Herpes Zoster (Shingles)

Herpes Zoster (Shingles) is a topic covered in the 5-Minute Clinical Consult.

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  • Results from reactivation of latent varicella-zoster virus (VZV) (human herpesvirus type 3) infection
  • Postherpetic neuralgia (PHN) is defined as pain persisting at least 1 month after rash has healed. The term zoster-associated pain is more clinically useful.
  • Usually presents as a painful unilateral vesicular eruption with a dermatomal distribution
  • System(s) affected: nervous; integumentary; exocrine
  • Synonym(s): shingles


  • Incidence increases with age—2/3 of cases occur in adults age ≥50 years. Incidence is increasing overall as the U.S. population ages.
  • Herpes zoster: 4/1,000 person-years
  • PHN: 18% in adult patients with herpes zoster; 33% in patients ≥79 years of age
  • Individual lifetime risk of 30% in the United States

~1 million new cases of herpes zoster annually in the United States

Pregnancy Considerations
May occur during pregnancy

Geriatric Considerations
  • Increased incidence of zoster outbreaks
  • Increased incidence of PHN
Pediatric Considerations
  • Occurs less frequently in children
  • Has been reported in newborns infected in utero

Etiology and Pathophysiology

Reactivation of VZV from dorsal root/cranial nerve ganglia. Upon reactivation, the virus replicates within neuronal cell bodies, and virions are carried along axons to dermatomal skin zones, causing local inflammation and vesicle formation.

Risk Factors

  • Increasing age
  • Immunosuppression (malignancy or chemotherapy)
  • Physical trauma
  • Female
  • HIV infection
  • Spinal surgery

General Prevention

  • Herpes zoster vaccination (Shingrix) is approved and recommended by the CDC for adults 50 years and older (1).
  • Shingrix is recommended for adults who previously received Zostavax and is the preferred vaccine.
  • Live VZV vaccine (Zostavax) (recommended for >60 years) is contraindicated in immunosuppressed persons, patients with HIV and CD4 counts <200, patients undergoing cancer treatment, and patients with hematologic or lymphatic (1,2).
  • Patients with active zoster may transmit disease-causing varicella virus—typically through direct contact.

Commonly Associated Conditions

Immunocompromised states, HIV infection, posttransplantation, immunosuppressive drugs, and malignancy

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