II. Epidemiology

  1. Incidence: 1 Million cases in United States annually
  2. Age: Peak onset at 50-79 years old
  3. Gender predominance: Women account for 60% of cases

III. Pathophysiology

  1. Reactivation of latent virus from dorsal root Ganglion
    1. Occurs in 10-20% of people previously exposed to Chicken Pox
  2. Inflammation to acute viral ID in segmental nerve
  3. Contagious to non-immune persons
    1. Avoid contact until rash heals

IV. Risk Factors

  1. Age over 50 years old
  2. Chicken Pox at age <1 year old
  3. Altered cell-mediated immunity (especially if onset in a younger patient)
    1. HIV Infection
    2. Malignancy
    3. Organ transplant status
    4. Immunosuppressant use

V. Symptoms: Prodrome

  1. Timing
    1. May be precede rash by 1-5 days
  2. Most common symptoms
    1. Fever (variably present)
    2. Headache
    3. Photophobia
    4. Paresthesias
      1. Pain within dermatome occurs first
      2. Examples: itching, burning, hyperesthesia
    5. Malaise

VI. Signs: Rash

  1. Timing
    1. Develops after 48-72 hours (up to 5 days before rash)
    2. Lesions crust and heal within 2-4 weeks
  2. Distribution
    1. Follows 1-2 dermatomes and rarely crossess the mid-line
    2. Back and face are most commonly affected
  3. Characteristics
    1. Starts as erythematous, maculopapular rash
    2. Clear Vesicles develop
    3. Vessicles turn cloudy within 3-5 days
  4. Associated Findings
    1. Tender regional lymph nodes
  5. Variants
    1. Zoster sine herpete (zoster without a rash)
      1. Zoster without rash is uncommon but does occur
    2. Hutchinson's Sign (Vesicle on the tip of nose)
      1. Associated with Herpes Zoster Ophthalmicus
      2. Stain the eye for Fluorescein and observe for dendrites
      3. Exercise high level of suspicion for ocular involvement
    3. Ramsay Hunt Syndrome (Vesicle in ear)
      1. Associated with Bell's Palsy
      2. Course may be more prolonged
  6. Images
    1. DermHerpesZosterEarly.jpg
    2. DermHerpesZosterLate.jpg

VII. Labs: Vesicle fluid testing

  1. Zoster PCR
    1. Test Sensitivity: 95%
    2. Test Specificity: 99%
  2. Direct immunofluorescent antigen staining
    1. Test Sensitivity: 82%
    2. Test Specificity: 76%
  3. Virus Culture
    1. Test Sensitivity: 20%
    2. Test Specificity: 99%
  4. Tzanck Smear of lesion base (Multinucleated giant cells)
    1. Rarely performed now in United States
  5. References
    1. Sauerbrei (1999) J Clin Virol 14(1): 31-36

VIII. Differential Diagnosis

  1. Cellulitis
  2. Painful serious condition (prior to dermatitis appearance)
    1. Acute Abdomen
    2. Acute Coronary Syndrome

IX. Complications

  1. Postherpetic Neuralgia
  2. Herpes Zoster Ophthalmicus
  3. Herpes Ophthalmicus
    1. Especially if Conjunctivitis or Vesicle at tip of nose
  4. Herpes Zoster Oticus (Ramsay Hunt Syndrome)
  5. Meningitis
  6. Encephalitis
  7. Granulomatous Angiitis with contralateral Hemiplegia
  8. Cutaneous dissemination in Lymphoma (40%)
  9. Diffuse involvement (including pneumonitis)
    1. Occurs in immunocompromised patients

X. Management: Antivirals

  1. Relative indications for antivirals (maximal benefit)
    1. Onset within 72 hours of starting treatment
    2. Facial involvement (due to associated risk of ocular involvement)
    3. Age 50 years and older
    4. More than 50 lesions
    5. Patients are likely to see benefit if still having active vessicle eruptions, even if delayed beyond the 72 hour window
  2. Oral antiviral agents
    1. Acyclovir
      1. Dose: 800 mg orally five times daily for 7-10 days
      2. Reduces healing time, pain, and rash dissemination
      3. Least expensive of all antiviral options by an order of magnitude
      4. Valacyclovir appeared more effective in over age 50
        1. (1999) Med Lett Drugs Ther 41:113-20
    2. Valacyclovir
      1. Dose: 1000 mg orally three times daily for 7 days
      2. Equivalent efficacy to Famciclovir
        1. Tyring (2000) Arch Fam Med 9:863-9
    3. Famciclovir
      1. Dose: 500 mg orally three times daily for 7 days
      2. Lesions healed faster, more brief virus shedding
      3. Reduces Postherpetic Neuralgia duration by 2 months
      4. Reference
        1. Tyring (1995) Ann Intern Med 123:89-96

