lotions (such as calamine).
Treatment is of greatest benefit in those patient populations at risk for prolonged or severe symptoms, specifically, immunocompromised people and persons older than 50 years. The benefit of treating younger and healthier populations is unclear.
Uncomplicated zoster does not require inpatient care. Hospital admission should be considered for patients with any of the following:
Atypical presentations (eg, myelitis)
Involvement of more than 2 dermatomes
Significant facial bacterial superinfection
Disseminated herpes zoster
Patients with disseminated disease or severe immunosuppression or who are unresponsive to therapy should be transferred to a higher level of care. If consultation is required but not available at the initial facility, patients should be transferred to a tertiary care medical center.
Medications used include steroids, analgesics, anticonvulsants, and antiviral agents. Surgical care is not generally indicated for the treatment of herpes zoster, though it may be required to treat certain complications (eg, necrotizing fasciitis). Rhizotomy (surgical separation of pain fibers) may be considered in cases of extreme, intractable pain.
Varicella-zoster virus (VZV) vaccine is used for preventive purposes. Varicella-zoster immune globulin (VZIG) is used to prevent or modify clinical illness in susceptible persons who are exposed to varicella or zoster.
Wet-to-dry dressings with sterile saline solution or Burow solution (a pharmacologic preparation made of 5% aluminum acetate dissolved in water) should be applied to the affected skin for 30-60 minutes 4-6 times daily. A modified form of Burow solution is commercially sold as Domeboro powder packets, which need to be dissolved in water.
Calamine lotion, a mixture of zinc oxide with about 0.5% iron (III) oxide, may be used as an antipruritic agent. It is also used as a mild antiseptic to prevent infections that can be caused by scratching the affected area, as well as an astringent for weeping or oozing blisters. There is, however, no proof that calamine lotion has any real therapeutic effect on rashes and itching.
The goals of therapy for herpes zoster are as follows:
To shorten the clinical course
To provide analgesia
To prevent complications
To decrease the incidence of PHN
Whether steroids are essential or even helpful for zoster remains subject to debate. Many practitioners have long used oral prednisone and similar medications to reduce acute pain. Some have also hoped to decrease the incidence of PHN, presumably by reducing inflammation in dorsal root ganglia and involved sensory nerves. Whereas some studies have provided evidence that the early use of steroids may decrease the incidence of PHN, others have failed to show benefit. Additional study is needed.
A substantial dose (40-60 mg every morning) typically is administered as early as possible in the course of the disease and is continued for 1 week, followed by a rapid taper over 1-2 weeks. Dissemination of viral particles beyond dermatomal limits always has been a theoretical concern, but clinically, it almost never is observed in individuals with intact immune systems. Typical risks inherent in the use of systemic steroids, such as adrenocortical suppression and femoral osteonecrosis, must be kept in mind.
Two controlled studies evaluated the addition of oral corticosteroids to acyclovir therapy.[71, 72] In comparison with antiviral agents alone, the combined regimen was were found to accelerate the resolution of acute neuritis and to yield a clear improvement in quality-of-life measures. The use of oral steroids had no effect on the development or duration of PHN.
A study involving a single epidural injection of steroids and local anesthetics given in conjunction with a standard regimen of oral antivirals and analgesics was found to yield a modest improvement in zoster-associated pain for 1 month as compared with treatment without steroids. No effect in preventing PHN was noted.
In view of the potential adverse effects of and contraindications to corticosteroid use, it has been suggested that these agents should be limited to cases of moderate to severe zoster pain or cases in which significant neurologic symptoms (eg, facial paralysis) or central nervous system (CNS) involvement is present and the use of corticosteroids is not otherwise contraindicated.
The optimal duration of steroid therapy is not known. It seems reasonable that if such therapy is prescribed, it should be administered concurrently with antiviral therapy. The duration of steroid use should not extend beyond the period of antiviral therapy. Steroids should not be given alone (without antiviral therapy).
Agents for pain control
The majority of patients with acute herpes zoster experience pain, and this pain is usually the most debilitating symptom of the disease. Accordingly, efforts should be made to reduce patients’ pain and suffering, even if opioid therapy is required. Failure to do so is problematic, especially in view of emerging evidence that providing adequate pain control on an acute basis may reduce the incidence of PHN.
Primary medications for acute zoster-associated pain include the following:
Narcotic and nonnarcotic analgesics (both systemic and topical)
Neuroactive agents (eg, tricyclic antidepressants [TCAs])
The efficacy of these treatments for general neuropathic pain has been well established, but only a few of them have been evaluated specifically for acute zoster-associated pain in controlled studies.
