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eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Zoster

Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Andrea N Driano, MD, Consulting Staff, Department of Emergency Medicine, Children's Hospital and Medical Center, Seattle WA

Updated: Apr 8, 2009

Introduction

Background

Herpes zoster (shingles) is an acute cutaneous viral infection caused by the reactivation of varicella-zoster virus (VZV), a herpes virus that initially produces chickenpox. After resolution of the primary VZV (chickenpox) infection, the virus lays dormant in the dorsal root ganglion until it undergoes local dermatomal reactivation in the form of herpes zoster (shingles).

The factors that induce the VZV (chickenpox) to reactivate are uncertain. Herpes zoster (shingles) is infrequent in healthy children. However, diminished cellular immunity seems to increase risk of reactivation because incidence increases with age and in immunocompromised states.


Herpes zoster, unilateral, trunk.

Herpes zoster, unilateral, trunk.


Pathophysiology

Herpes zoster (shingles) is a cutaneous viral infection; patients present with a vesicular rash that generally involves the skin of a single unilateral dermatome. Approximately 4-5 days before the eruption appears, the patient may experience preeruptive pain, itching, or burning along the affected dermatome.

Historically, herpes zoster (shingles) was thought to be an indicator for an underlying malignancy. More recent studies have shown no increased incidence of malignancy in children with herpes zoster (shingles). Approximately 3% of pediatric zoster cases occur in children with malignancies. Because of this evidence, a malignancy workup is not indicated in an otherwise healthy child who has herpes zoster (shingles).

Frequency

United States

Herpes zoster (shingles) is uncommon in childhood. More than 66% of patients are older than 50 years. Of all patients with zoster, fewer than 10% are younger than 20 years, and 5% are younger than 15 years. Although zoster is primarily a disease of adults, it has been noted as early as the first week of life. This occurs in infants born to mothers who had primary VZV (chickenpox) infection during pregnancy.

Incidence of the disease increases with age throughout childhood and adult life. Lifetime incidence is 10-20%. Approximately 25% of patients with human immunodeficiency virus (HIV) and 7-9% of patients receiving renal transplantation and cardiac transplantation experience a bout of zoster. Recurrent herpes zoster (shingles) occurs almost exclusively among people who are immunosuppressed.

In the United States, zoster occurs in 300,000-500,000 individuals annually. Nearly 100% of American adults are seropositive for VZV (chickenpox) antibodies. Since routine use of the live attenuated varicella vaccine began in 1994, preliminary observations have revealed that zoster frequency is significantly higher among children who had natural exposure to VZV (chickenpox), compared with those who were vaccinated.

Race

Blacks are 25% less likely than whites to develop herpes zoster (shingles).

Sex

Men and women are equally affected.

Age

Incidence increases with age. From birth to age 9 years, annual incidence is 0.74 cases per 1000 population; in persons aged 10-19 years, annual incidence is 1.38 cases per 1000 population; and in persons aged 20-29 years, annual incidence is 2.58 cases per 1000 population.

Clinical

History

  • Children commonly experience systemic symptoms before cutaneous manifestations erupt. Acute phase symptoms include the following:
    • Pain: This may occasionally be so severe that it may mimic appendicitis, renal calculi, or biliary colic.
    • Pruritus
    • Low-grade fever
    • Malaise
    • Headache
    • Regional lymphadenopathy
  • Patients with multiple myeloma and colon cancer treated with arsenic trioxide may have a propensity to develop herpes zoster (shingles). Arsenic compounds have been suggested as a possible predisposing factor for herpes viral reactivation in these patients.1
  • Herpes zoster (shingles) in childhood is unusual.2 This reactivation of varicella zoster virus (VZV) is seen with increased frequency in otherwise healthy children who acquire VZV (chickenpox) either in utero or within the first year of life.
  • VZV (chickenpox) infection may produce a facial palsy in children.3 It may also result in zoster sine herpete and does so more frequently in children than adults. In one survey of children, Ramsay Hunt syndrome tended to be found in school-aged children, and zoster sine herpete was often found in preschool children.
  • Ambilateral reactivation of herpes zoster V2 following cataract operation of both eyes has been described.4

Physical

  • A unilateral dermatomal eruption begins as grouped vesicles on an erythematous base. These round-to-oval red lesions with surmounting clear fluid-filled blisters usually measure several centimeters in diameter and are oriented along the track of dermatomal innervation. Over the ensuing days, the fluid becomes cloudy and pustular, and, finally, with rupture of the blisters, grouped crusted erosions are left. Thoracic dermatomes are the most common site, and involvement of multiple contiguous dermatomes is common. Lesions erupt over 7 days and develop a crust by 14-21 days.
  • Approximately 17-35% of patients with herpes zoster also have a few scattered vesicles in sites remote from the primary dermatome. This is likely secondary to viremia and should not be confused with generalized herpes zoster (shingles). The generalized form occurs in 2-10% of patients with herpes zoster (shingles).
  • Physical examination should include a slit lamp examination for corneal findings if lesions are found in the distribution of the V1 branch of the trigeminal nerve.
  • Zoster sine herpete appears as a tender erythematous unilateral patch or plaque without vesicle or bullae formation. It tends to be preceded by dysthesias, as is typical herpes zoster (shingles).
  • Herpes zoster ophthalmicus can be initially evident in the eyelids.5 Careful follow-up with attention to the eyelids and eyelid eversion is recommended in patients with herpes zoster to detect early ocular involvement.

