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Herpes Zoster

(Shingles; Acute Posterior Ganglionitis)


Kenneth M. Kaye

, MD, Harvard Medical School

Reviewed/Revised Dec 2023
Topic Resources

Herpes zoster is infection that results when varicella-zoster virus reactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with pain along the affected dermatome, followed within 2 to 3 days by a vesicular eruption that is usually diagnostic. Treatment is with antiviral medications, ideally given within 72 hours after skin lesions appear.

Chickenpox Chickenpox Chickenpox is an acute, systemic, usually childhood infection caused by the varicella-zoster virus (human herpesvirus type 3). It usually begins with mild constitutional symptoms (eg, fever... read more Chickenpox and herpes zoster are caused by the varicella-zoster virus (human herpesvirus type 3); chickenpox is the acute, primary infection phase of the virus, and herpes zoster (shingles) represents reactivation of virus from the latent phase.

Herpes zoster inflames the sensory root ganglia, the skin of the associated dermatome, and sometimes the posterior and anterior horns of the gray matter, meninges, and dorsal and ventral roots. Herpes zoster frequently occurs in older adults and people living with HIV and is more frequent and severe in patients who are immunocompromised because cell-mediated immunity in these patients is decreased. There are no clear-cut precipitants.

Symptoms and Signs of Herpes Zoster

Lancinating, dysesthetic, or other pain develops in the involved site, typically followed within 2 to 3 days by a rash, usually crops of vesicles on an erythematous base. The site is usually one or more adjacent dermatomes in the thoracic or lumbar region, although a few satellite lesions may also appear. Lesions are typically unilateral and do not cross the midline of the body. The site is usually hyperesthetic, and pain may be severe. Lesions usually continue to form for about 3 to 5 days.

Herpes zoster may disseminate to other regions of the skin and to visceral organs, especially in patients who are immunocompromised.

Geniculate zoster (Ramsay Hunt syndrome, herpes zoster oticus Herpes Zoster Oticus Herpes zoster oticus is an uncommon manifestation of herpes zoster that affects the 8th cranial nerve ganglia and the geniculate ganglion of the 7th (facial) cranial nerve. Herpes zoster (shingles)... read more ) results from involvement of the geniculate ganglion. Ear pain, facial paralysis, and sometimes vertigo occur. Vesicles erupt in the external auditory canal, and taste may be lost in the anterior two thirds of the tongue.

Ophthalmic herpes zoster Herpes Zoster Ophthalmicus Herpes zoster ophthalmicus is a reactivated latent varicella-zoster virus (VZV) infection ( shingles) involving the eye. Symptoms and signs, which may be severe, include unilateral dermatomal... read more Herpes Zoster Ophthalmicus results from involvement of the gasserian ganglion, with pain and vesicular eruption around the eye and on the forehead, in the V1 distribution of the ophthalmic division of the 5th (trigeminal) cranial nerve. Ocular disease can be severe. Vesicles on the tip of the nose (Hutchinson sign) indicate involvement of the nasociliary branch and a higher risk of severe ocular disease. However, the eye may be involved in the absence of lesions on the tip of the nose. An ophthalmology consultation should be sought in V1 distribution zoster.

Intraoral zoster is uncommon but may produce a sharp unilateral distribution of lesions. No intraoral prodromal symptoms occur.

Symptoms and signs reference

Postherpetic neuralgia

Up to 6% of patients with herpes zoster experience another outbreak (1 Symptoms and signs reference Herpes zoster is infection that results when varicella-zoster virus reactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with pain along the affected... read more Symptoms and signs reference ), although this percentage may be higher in immunocompromised hosts. However, many patients, particularly older patients, have localized pain with variable intensity lasting > 3 months from the last crusted lesion in the involved distribution (postherpetic neuralgia).

Pearls & Pitfalls

  • Fewer than 6% of patients with herpes zoster experience another outbreak.