The oral narcotic oxycodone and the oral anticonvulsant gabapentin, as well as the topical analgesics aspirin and lidocaine, proved capable of reducing acute zoster-associated pain in double-blind, placebo-controlled studies.[74, 75, 7, 76, 77] On the other hand, the oral anticonvulsant pregabalin had no statistically significant effect in relieving acute zoster pain in a small double-blind, placebo-controlled study. However, other controlled studies showed this medication to be effective in treating the pain of PHN.
Corticosteroids (see above) and antiviral agents (see below) have also been shown to accelerate the resolution of zoster-associated pain.[41, 1, 79, 80, 81, 82, 71, 83]
Nonpharmacologic therapies that may be considered for acute zoster-associated pain include sympathetic, intrathecal, and epidural nerve blocks and percutaneous electrical nerve stimulation. Although well-controlled studies are few, meta-analyses and clinical trials suggest that these treatments are effective in treating acute zoster-associated pain.[4, 84, 85]
Many studies have found acyclovir and its derivatives (valacyclovir, famciclovir, penciclovir, and desciclovir, which is not available in the United States) to be safe and effective in treating active disease and preventing PHN. Their mechanism of action involves preventing VZV replication through inhibition of viral DNA polymerase.[42, 86] Valacyclovir and famciclovir are not approved by the US Food and Drug Administration (FDA) for treatment of herpes zoster in children; acyclovir is more commonly used.
Antiviral therapy for herpes zoster may decrease the length of time for new vesicle formation, the number of days to attain complete crusting, and the days of acute discomfort. Usually, the earlier antiviral medications are started, the more effective they are in shortening the duration of zoster and in preventing or decreasing the severity of PHN. Ideally, therapy should be initiated within 72 hours of symptom onset.
Controlled studies of antiviral use in herpes zoster have only evaluated the efficacy of initiation of therapy within 48-72 hours of rash onset, demonstrating no loss of effectiveness when medications are started at any point during that period. Several observational studies found antiviral therapy to be capable of reducing zoster pain even when started beyond the traditional 72-hour therapeutic window.[87, 88] Thus, antiviral therapy should be considered for acute zoster treatment regimens, regardless of the time of presentation.
Clinical trials showed that oral acyclovir, famciclovir, and valacyclovir reduce viral shedding and accelerate resolution of symptoms (eg, pain) in uncomplicated herpes zoster. Some studies suggested that valacyclovir and famciclovir may be superior to acyclovir in resolving pain and accelerating cutaneous healing. In addition, both agents have greater bioavailability than acyclovir and thus require less frequent dosing.[41, 1, 79, 80, 81, 82] Moreover, acyclovir-resistant viral strains are emerging, suggesting a potentially increased role for newer agents.
The duration of antiviral treatment in studies has ranged from 7 to 21 days. For immunocompetent patients, a 7- to 10-day course of acyclovir or a 7-day course of one of the newer agents is probably appropriate; longer courses may be needed in immunocompromised patients.
The evidence of benefit notwithstanding, there remains some debate about the use of antivirals in this setting. For example, a study by Kubeyinje concluded that acyclovir did not decrease acute pain duration or the incidence of complications in healthy young adults with typical herpes zoster. However, these results cannot be extrapolated to the elderly, who are at greater risk of PHN.
Treatment of Complicated Herpes Zoster
Individuals with altered cell-mediated immunity, due either to an immunosuppressive condition (eg, HIV infection or cancer) or to a treatment (eg, extended corticosteroid use), are at increased risk for herpes zoster. Furthermore, herpes zoster presentations in the immunocompromised population can be complicated by disseminated disease and visceral organ involvement.[1, 90]
Antiviral therapy has been demonstrated to halt progression and dissemination of acute herpes zoster in immunocompromised patients, even when initiated more than 72 hours after rash onset. Accordingly, such therapy is recommended for all immunocompromised herpes zoster patients who present before the full crusting of all lesions.
IV acyclovir remains the drug of choice for the following populations of immunocompromised patients:
Patients with evidence of disseminated disease or visceral organ involvement
Patients with ophthalmic involvement
Patients with advanced HIV/AIDS who harbor active opportunistic infections or exhibit prominent wasting
Transplant recipients who have just undergone transplantation or are being treated for rejection
Patients without such risk factors can be treated with oral antiviral agents. Data on adjunctive therapy with corticosteroids are insufficient to permit a recommendation recommended. Antiviral therapy should be continued until all lesions have resolved.
Herpes zoster ophthalmicus
A study by Morgan and King showed that the eye was the most common site of zoster involvement in patients requiring hospital admission. Pain was the main complaint.
Two trials comparing oral acyclovir with famciclovir or valacyclovir in patients with herpes zoster ophthalmicus (HZO) found outcomes to be comparable with any of the regimens.[93, 94] Patients with diagnosed or suspected HZO should receive antiviral therapy and should be promptly referred to an ophthalmologist.