Causes

Although VZV (chickenpox) reactivates for unknown reasons, childhood herpes zoster (shingles) has several recognized risk factors. These include the following:

  • Acute lymphocytic leukemia and other malignancies
  • Immunocompromised state as a result of treatments or human immunodeficiency virus (HIV)
  • Immune reconstitution inflammatory syndrome: This is a paradoxical deterioration in clinical status in a patient on antiretroviral treatment despite satisfactory control of viral replication and improvement of CD4 count, may be evident with herpes zoster; early recognition and prompt treatment, along with continuation of highly active antiretroviral treatment, are especially important in this case.6
  • In utero varicella exposure
  • Primary VZV infection (chickenpox) that occurred in the first year of life
  • Antitumor necrosis factor alpha agents (may pose an increased risk)7

Differential Diagnoses

Acropustulosis
Herpes Simplex Virus Infection
Impetigo

Other Problems to Be Considered

Bell palsy
Cholecystitis and biliary colic
Coxsackievirus infection
Conjunctivitis
Corneal ulceration and ulcerative keratitis
Renal calculi
Trigeminal neuralgia
Poison ivy, poison oak, and poison sumac
Ramsay-Hunt syndrome
Herpes simplex virus infection: This infection may be recurrent and may appear in a dermatomal distribution, mimicking herpes zoster and leading to misdiagnosis if no confirmatory laboratory tests are performed.8

Workup

Laboratory Studies

  • Patient history and clinical findings are the primary basis for a herpes zoster (shingles) diagnosis. Although varicella zoster virus (VZV) can be cultured, its growth rate is usually too slow to make a timely contribution to diagnosis.
  • A Tzanck smear, prepared from fluid contained in vesicular lesions, confirms the lesion is herpetic. The test does not differentiate among herpes zoster (shingles), VZV (chickenpox), and herpes simplex.
  • Direct fluorescent assay (DFA) from vesicular fluid or corneal lesion can yield the varicella-zoster viral antigen.
  • A polymerase chain reaction (PCR) from vesicular fluid or corneal scraping can yield the VZV (chickenpox) nucleic acid.
  • Detection of VZV (chickenpox) DNA in plasma can facilitate the early recognition of VZV (chickenpox) infection in immunocompromised hosts.9

Histologic Findings

Skin biopsy may be performed to reveal an intraepidermal vesicle with degeneration of epidermal cells and acantholysis.

  • Typical signs such as multinucleated epithelial cells or "ghosts" of them are usually, but not invariably, evident.10
  • Lymphocytes may be found in the lower part of the epidermis, accompanied by a combination of spongiosis and vacuolar alteration.
  • The papillary dermis is often edematous.
  • Extravasated erythrocytes in variable numbers are a common finding.
  • A brisk lymphocytic infiltrate is present in the upper dermis.
  • Some of these lymphocytes may have large and polygonal nuclei. They are dense perivascular and sparse interstitial, superficial, and deep collections, sometimes assuming a patchy lichenoid pattern, and may be prominent in and around adnexal structures, often peppering follicles, sebaceous glands, and eccrine glands.
  • Neutrophils and nuclear dust are occasionally seen; eosinophils are rare.

Conventional microscopy is routinely used to confirm infection by herpesviruses, although, occasionally, polymerase chain reaction may then be used to show herpesvirus-specific DNA.

Treatment

Medical Care

Unlike herpes zoster in adults, in most children, herpes zoster (shingles) runs a benign mild course lasting 1-3 weeks. Although pain may occur, postherpetic neuralgia is quite rare in the pediatric population. Conservative therapy includes nonsteroidal anti-inflammatory drugs (NSAIDs), wet dressings with 5% aluminum acetate (Burrow solution) applied 30-60 minutes 4-6 times daily, and lotions such as calamine. Antiviral therapy for herpes zoster (shingles) may decrease time of new vesicle formation, number of days to attain complete crusting, and days of acute discomfort. Initiate treatment as soon as possible because treatment is most effective within 72 hours of eruption. Valacyclovir and famciclovir are not approved by the US Food and Drug Administration (FDA) for pediatric use to treat herpes zoster (shingles), and acyclovir is more commonly used.

