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The varicella-zoster virus belongs to a group of herpes viruses that includes eight human viruses (it also includes animal viruses). All herpes viruses share some common properties, including a pattern of active symptoms followed by latent inactive periods that can last for months, years, or even a lifetime. People can also catch chickenpox from direct exposure to a shingles rash if they have not been immunized by vaccination or a previous bout of chickenpox.
A patient with chickenpox can transmit the disease from about 2 days before the appearance of the spots until the end of the blister stage. These drugs are used for patients who have undergone organ transplantation and are also used for severe autoimmune diseases caused by the inflammatory process.
Adults have the greatest risk for dying from chickenpox, with infants having the next highest risk. The major long-term complication of varicella is the later reactivation of the herpes zoster virus and the development of shingles. Itching, the most common complication of the varicella infection, can be very distressing, particularly for small children. Small scars may remain after the scabs have fallen off, but they usually clear up within a few months. Bacterial superinfection of the skin caused by group A streptococcus is the most common serious complication of chickenpox (but it is still rare). Pneumonia is suspected if coughing and abnormally rapid breathing develop in patients who have chickenpox.
Disseminated varicella, which develops when the virus spreads to organs in the body, is extremely serious and is a major problem for patients with compromised immune systems.
Reye syndrome, a disorder that causes sudden and dangerous liver and brain damage, is a side effect of aspirin therapy in children who have chickenpox or influenza. Other extremely rare complications of varicella include problems in blood clotting and inflammation of the nerves in the hands and feet. The pain and discomfort of the active herpes zoster infection is the primary symptom and complication of herpes zoster.
Allodynia is pain caused by factors, such as a light touch of clothing or a cold wind, which occurs from very little stimulation.
Postherpetic neuralgia (PHN) is pain that persists for longer than a month after the onset of herpes. The herpes zoster virus appears to produce persistent inflammation in the spinal cord that causes long-term damage, including nerve scarring.
Nerves that are injured in the initial attack may heal abnormally and provoke an exaggerated response in the brain that produces intense sensitivity or pain.
Guillain-Barre syndrome is caused by inflammation of the nerves and has been associated with a number of viruses, including herpes zoster. Sometimes, it is difficult to distinguish between Bell's palsy and Ramsay Hunt syndrome, particularly in the early stages.
Inflammation of the membrane around the brain (meningitis) or in the brain itself (encephalitis) is a rare complication in people with herpes zoster.
In rare situations, herpes zoster can infect the urinary tract and cause difficulty in urination. If shingles occurs in the face, the eyes are at risk, particularly if the path of the infection follows the side of the nose. As with disseminated chickenpox, disseminated herpes zoster, which spreads to other organs, can be serious to life-threatening, particularly if it affects the lungs. The older the patient, the higher the risk for complications from either chickenpox or shingles. Pregnant women who become infected with the varicella-zoster virus, whether in the form of chickenpox or shingles, are at increased risk for serious pneumonia. Chickenpox in the mother during early pregnancy poses a slightly increased risk for birth defects in the infant. The highest risk for birth defects is about 2%, which usually occurs if the mother has chickenpox between the 13th and 20th week.
The time between exposure to the virus and eruption of symptoms is called the incubation period.
Chickenpox itself usually occurs only once, although mild second infections, marked by the telltale rash, have been reported in older children years after their first infection. Pain is so common to all stages of herpes zoster that doctors often refer to all syndromes with a single term: Zoster-Associated Pain (ZAP). The prodrome stage lasts 1 - 5 days before the infection becomes active and the skin rash erupts. The rash that marks the active infection follows the same track of inflamed nerves as the prodrome pain. