Herpes Zoster

Causes and Risks:
Herpes zoster, or shingles, is caused by the same virus that causes chickenpox . It occurs as a result of the virus becoming dormant (inactive) after an attack of chickenpox and re-emerging many years later. The cause of the reactivation is unknown. Usually only one attack occurs, without recurrence. If an adult is exposed to herpes zoster virus and has not had chickenpox, a severe case of chickenpox usually develops rather than shingles.

The virus resides in a dormant condition in the nerve tracts that emerge from the spine. When it is reactivated, it spreads along the nerve tract, first causing pain or a burning sensation. The typical rash appears in 2 to 3 days, after the virus has reached the skin. It consists of red patches of skin with small blisters ( vesicles ) that look very similar to early chickenpox. The rash maximizes over the next 3 to 5 days. Then the blisters break forming small ulcers which begin to dry and form crusts. The crusts fall off in 2 to 3 weeks, leaving behind pink healing skin.

Lesions typically appear along a single dermatome (the body area served by a single spinal nerve) and are only on one side of the body (unilateral). The trunk is most often affected, showing a rectangular belt of rash from the spine around one side of the chest to the breastbone (sternum). Lesions may also occur on the neck or face, particularly the trigeminal nerve in the face. The trigeminal has three branches: the superior which goes to the forehead, the middle which goes to the mid-face and the inferior which goes to the lower face. Which branch is involved determines where on the face the skin lesions will be. Trigeminal nerve involvement may include lesions in the mouth or eye. Eye lesions may lead to permanent blindness .

Involvement of the facial nerve may cause Ramsay Hunt syndrome with facial paralysis , hearing loss , loss of taste in half of the tongue and skin lesions around the ear and ear canal. Shingles may, on rare occasion, involve the genitalia or upper leg.

Shingles may be complicated by a condition known as post-herpetic neuralgia . This is persistence of pain in the area where the shingles occurred that may last from months to years following the initial episode. This pain can be severe enough to be incapacitating to a person, especially if they are elderly.

Herpes zoster can be contagious through direct contact in an individual who has not had chickenpox and therefore has no immunity . Herpes zoster may affect any age group but is much more common in adults over 60 years old, in children who had chickenpox before the age of one year, and in individuals who are immunocompromised. The disorder is common, with about 300,000 cases in the U.S. per year (about 2 out of every 1,000 people).

Localized shingles involving only one dermatome is typical for an outbreak of shingles. Generalized or recurrent shingles may indicate an underlying disorder with the immune system such as leukemia , Hodgkin's disease , other cancers, atopic dermatitis , or HIV infection (ARC or AIDS ). Those who are immunosuppressed because of organ transplant or treatment for cancer or similar disorders may also experience the disorder. Shingles may be an early sign in persons with HIV infection that the immune system has deteriorated enough that they would now be classified as having ARC (AIDS Related Complex) or AIDS.

Prevention:
Prevention is uncertain. Avoid contact with the skin lesions of persons with known herpes zoster infection (shingles or chickenpox ) if you have never had chickenpox or especially if your immune system is compromised.

Symptoms:

Additional symptoms that may be associated with this disease:



Signs and Tests:
Diagnosis is suspected based on the appearance of the skin lesions , and strengthened by a prior history of chickenpox or shingles.

Tests are rarely necessary, but may include:



Treatment:
Herpes zoster usually resolves spontaneously, and may not require treatment except for symptomatic relief.

Acyclovir is an antiviral medications that may be prescribed to shorten the course, reduce pain, reduce complications or protect an immunocompromised individual. For the greatest efficacy acyclovir should be started within 24 hours of the appearance of pain or burning sensation and preferably before the appearance of the characteristic blisters . Typically it is given in oral doses four times those recommended for herpes simplex or herpes genitalia. Severely immunocompromised individuals such as those with AIDS may require IV acyclovir therapy.

Corticosteroids such as prednisone may occasionally be used to reduce inflammation but have the drawback of interfering with immune function.

Analgesics , mild to strong, may be needed to control pain. Antihistamines may be used topically or orally to reduce itching and pain. Zostrix, a cream containing capzasin (an extract of pepper), can be used to prevent post-herpetic neuralgia .

Cool wet compresses may reduce pain. Soothing baths and lotions such as colloidal oatmeal bath, starch baths or lotions, and calamine lotion may help to relieve itching and discomfort. Rest in bed until fever resolves.