The pain of postherpetic neuralgia may be sharp and intermittent or constant and may be debilitating. It may persist for months or years or permanently.

Diagnosis of Herpes Zoster

  • History and physical examination

Herpes zoster is suspected in patients with the characteristic rash and sometimes even before the rash appears if patients have typical pain in a dermatomal distribution. Diagnosis is usually based on the virtually pathognomonic rash.

If the diagnosis is equivocal, detecting multinucleate giant cells with a Tzanck test can confirm infection, but the Tzanck test is positive with herpes zoster or herpes simplex Herpes Simplex Virus (HSV) Infections Herpes simplex viruses (human herpesviruses types 1 and 2) commonly cause recurrent infection affecting the skin, mouth, lips, eyes, and genitals. Common severe infections include encephalitis... read more Herpes Simplex Virus (HSV) Infections . Herpes simplex virus (HSV) may cause nearly identical lesions, but unlike herpes zoster, HSV tends to recur and is not dermatomal. Viruses can be differentiated by culture or polymerase chain reaction (PCR). Antigen detection from a biopsy sample can also be used to detect herpes zoster.

Treatment of Herpes Zoster

  • Symptomatic treatment

  • Antivirals (acyclovir, famciclovir, valacyclovir), especially for patients who are immunocompromised

Wet compresses are soothing, but systemic analgesics are often necessary.

Antiviral therapy

Treatment with oral antivirals decreases the severity and duration of the acute eruption and decreases the rate of serious complications in patients who are immunocompromised; it may decrease the incidence of postherpetic neuralgia. In patients who are immunocompetent, antiviral therapy is often reserved for those who are ≥ 50 years in whom benefit is greatest. Treatment is also indicated in patients with severe pain, facial rash especially around the eye, and in patients who are immunocompromised.

Treatment of herpes zoster should start as soon as possible, ideally during the prodrome, and is less likely to be effective if given > 72 hours after skin lesions appear, especially in the absence of newly forming lesions. Famciclovir and valacyclovir have better bioavailability with oral dosing than acyclovir, and therefore for herpes zoster, they are generally preferred. Corticosteroids do not decrease the incidence of postherpetic neuralgia.

For less severely immunocompromised patients, oral famciclovir, valacyclovir, or acyclovir is a reasonable option; famciclovir and valacyclovir are preferred. For patients who are severely immunocompromised, intravenous acyclovir is recommended. Some experts recommend treatment beyond 7 to 10 days, lasting until all lesions are crusted, for immunocompromised patients.

Although data concerning the safety of acyclovir and valacyclovir during pregnancy are reassuring, the safety of antiviral therapy during pregnancy is not firmly established. Because congenital varicella can result from maternal varicella but rarely results from maternal zoster, the potential benefit of treatment of pregnant patients should outweigh possible risks to the fetus. Pregnant patients with severe rash, severe pain, or ophthalmic zoster can be treated, preferably with acyclovir, because there is longer experience with its use in pregnancy as compared to other medications, although valacyclovir remains an option. There are little data regarding the safety of famciclovir in pregnancy, so it is not generally recommended in pregnant women.

Management of postherpetic neuralgia

Management of postherpetic neuralgia can be particularly difficult. Treatments include gabapentin, pregabalin, cyclic antidepressants, topical capsaicin or lidocaine ointment, and botulinum toxin injection. Opioid analgesics may be necessary. Intrathecal methylprednisolone may be of benefit.

Prevention of Herpes Zoster

A recombinant zoster vaccine Herpes Zoster Vaccine Chickenpox (varicella) and shingles ( herpes zoster) are caused by the varicella-zoster virus; chickenpox is the acute invasive phase of the virus, and shingles represents reactivation of the... read more is recommended for adults ≥ 50 years whether they have had herpes zoster or been given the older, live-attenuated vaccine or not; 2 doses of the recombinant zoster vaccine are given 2 to 6 months apart (for more information, see Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines). The recombinant zoster vaccine is also recommended for adults ≥ 19 years who are or will be immunodeficient or immunosuppressed because of disease or therapy, including those with a prior history of varicella, varicella vaccine, or herpes zoster (for more information, see Use of Recombinant Zoster Vaccine in Immunocompromised Adults Aged ≥ 19 Years: Recommendations of the Advisory Committee on Immunization Practices-Unites States, 2022).

