Varicella-Zoster Virus (VZV) Follow-up

Updated: Sep 30, 2022
  • Author: Zartash Zafar Khan, MD, FACP; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Further Outpatient Care

Typical cases of zoster may be treated in the outpatient setting.

Initial evaluation should address the possibility of atypical manifestations.


Further Inpatient Care

Patients with ocular involvement may be treated in the hospital.

Inpatient treatment may be appropriate for people who develop complications.

The main patient complaint is pain.

Inpatient treatment is appropriate for immunocompromised people or those with atypical presentations, including myelitis.



In May 1995, the American Academy of Pediatrics reviewed the literature on the safety and effectiveness of varicella vaccine and recommended that all susceptible children and adolescents without a contraindication receive routine varicella vaccination. They reaffirmed this recommendation in January 2000. However, many logistic and financial barriers have prevented the widespread adoption of this recommendation.

Both clinical varicella and zoster may occur despite vaccination. However, in 3 large studies, vaccination was 100% effective in preventing severe disease.

A study by Tseng et al examined the risk of herpes zoster in patients who underwent vaccination. [25] Among older adults (>60 y), a lower incidence rate was noted.

In March 2011, the Food and Drug Administration (FDA) lowered the approved age for use of Zostavax to 50-59 years. Zostavax was already approved for use in individuals aged 60 years or older. Annually, in the United States, shingles affects approximately 200,000 healthy people aged 50-59 years. Approval was based on a multicenter study, the Zostavax Efficacy and Safety Trial (ZEST). [26] The trial was conducted in the United States and 4 other countries in 22,439 people aged 50-59 years. Participants were randomized in a 1:1 ratio to receive either Zostavax or placebo. Participants were monitored for at least 1 year to see if shingles developed. Compared with placebo, Zostavax significantly reduced the risk of developing zoster by approximately 70%.

The virus was found in the saliva of individuals who received the zoster vaccine; persons older than 60 years shed virus in their saliva for as long as 4 weeks after vaccination. [27]

Severe herpes zoster has been described as a rare complication of varicella vaccination in immunocompetent young children, with these children at low risk of developing meningoencephalitis. [28] In children, VZV infection may produce a facial palsy [29] ; it may also result in zoster sine herpete, more so in children than in adults. Ramsay Hunt syndrome (herpes zoster oticus) tends to develop more often in school-aged children, while zoster sine herpete is more likely to develop in preschool children.



In cases of typical zoster, both streptococcal and staphylococcal superinfections are common potential complications. With ocular, spinal cord, or other involvement, permanent injury is a risk. With ocular involvement, the patient may require long-term antiviral treatment. One study suggests that trigeminal distribution and advanced age increase risk of complications. [30]

Other complications include the following:

  • Necrotizing fasciitis

  • Gastrointestinal complications

  • Fatal hemorrhagic encephalitis

  • Motor weakness

  • Postherpetic neuralgia (most common) (The underlying pathophysiology of the condition may involve peripheral nerve injury or continued viral activation without rash, similar to zoster sin herpete.)

  • Vasculopathy



Postherpetic neuralgia remains the most common complication of varicella-zoster virus (VZV) infection reactivation, affecting up to 50% of the patients older than 60 years. Most cases are temporary, but many cases persist chronically, impairing productivity and quality of life.

A landmark study by Rowbotham and Fields (1996) shows no clear relationship between loss of peripheral nerve function and postherpetic neuralgia pain. [31] Although many mechanisms may cause the pain, this study helps explain the efficacy of topical agents such as capsaicin or lidocaine patches.

As evidence of the complexity of the issue, Oaklander and colleagues (1998) examined patients with postherpetic neuralgia and found bilateral damage in patients with unilateral shingles. Neurite loss was noted in the contralateral homologous region in test subjects who experienced no pain and had no history of shingles. [32]

Many treatment options are available for postherpetic neuralgia.

  • Oral medications

  • Topical preparations

  • Gamma knife procedures

  • Jaipur blocks


Patient Education

For excellent patient education resources, visit eMedicineHealth's Infections Center. Also, see eMedicineHealth's patient education articles Shingles and Chickenpox.