Consultations

Immediately refer children with zoster that involves the first branch of the trigeminal nerve to an ophthalmologist.

Medication

Conservative treatments are standard because the natural course of a pediatric herpes zoster (shingles) infection is short, benign, and self-limited. Topical lidocaine is occasionally used to treat patients with postherpetic neuralgia. Current evidence is insufficient to recommend topical lidocaine as a first-line agent in the treatment of postherpetic neuralgia with allodynia.11

Antiviral agents

Nucleoside analogs are initially phosphorylated by viral thymidine kinase to eventually form a nucleoside triphosphate. These molecules inhibit herpes simplex virus polymerase with 30-50 times the potency of human alpha-DNA polymerase.


Acyclovir (Zovirax)

Indicated in patients with involvement of the first branch of the trigeminal nerve, those who are immunocompromised, or those with increased risk for major complications from a varicella infection (ie, patients >13 y, those receiving long-term corticosteroid or aspirin therapy, those with chronic cutaneous or pulmonary diseases). Zoster in adolescents may be treated with PO acyclovir if initiated within 72 h of eruption.

Dosing

Adult

250-600 mg/m2 per dose PO 4-5 times per d for 7-10 d
10 mg/kg per dose IV or 500 mg/m2 per dose IV q8h

Pediatric

Administer as in adults

Interactions

CNS toxicity of acyclovir is increased by concomitant use of probenecid or zidovudine

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Carefully monitor renal function of patients with renal failure or concurrent therapy with nephrotoxic medications

Analgesics

Pain control is fundamental to care of patients with herpes zoster (shingles).


Acetaminophen (Tylenol)

Indicated in patients with mild pain or fever. DOC for patients with aspirin sensitivity, GI disease, or anticoagulation.

Dosing

Adult

650 mg PO q4h; not to exceed 4 g/d

Pediatric

<12 years: 15 mg/kg per dose PO q4h prn; not to exceed 2.6 g/d
>12 years: Administer as in adults

Interactions

Therapeutic effects may be diminished and hepatotoxicity may be increased when coadministered with barbiturates, carbamazepine, hydantoins, isoniazid, rifampin, or sulfinpyrazone

Contraindications

Documented hypersensitivity; G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Carefully monitor hepatic function of patients with hepatic failure; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum dose


Ibuprofen (Advil, Motrin)

Indicated in patients with mild-to-moderate pain.

Dosing

Adult

200-400 mg PO q6h

Pediatric

<12 years: 5-10 mg/kg per dose PO q6h; not to exceed 2.4 g/d
>12 years: Administer as in adults

Interactions

Loop diuretics may be less effective when coadministered with ibuprofen; probenecid can increase serum concentration

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with renal disease or compromised renal perfusion are at increased risk of acute renal failure

Follow-up

Deterrence/Prevention

  • A varicella zoster virus (VZV) vaccine has considerable potential.12
  • The cost-effectiveness of vaccination against herpes zoster may be best for the elderly.13

Complications

  • Secondary bacterial infection
  • Herpetic keratitis
  • Postherpetic neuralgia
  • Meningoencephalitis

Prognosis

  • Rash and symptoms generally resolve within 14-21 days.
  • Postherpetic neuralgia is rare in the pediatric population.

Patient Education

  • Herpes zoster (shingles) infections are contagious to those not previously immune to the VZV. However, zoster is estimated to be only one third as contagious as a primary varicella infection. Zoster is transmitted by direct contact with the lesions or by the respiratory route. A child can be allowed to return to school while lesions are still evident if the lesions can be covered fully by clothing or dressings.
  • For excellent patient education resources, visit eMedicine’s Bacterial and Viral Infections Center. Also, see eMedicine’s patient education article Chickenpox.

Miscellaneous

Medicolegal Pitfalls

  • Failure to perform a slit lamp examination to identify dendritic corneal lesions of herpetic keratitis when lesions occur along the course of the nasociliary nerve, as indicated by lesions that appear on the tip of the nose, is a pitfall. When these conditions are observed, promptly refer the patient to an ophthalmologist.

Special Concerns

  • Persistent pain after the resolution of herpes zoster was assessed in terms of excess annualized costs, amounting to $4,917 for commercially insured patients, $2,696 for patients using Medicare, and $9,310 for patients using Medicaid.14 The cost-effectiveness of existing treatments and emerging prevention strategies may require evaluation.

Multimedia

Herpes zoster, unilateral, trunk.

Media file 1: Herpes zoster, unilateral, trunk.

References

  1. 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. Feb 2006;5(2):182-5. [Medline].

  2. Papadopoulos AJ, Birnkrant AP, Schwartz RA, Janniger CK. Childhood herpes zoster. Cutis. Jul 2001;68(1):21-3. [Medline].

