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Herpes Zoster Infection

  1. What is herpes zoster infection?
  2. Symptoms
  3. Causes
  4. Diagnosis
  5. Prevention
  6. Treatment
  7. FAQ
  8. Other names for herpes zoster infection

What is herpes zoster infection?

Herpes zoster infection, often known as shingles, is a common viral infection. Around one in three people in the United States will develop shingles in their lives, with 1 million cases in the country each year.[1]

Shingles is caused by the chickenpox virus – the varicella zoster virus – which remains dormant in the body after a person has had chickenpox. It can reactivate years later and cause new symptoms.[2]

Herpes zoster infection is more likely to affect older people and people with a weak immune system. It causes a burning pain, followed by a blistering rash, which tends to only affect one area of the body.

Shingles is treated with antiviral medications. The rash will usually begin to get better within two weeks, and although most people recover well, some may be left with persistent pain in the affected area. Effective pain management from the early stages is therefore very important.

People with shingles should avoid contact with people who have not been vaccinated against chickenpox and people who have a weakened immune system.

Symptoms of herpes zoster infection

The first sign of herpes zoster infection is often a painful sensation in one area of the body. The pain is commonly described as:[3][4]l

  • Burning
  • Stabbing
  • Itching
  • Tingling
  • Numbness

The most commonly known symptom of shingles is the rash. Where the rash appears will depend on what part of the body the herpes zoster virus has been dormant in. The rash appears on the dermatome[5] associated with the affected nerve. The rash is most common on the chest, back, shoulders or face. Pain and the accompanying rash can occur anywhere on the body, depending on which nerve is affected by the infection.

Between one and five days after the pain begins, a rash will develop in the same area:[2][3][4]

  • The rash is vesicular; vesicles are small, blister-like sacs that appear on the surface of the skin
  • The skin around the vesicular rash becomes red
  • The rash is generally confined to one area of the body in a stripe-like pattern; usually one side of the body or, in some cases, the face. In immunosuppressed people the rash may be more widespread
  • The rash blisters burst and scab over, usually seven to 10 days after first appearing
  • The rash generally goes away after two to four weeks

Most people will only experience shingles once, though less than 4 percent will have another episode.[2]

For more information, see the resource about signs and symptoms of shingles.

Complications of herpes zoster infection

Shingles can cause complications if it affects the eye and the ear. It can also cause long lasting pain even after the rash has gone.

Herpes zoster ophthalmicus

Herpes zoster ophthalmicus, or ophthalmic shingles, is a variant of shingles where the virus affects the ophthalmic nerve and eye. If not treated quickly, it has the potential to cause permanent vision problems.

For more information, see the resource on herpes zoster ophthalmicus.

Herpes zoster oticus

Herpes zoster oticus, or Ramsay Hunt syndrome, occurs when the herpes zoster virus affects facial nerves. It is a rare form of shingles that causes pain deep within the ear and facial palsy as well as the rash. With treatment, most people will recover full use of facial nerves.[6]

Postherpetic neuralgia

Some people infected with herpes zoster will continue to feel pain in the affected areas of the body. Pain that persists for three months or longer is called postherpetic neuralgia (PHN).[2]

Postherpetic neuralgia pain is caused by damage to nerves during the shingles infection. It is more common in older people, rising to 20 percent of people 80 years and older experiencing PHN after shingles.[7]

Symptoms and effects of postherpetic neuralgia include:

  • Sharp pain
  • Intermittent or constant pain
  • Allodynia, which is pain caused by light touches or the feel of clothing on skin
  • Difficulty sleeping

The experience of living with PHN may bring on clinical depression.

Causes of herpes zoster infection

People at risk of developing shingles are those who have had chickenpox in the past. Herpes zoster infection occurs years, often decades, after a person has been infected with the varicella zoster virus that causes chickenpox.

The virus remains dormant in the body in the ganglia[^7] of the sensory cranial nerves[8] and spinal dorsal root[9]. If a person’s immunity to varicella zoster weakens over time, either due to age or if a person is immunosuppressed, the virus can reactivate. This reactivation is called herpes zoster infection, or shingles.[7]

Conditions and situations that can suppress the immune system and make someone more at risk of developing shingles include:[10]

  • HIV/AIDS
  • Receiving chemotherapy
  • Diabetes
  • Having the spleen removed
  • Hypogammaglobulinemia, a condition where the body does not make enough antibodies

Diagnosis of herpes zoster infection

A diagnosis can usually be made based on the symptoms and the appearance of the rash. If there is uncertainty, the diagnosis can be confirmed with blood tests or by taking a sample of fluid from a blister and testing for the virus.

Prevention of herpes zoster infection

People who have shingles should keep away from people who have not been vaccinated against chickenpox, especially newborns, and people who have a weak immune system. Although shingles itself cannot be passed from person to person, the varicella zoster virus which causes chickenpox can be transmitted by contact with the fluid in the rash blisters.[11]

Vaccination for herpes zoster infection

Vaccination against chickenpox (the varicella vaccination) and herpes zoster (a herpes zoster vaccination) can help to prevent and reduce the severity of some cases of shingles.