XI. Management: Pain Management

  1. Analgesics
    1. Schedule Analgesics around the clock (not prn)
    2. Mild to moderate pain
      1. Acetaminophen
      2. NSAIDs
    3. Moderate to severe pain
      1. Opioid Analgesics
    4. Refractory pain (agents used in Postherpetic Neuralgia)
      1. No evidence that these agents reduce acute Shingles pain or that they prevent Postherpetic Neuralgia
      2. Amitriptyline (Elavil)
      3. Gabapentin (Neurontin)
  2. Systemic Corticosteroids
    1. Use is controversial and not routinely recommended
    2. May be associated with increased complications (e.g. bacterial superinfection)
    3. May reduce acute pain, inflammation and speed up healing
    4. Does not reduce risk of Postherpetic Neuralgia
    5. References
      1. Wood (1994) N Engl J Med 330:896-900

XII. Management: Special Circumstances

  1. Zoster Ophthalmicus
    1. See Herpes Zoster Ophthalmicus
  2. Immunocompromised Patient
    1. Acyclovir 10 mg/kg IV every 8 hours for 10 days

XIII. Prophylaxis: Varicella Immune Globulin (VZIG) Indications

  1. Immunodeficient under age 15 years
    1. Give within 72-96 hours exposure
  2. Newborn of infected mother
    1. Exposure 5 days before delivery or 2 days after

XIV. Prevention

  1. Avoid contact with active Shingles or Chicken Pox
  2. Consider prophylaxis if exposure in high-risk groups
  3. Varicella Vaccine routinely in children, teens, and adults
    1. May reduce risk of developing Shingles
    2. Part of routine Primary Series
  4. Herpes Zoster Vaccine (Shingles Vaccine, Zostavax)
    1. Recommended in adults over age 50 years (if not contraindicated)
    2. Following a Shingles episode, delay vaccination until acute Shingles has resolved prior to vaccination (~8 weeks)
    3. Reduces risk of Herpes Zoster Incidence by 60% and post-herpetic neuralgia by 65%

XV. References

  1. Takhar in Majoewsky (2012) EM:Rap 12(11): 12
  2. Berger in Goldman (2000) Cecil Medicine, p. 2130-1
  3. Habif (1996) Dermatology, p. 351-9
  4. Gnann (2002) N Engl J Med 347:340-6
  5. Fashner (2011) m Fam Physician 83(12): 1432-7

Images: Related links to external sites (from Google)

Ontology: Herpes zoster disease (C0019360)

Definition (NCI) A common dermal and neurologic disorder caused by reactivation of the varicella-zoster virus that has remained dormant within dorsal root ganglia, often for decades, after the patient's initial exposure to the virus in the form of varicella (chickenpox). It is characterized by severe neuralgic pain along the distribution of the affected nerve and crops of clustered vesicles over the area.
Definition (MSHFRE) Infection aiguë mais généralement limitée, due à une réactivation du virus de la varicelle et du zona (herpès virus 3 humain). Cette infection survient obligatoirement chez des personnes ayant déjà fait une varicelle (partiellement immunisées). Le virus reste latent dans les cellules des ganglions des nerfs sensitifs et la réactivation se fait dans le territoire d'un des nerfs sensitifs. Elle est caractérisée au niveau de la peau par une éruption vésiculaire à topographie radiculaire, en général unilatérale, évoluant par poussées et associée à des douleurs très sévères le long des nerfs infectés.(Extr. Dorland, 27ème éd.)
Definition (MEDLINEPLUS)

Shingles is a disease caused by the varicella-zoster virus - the same virus that causes chickenpox. After you have chickenpox, the virus stays in your body. It may not cause problems for many years. As you get older, the virus may reappear as shingles. Unlike chickenpox, you can't catch shingles from someone who has it.