Management of Postherpetic Neuralgia
If a patient complains of severe pain at any point at or beyond the appearance of crusted vesicles, the clinician should strongly suspect that PHN has developed. Once established, the pain is notoriously difficult to alleviate with traditional analgesics, including narcotics. Consequently, treatment of PHN is complex; a multifaceted, patient-specific approach is important.
It should be noted that whereas acute zoster pain and PHN are believed to result from different pathophysiologic mechanisms, it is clinically and experimentally impossible to determine precisely when the 2 types of pain cross over. Accordingly, some workers use the term zoster-associated pain to describe both acute and chronic pain as a continuum.
The only consistently successful method of treating PHN is to prevent it via prompt treatment of acute zoster and its associated pain. Initiation of antiviral therapy as early as possible in the course of acute zoster, and definitely within 72 hours of onset, has been shown to be effective in alleviating acute pain and preventing PHN in most patients (though treating already-established PHN with antivirals appears not to be beneficial ). Consultation with pain specialists may also be required.[5, 96, 97, 98]
Once PHN has developed, various treatments are available, including the following:
Neuroactive agents (eg, TCAs) 
Anticonvulsant agents (eg, gabapentin  and pregabalin)
Narcotic and nonnarcotic analgesics, both systemic (eg, opioids) and topical
Two placebo-controlled studies that evaluated gastroretentive gabapentin in 357 patients with PHN found that more of the patients in the gabapentin group felt better and exhibited a response to treatment. The reduction in PHN pain with gabapentin was noted as early as day 2 of therapy and lasted for at least 10 weeks.
Topical capsaicin can be helpful; its active ingredient depletes neurotransmitters at involved nerve endings. However, the cream must be applied at least 5 times daily, and pain may increase upon application for the first few days as accumulated neurotransmitters are released. Once neurotransmitter reserves have been depleted, any resultant pain relief is temporary.
Topical lidocaine is occasionally used to treat patients with PHN, though the data are insufficient to allow it to be recommended as a first-line agent for PHN with allodynia. In one small study, administration of lidocaine 4% ophthalmic eyedrops produced a significant reduction in eye and forehead pain.
The use of oral or epidural corticosteroids in conjunction with antiviral therapy has been found to be beneficial in treating moderate-to-severe acute zoster but to have no effect on the development or duration of PHN.[71, 83, 73] Intrathecal administration of corticosteroids has also been attempted but is not currently recommended.
Combination therapies have shown promise for relieving PHN, but clinical evidence to support such approaches is limited.
Pavan-Langston has proposed the following protocol for treatment of PHN :
TCAs – Nortriptyline, amitriptyline, or desipramine 25 mg; adjust up to 75 mg at bedtime; continue for several weeks if necessary
Topical treatment with either capsaicin ointment (once or 4 times daily) or lidocaine patches
Gabapentin (30-600 mg 3 times daily), sustained-release oxycodone (10-20 mg twice daily), or both [105, 106, 107]
Although anesthesia-based interventions such as local anesthetic blocking of sympathetic nerves or stellate ganglion blockade may produce transient relief, their effectiveness in reducing the protracted pain of PHN remains to be determined. Transcutaneous electric nerve stimulation (TENS) and, if necessary, neurosurgery (eg, thermocoagulation of substantia gelatinosa Rolandi) have been found to be helpful in exceptional cases.
Diet and Activity
No specific dietary changes are recommended.
Patients with shingles can perform activities as tolerated. Most are capable of self-restricting their activities on the basis of any limitations that may be imposed by pain; additional advice from physicians is rarely, if ever, necessary.
During the acute phase, patients should be counseled to avoid direct skin contact with immunocompromised persons, pregnant women, and individuals with no history of chickenpox infection. If the patient is hospitalized, contact isolation measures should be considered.
Varicella-zoster virus vaccine
It has been proposed that zoster occurs when varicella antibody titers and varicella-specific cellular immunity drop to a level at which they no longer are completely effective in preventing viral invasion. Evidence for this hypothesis includes observation that pediatricians, who presumably are reexposed to varicella virus routinely and thus maintain high levels of immunity, seldom develop zoster. It follows that there is a rationale for vaccination.
Since 1995, live attenuated VZV vaccine (Varivax) has been available in the United States and has been up to 99% effective in protecting susceptible individuals from varicella infection. The higher-potency live attenuated VZV vaccine introduced in 2005 (Zostavax) has demonstrated a reduction in the incidence rate of herpes zoster of 51.3% during 3 years of follow-up in one study.