The Centers for Disease Control recommends that all healthy adults aged 50 and older should receive a shingles vaccine. Depending on the age of the person receiving the vaccine, it is between 89 and 97 percent effective at preventing shingles and postherpetic neuralgia.[12]

Treatment of herpes zoster infection

Herpes zoster infection is usually treated with antiviral medication in people who are immunocompetent[13]. These drugs helps shorten the duration and lessen the severity of shingles by easing the associated pain and promoting healing of the blisters. Medication should be taken as soon as possible after the rash appears.[14]

Drugs often prescribed include:[15][16][17][18]

  • Acyclovir: taken orally, acyclovir has been the traditional antiviral for use in shingles treatment. However, other drugs have been developed which can be taken less frequently and are better absorbed by the body
  • Famciclovir: taken orally, famciclovir converts to the compound penciclovir which is effective against the varicella zoster virus
  • Valacyclovir: taken orally, valacyclovir treats pain and itching and helps sores to heal while preventing new sores forming

Common side effects of these drugs can include:[16][17][18]

  • Headache
  • Nausea
  • Vomiting
  • Upset stomach
  • Diarrhea
  • Constipation
  • Tiredness
  • Painful menstruation

Some doctors may prescribe steroid tablets to reduce swelling and itching, but this is not recommended in most cases. Anti-inflammatory medications, such as ibuprofen, or other analgesics, may also help to reduce the pain and swelling.

People with shingles should try to avoid scratching at the rash. Calamine lotion and wet compresses can help soothe the itching.

Treatment of herpes zoster infection in the immunosuppressed

People whose immune systems are compromised are more likely to experience complications from shingles, which can include:[19][20]

  • The rash spreading across the body
  • Infection of the lesions, usually due to Staphylococcus aureus
  • Pneumonia
  • Encephalitis
  • Blindness
  • Deafness caused by herpes zoster oticus

It is even more important to treat immunosuppressed people with antiviral drugs to limit complications, potentially requiring hospitalization to administer drugs intravenously. The antiviral drugs are the same as those given to immunocompetent people.

Treatment of postherpetic neuralgia

Early prescription of painkillers to people with herpes zoster infection is advised to try and prevent the development of postherpetic neuralgia. Types of painkiller prescribed may include:

  • Ibuprofen
  • Paracetamol (acetaminophen)
  • Tramadol
  • Oxycodone
  • Morphine

If postherpetic neuralgia develops, it can be treated with:[7]

  • Topical creams, such as lidocaine and capsaicin, to ease pain and allodynia in particular
  • Antidepressants, such as tricyclics or selective serotonin and norepinephrine reuptake inhibitors to relieve pain and counter effects of clinical depression
  • Anticonvulsants, such as pregabalin or gabapentin, to relieve neuropathic pain

FAQs for herpes zoster infection

Q: Is herpes zoster contagious?
A: Herpes zoster itself is not contagious. However, it is possible for someone with shingles to pass on the varicella virus that causes chickenpox through contact with fluid from the rash blisters.

Other names for herpes zoster infection

  • Shingles

  1. Centers for Disease Control and Prevention. “Shingles (Herpes Zoster).” October 2017. Accessed May 15, 2018.

  2. MSD Manual: Professional Version. “Herpes Zoster.” February 2018. Accessed May 15, 2018.

  3. BMJ Best Practice. “Herpes zoster infection.” April 2018. Accessed May 15, 2018.

  4. Centers for Disease Control and Prevention. “Shingles: Signs & Symptoms.” January 2018. Accessed May 15, 2018.

  5. Dermatome: the area of skin supplied by a nerve.

  6. Patient Info. “Herpes Zoster Oticus.” September 2015. Accessed June 19, 2018.

  7. US National Library of Medicine. “Herpes Zoster (Shingles) and Postherpetic Neuralgia.” March 2009. Accessed May 15, 2018. [^7] Ganglia: a cluster of nerve cells.

  8. Sensory cranial nerves: the nerves in the head which are responsible for sensations such as sight and smell.

  9. Spinal dorsal root: there are 31 pairs of spinal nerves along the vertebrae. The dorsal roots contain sensory fibers.

  10. MedlinePlus. “Immunodeficiency disorders.” March 2016. Accessed May 15, 2018.

  11. Centers for Disease Control and Prevention. “Shingles: Transmission.” January 2018. Accessed May 15, 2018.

  12. Centers for Disease Control and Prevention. “Shingles Vaccination.” January 2018. Accessed May 15, 2018.

  13. Immunocompetent: a person with a normal immune system.

  14. Centers for Disease Control and Prevention. “Shingles: Prevention & Treatment.” January 2018. Accessed May 15, 2018.

  15. UpToDate. “Treatment of herpes zoster in the immunocompetent host.” April 2018. Accessed May 15, 2018.

  16. MedlinePlus. “Acyclovir.” June 2017. Accessed May 15, 2018.

  17. MedlinePlus. “Famciclovir.” December 2017. Accessed May 15, 2018.

  18. MedlinePlus. “Valacyclovir.” February 2018. Accessed May 15, 2018.

  19. Centers for Disease Control and Prevention. “Shingles: Complications.” January 2018. Accessed May 15, 2018.

  20. MedlinePlus. “Herpes zoster (shingles) disseminated.” September 2017. Accessed May 15, 2018.