Early signs of shingles include burning or shooting pain and tingling or itching, usually on one side of the body or face. The pain can be mild to severe. Blisters then form and last from one to 14 days. If shingles appears on your face, it may affect your vision or hearing. The pain of shingles may last for weeks, months or even years after the blisters have healed.

There is no cure for shingles. Early treatment with medicines that fight the virus may help. These medicines may also help prevent lingering pain. A vaccine may prevent shingles or lessen its effects. The vaccine is for people 60 or over.

NIH: National Institute of Allergy and Infectious Diseases

Definition (CSP) acute infectious, usually self-limited, disease believed to represent activation of latent varicella zoster virus in those who have been rendered partially immune after a previous attack of chickenpox; it involves the sensory ganglia and their areas of innervation and is characterized by severe neuralgic pain along the distribution of the affected nerve and crops of clustered vesicles over the area.
Definition (MSH) An acute infectious, usually self-limited, disease believed to represent activation of latent varicella-zoster virus (HERPESVIRUS 3, HUMAN) in those who have been rendered partially immune after a previous attack of CHICKENPOX. It involves the SENSORY GANGLIA and their areas of innervation and is characterized by severe neuralgic pain along the distribution of the affected nerve and crops of clustered vesicles over the area. (From Dorland, 27th ed)
Concepts Disease or Syndrome (T047)
MSH D006562
ICD9 053
ICD10 B02 , B02.9
SnomedCT 154326002, 186533008, 4740000, 186514003
English Herpes Zoster, Shingles, Zona, Zoster, HERPES ZOSTER, SHINGLES, ZONA, Herpes zoster, NOS, Herpes zoster NOS, herpes zona, Herpes zoster infection (disorder), herpes zoster, herpes zoster (diagnosis), shingles, Herpes zoster NOS (disorder), zona, Zoster [herpes zoster], Zoster NOS, Herpes Zoster [Disease/Finding], zoster, zonas, herpes zoster infection, Herpes zoster infection, Herpes zoster, Herpes zoster (disorder), herpes; zoster, zoster; herpes, Herpes zoster disease
French HERPES ZOSTER, Zona SAI, Herpes zoster, Zona
Portuguese HERPES ZOSTER, Herpes zóster NE, Zóster, Herpes zona, Herpes zoster, Herpes zóster, Cobreiro, Cobrelo, Herpes Zoster, Zona, Zoster
Spanish HERPES ZOSTER, Herpes zoster NEOM, Herpes zoster, SAI, Shingles, Herpes zoster infection, Herpes zoster, Herpes zona, herpes zóster (trastorno), herpes zoster (trastorno), zóster, herpes zóster, zona ígnea, zona serpiginoso, herpes zoster, Herpes zoster, SAI (trastorno), culebrilla, herpes zóster, SAI (trastorno), herpes zóster, SAI, zona, Herpes, Herpes Zoster, Zona, Zoster
German HERPES ZOSTER, Herpes zoster NNB, Guertelrose, Zona, Herpes Zoster, Zoster [Herpes zoster], Herpes zoster, Zoster, Gürtelrose, Rose, Gürtel-
Italian Herpes zoster, Herpes zoster NAS, Zona, Zoster, Herpes Zoster
Dutch gordelroos, herpes zoster NAO, zona, herpes; zoster, zoster; herpes, herpes zoster, Herpes zoster, Gordelroos, Zona
Japanese 帯状疱疹NOS, タイジョウホウシンNOS, タイジョウホウシン, 帯状疱疹, 帯状ヘルペス, 疱疹-帯状, ヘルペス-帯状
Swedish Bältros, HERPES ZOSTER/BALTROS
Czech herpes zoster, pásový opar, Herpes zoster, Herpes zoster NOS, Pásový opar
Finnish Vyöruusu, VYORUUSU
Russian LISHAI OPOIASYVAIUSHCHII, OPOIASYVAIUSHCHII LISHAI, HERPES ZOSTER, ЛИШАЙ ОПОЯСЫВАЮЩИЙ, ОПОЯСЫВАЮЩИЙ ЛИШАЙ
Norwegian HERPES ZOSTER
Danish Herpes Zoster
Hungarian herpes zooster, herpes zoster k.m.n., herpes zoster, Zóna, Övsömör
Korean 대상포진
Basque ZOSTER HERPESA
Hebrew shalbeket xogeret
Polish Półpasiec