A postmarketing observational study observed an increased risk of Guillain-Barré syndrome Guillain-Barré Syndrome (GBS) Guillain-Barré syndrome is an acute, usually rapidly progressive but self-limited inflammatory polyneuropathy characterized by muscular weakness and mild distal sensory loss. Cause is thought... read more during the 42 days following vaccination with the recombinant zoster vaccine, and as a result some clinicians avoid recombinant zoster vaccine in patients with a prior history of Guillain-Barre syndrome (see FDA Requires a Warning about Guillain-Barré Syndrome (GBS) be Included in the Prescribing Information for Shingrix).

The older, live-attenuated vaccine is no longer available in the United States but remains available in many other nations. The newer, recombinant vaccine appears to provide much better and longer-lasting protection than the older, single-dose, live-attenuated zoster vaccine (which is a higher-dose version of the varicella vaccine). In a large clinical trial, the recombinant zoster vaccine was about 97% effective at preventing herpes zoster (1 Prevention reference Herpes zoster is infection that results when varicella-zoster virus reactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with pain along the affected... read more Prevention reference ). The live-attenuated vaccine is contraindicated in patients who are immunocompromised.

Prevention reference

  • 1. Lal H, Cunningham AL, Godeaux O, et al: Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med 372(22):2087-96, 2015. Epub 2015 Apr 28. PMID: 25916341. doi: 10.1056/NEJMoa1501184

Key Points

  • Herpes zoster is caused by reactivation of the varicella-zoster virus (the cause of chickenpox) from its latent phase.

  • A painful rash, usually crops of vesicles on an erythematous base, develops on one or more adjacent dermatomes.

  • Fewer than 4% of patients have another outbreak of zoster, but many, particularly older patients, have persistent or recurrent pain for months or years (postherpetic neuralgia).

  • Antivirals (acyclovir, famciclovir, valacyclovir) are beneficial, especially for patients who are immunocompromised.

  • Analgesics are often necessary.

  • Adults 50 years and adults ≥ 19 years who are immunocompromised and at risk for zoster should be given recombinant zoster vaccine whether they have had herpes zoster or not.

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

Drugs Mentioned In This Article

Drug Name Select Trade
Sitavig, Zovirax, Zovirax Cream, Zovirax Ointment, Zovirax Powder, Zovirax Suspension
Active-PAC with Gabapentin, Gabarone , Gralise, Horizant, Neurontin
Lyrica, Lyrica CR
Arthricare for Women, Arthritis Pain Relieving, Capsimide, Capzasin-HP, Capzasin-P, Castiva Warming, Circatrix, DermacinRx Circata, DermacinRx Penetral, DiabetAid, Qutenza, Zostrix, Zostrix HP, Zostrix Maximum Strength, Zostrix Neuropathy
7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme with Lidocaine, AsperFlex, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidocan III, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Dologesic, Ela-Max, GEN7T, Glydo, Gold Bond, LidaFlex, LidaMantle, Lido King Maximum Strength, Lidocan, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , LidoLite, Lidomar , Lidomark, LidoPure, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, Lidosol, Lidosol-50, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lubricaine For Her, Lydexa, Moxicaine, Numbonex, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Salonpas Lidocaine, Senatec, Solarcaine, SUN BURNT PLUS, Tranzarel, Xyliderm, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, Zingo, Zionodi, ZTlido
A-Methapred, Depmedalone-40, Depmedalone-80 , Depo-Medrol, Medrol, Medrol Dosepak, Solu-Medrol
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