Keep the skin clean, and do not re-use contaminated items. Nondisposable items should be washed in boiling water or otherwise disinfected before re-use. The person may need to be isolated while lesions are oozing to prevent infecting others.

Prognosis:
Herpes zoster usually clears in 2 to 3 weeks and rarely recurs. Involvement of motor nerves may cause a temporary or permanent nerve palsy. Neuralgia (continued nerve pain ) may persist for years in 50% of those over 60 years old who have shingles, particularly if the trigeminal nerve was affected.

Complications:

immunosuppressed persons)



Call Your Healthcare Provider:
Call your health care provider if the symptoms indicate herpes zoster, particularly if you are immunosuppressed or if symptoms persist or worsen.


A classical pattern for shingles. The infection follows a nerve root from the spine, along a rib, to the front of the chest. The area innervated by the nerve is called a "dermatome".



This is a severe case of shingles (herpes zoster) on the back, side, and breast. The blisters (vesicles) appear along a nerve, in a distribution pattern called a dermatome (see the "dermatomes" picture).



Shingles are caused by the same virus that causes chickenpox. Outbreaks of shingles often follow the distribution of nerves in the skin. This distribution pattern, seen here on the back, is called a dermatome (see the "dermatomes" picture).



A close-up picture of herpes zoster skin lesions. Four small blisters (vesicles) are shown with red inflammation (erythema) around them. These vesicles will break, crust over, scab, and finally heal.



This illustration shows the distribution of dermatomes across the skin surface of a child. Knowing about these areas is helpful in understanding certain diseases, such as shingles and some other neurological conditions. The letter-number combinations show the relationship between the area shown in the illustration and the corresponding spinal sensory nerves. The vertebra are classified as C for cervical, T for thoracic, L for lumbar, and S for sacral.



This illustration shows the distribution of dermatomes across the skin surface of a child. Knowing about these areas is helpful in understanding certain diseases, such as shingles and some other neurological conditions. The letter-number combinations show the relationship between the area shown in the illustration and the corresponding spinal sensory nerves. The vertebra are classified as C for cervical, T for thoracic, L for lumbar, and S for sacral.



This is a picture of herpes zoster (shingles) on the arm. Shingles are caused by the same virus that causes chickenpox. Outbreaks of shingles follow the distribution of nerves in the skin. This distribution pattern, seen here on the arm, follows a dermatome (see the "dermatomes" picture).



This is a picture of herpes zoster (shingles) on the chest. Shingles are caused by the same virus that causes chickenpox. Outbreaks of shingles often follow the distribution of nerves in the skin. This distribution pattern is called a dermatome (see the "dermatomes" picture). The linear distribution of the nerve in the skin is very easily seen in this photograph.



This is a picture of herpes zoster (shingles) on the hand and fingers. Shingles are caused by the same virus that causes chickenpox. Outbreaks of shingles often follow the distribution of nerves in the skin. This distribution pattern is called a dermatome (see the "dermatomes" picture).



This is a picture of herpes zoster (shingles). Shingles are caused by the same virus that causes chickenpox. Outbreaks of shingles often follow the distribution of nerves in the skin. This distribution pattern, seen here on the chest, is called a dermatome (see the "dermatomes" picture).



This close-up photograph of herpes zoster (shingles) shows multiple blisters (vesicles) or groups of blisters on a red (erythematous) base. These blisters will rupture, leaving small, shallow ulcers behind.



This is a picture of herpes zoster (shingles) on the neck and cheek. Shingles are caused by the same virus that causes chickenpox. Outbreaks of shingles often follow the distribution of nerves in the skin. This distribution pattern is called a dermatome (see the "dermatomes" picture).



Shingles occurs more commonly on the chest and back (trunk), but can involve the extremities. The large blisters (vesicles) on this person's hand represent involvement of the dermatome innervated by the 7th cervical nerve (see the "Dermatomes" picture).



Herpes zoster (shingles) normally occurs in a limited area that follows a dermatome (see the "dermatome" picture). In individuals with damaged immune systems, herpes zoster may be widespread (disseminated), causing serious illness. Herpes zoster is caused by the same virus that causes chickenpox.



This photograph shows clusters of blisters (vesicles) and redness (erythema) caused by herpes zoster (shingles). The pattern follows a "dermatome" (see the dermatome picture). The area may burn or sting before the appearance of these vesicles. Early treatment with acyclovir (within 24 hours of the appearance of the vesicles) may prevent progression or reduce the time the infection is active (duration).