  3. 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. Jun 2006;48(3):245-9. [Medline].

  4. 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. May 2007;21(5):712-3. [Medline].

  5. Najjar DM, Youssef OH, Flanagan JC. Palpebral subconjunctival hemorrhages in herpes zoster ophthalmicus. Ophthal Plast Reconstr Surg. Mar-Apr 2008;24(2):162-4. [Medline].

  6. Sharma A, Makrandi S, Modi M, Sharma A, Marfatia Y. Immune reconstitution inflammatory syndrome. Indian J Dermatol Venereol Leprol. Nov-Dec 2008;74(6):619-21. [Medline].

  7. Strangfeld A, Listing J, Herzer P, et al. Risk of herpes zoster in patients with rheumatoid arthritis treated with anti-TNF-alpha agents. JAMA. Feb 18 2009;301(7):737-44. [Medline].

  8. Koh MJ, Seah PP, Teo RY. Zosteriform herpes simplex. Singapore Med J. Feb 2008;49(2):e59-60. [Medline].

  9. Kalpoe JS, Kroes AC, Verkerk S, et al. Clinical relevance of quantitative varicella-zoster virus (VZV) DNA detection in plasma after stem cell transplantation. Bone Marrow Transplant. Jul 2006;38(1):41-6. [Medline].

  10. Boer A, Herder N, Blodorn-Schlicht N, Falk T. Herpes incognito most commonly is herpes zoster and its histopathologic pattern is distinctive!. Am J Dermatopathol. Apr 2006;28(2):181-6. [Medline].

  11. Khaliq W, Alam S, Puri N. Topical lidocaine for the treatment of postherpetic neuralgia. Cochrane Database Syst Rev. 2007;(2):CD004846. [Medline].

  12. Caple J. Varicella-zoster virus vaccine: a review of its use in the prevention of herpes zoster in older adults. Drugs Today (Barc). Apr 2006;42(4):249-54. [Medline].

  13. 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. Feb 25 2009;27(9):1454-67. [Medline].

  14. Dworkin RH, White R, O'Connor AB, Hawkins K. Health care expenditure burden of persisting herpes zoster pain. Pain Med. Apr 2008;9(3):348-53. [Medline].

  15. Coen PG, Scott F, Leedham-Green M, et al. Predicting and preventing post-herpetic neuralgia: are current risk factors useful in clinical practice?. Eur J Pain. Nov 2006;10(8):695-700. [Medline].

  16. Courter BJ. Pediatric herpes zoster with mild cutaneous dissemination. Pediatr Emerg Care. Feb 1993;9(1):33-5. [Medline].

  17. Kucukardali Y, Solmazgul E, Terekeci H, Oncul O, Turhan V. Herpes zoster ophthalmicus and syndrome of inappropriate antidiuretic hormone secretion. Intern Med. 2008;47(5):463-5. [Medline].

  18. Lopez N, Alcaraz I, Cid-Manas J, et al. Wolf's isotopic response: zosteriform morphea appearing at the site of healed herpes zoster in a HIV patient. J Eur Acad Dermatol Venereol. Mar 18 2008;[Medline].

  19. Piette ML. Herpes zoster at school-age: a case presentation and discussion of the unique aspects within the pediatric population. Hawaii Med J. Jul 1996;55(7):118-21. [Medline].

  20. Quan D, Hammack BN, Kittelson J, Gilden DH. Improvement of postherpetic neuralgia after treatment with intravenous acyclovir followed by oral valacyclovir. Arch Neurol. Jul 2006;63(7):940-2. [Medline].

  21. Smith CG, Glaser DA. Herpes zoster in childhood: case report and review of the literature. Pediatr Dermatol. May-Jun 1996;13(3):226-9. [Medline].

  22. Straus SE. Overview: the biology of varicella-zoster virus infection. Ann Neurol. 1994;35 Suppl:S4-8. [Medline].

  23. Wung PK, Holbrook JT, Hoffman GS, et al. Herpes zoster in immunocompromised patients: incidence, timing, and risk factors. Am J Med. Dec 2005;118(12):1416. [Medline].

  24. Wurzel CL, Kahan J, Heitler M, Rubin LG. Prognosis of herpes zoster in healthy children. Am J Dis Child. May 1986;140(5):477-8. [Medline].

Keywords

zoster, herpes zoster, shingles, varicella-zoster virus, VZV, chickenpox, vesicular rash, human immunodeficiency virus, HIV, cardiac transplant, renal transplant, appendicitis, renal calculi, biliary colic, myeloma, colon cancer, lymphadenopathy, treatment, diagnosis

Contributor Information and Disclosures

Author

Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Andrea N Driano, MD, Consulting Staff, Department of Emergency Medicine, Children's Hospital and Medical Center, Seattle WA
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
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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