The routine use of the live attenuated varicella vaccine has led to a remarkable reduction in the incidence of primary varicella infection. Furthermore, vaccinated children have demonstrated lower rates of herpes zoster than those infected through natural exposure to VZV.[109, 110] However, the effect of childhood vaccination on the incidence of herpes zoster in adult populations remains to be fully elucidated.
Prevention or attenuation of herpes zoster is particularly desirable in older patients because zoster is more frequent and is associated with more complications in older populations and because declining cell-mediated immunity in older age groups is associated with an increased risk of zoster. Zostavax is generally well tolerated in older adults. A zoster vaccine immunization program in older adults may be cost effective and has the potential to decrease the incidence of herpes zoster or reduce its severity.[112, 113]
In 2006, on the basis of the findings from the Shingles Prevention Study, the US Food and Drug Administration (FDA) approved Zostavax for prevention of herpes zoster in people aged 60 years and older. This randomized, double-blind, placebo-controlled trial of the vaccine enrolled more than 38,000 adults older than 60 years. The vaccine reduced the incidence of herpes zoster by 61.1% and the incidence of PHN by 66.5%.
Shortly thereafter, the CDC recommended that the zoster vaccine be given to all nonimmunocompromised, nonpregnant people aged 60 years of age and older, including those who have had a previous episode of zoster.[114, 108]
In March 2011, the FDA lowered the approved age for use of Zostavax to 50-59 years. Approval was based on a multicenter study, the Zostavax Efficacy and Safety Trial (ZEST), which was conducted in the United States and 4 other countries and included 22,439 subjects aged 50-59 years. Participants were divided into 2 equal groups and randomly assigned to receive either Zostavax or placebo, then monitored for at least 1 year for development of shingles. Zostavax reduced the risk of developing zoster significantly (approximately 70%).
Persons with a reported history of zoster can be vaccinated. Repeated zoster has been confirmed in immunocompetent persons soon after a previous episode. Although the precise risk for and severity of zoster as a function of time after an earlier episode are unknown, some studies suggest it may be comparable to the risk in persons without a history of zoster. Furthermore, no laboratory evaluations exist to test for the previous occurrence of zoster, and any reported diagnosis or history might be erroneous.
Although the safety and efficacy of the zoster vaccine have not been assessed in persons with a history of zoster, different safety concerns are not expected in this group.
Eligible patients who are about to begin biologic therapy (eg, for psoriasis, rheumatoid arthritis, or other indicated diseases) should receive Zostavax (along with any other appropriate vaccines) administered before starting their course of biologic therapy. However, it should be kept in mind that Zostavax is a live-virus vaccine, which means that it should not be given to patients who have already been started on biologic therapies.
The vaccine is similarly contraindicated in patients receiving long-term corticosteroid treatment and in patients receiving chemotherapy or radiation therapy for hematopoietic malignancies and solid tumors.
The effective duration of this vaccination is not yet known. However, ongoing follow-up of a portion of the study population has demonstrated that benefits persist for at least 5 years after vaccination, though their magnitude declines somewhat over time.
Other methods of prevention of initial infection include contact and respiratory isolation of infected patients until full crusting of lesions is achieved, as well as postexposure prophylaxis with VZIG in select populations.
Varicella-zoster immune globulin
The CDC recommends administration of VZIG to prevent or modify clinical illness in persons with exposure to varicella or herpes zoster who are susceptible or immunocompromised. It should be reserved for patients at risk for severe disease and complications, such as neonates and patients who are immunocompromised or pregnant.
VZIG provides maximum benefit when administered as soon as possible after the presumed exposure, but it may be effective if administered as late as 96 hours after exposure. Protection after VZIG administration lasts for an average of approximately 3 weeks, according to the CDC.
Consultation is rarely necessary in cases of uncomplicated zoster. Consultation with the appropriate specialist may be indicated when symptoms point toward meningitis (HZO), dental disease (zoster of the maxillary branch), ear infections or deafness (Ramsay Hunt syndrome), oropharyngeal infections, meningoencephalitis, or encephalomyelitis; when the patient is immunocompromised; when the rash is atypical; when motor complications are present; or when the urinary bladder, the lungs, or the gastrointestinal tract is involved.
Typical cases of zoster may be treated in the outpatient setting and do not require extensive follow-up. Patients should be informed about the natural progression of herpes zoster and its potential complications. Initial evaluation should address the possibility of atypical manifestations. Pain relief should be a primary concern.
After initial treatment, further care consists solely of monitoring the patient and remaining alert for complications (eg, secondary infection, eye involvement, and meningeal or visceral involvement) and for sequelae such as PHN. Patients who develop PHN should be seen regularly and should receive emotional support in addition to medical therapy.
[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].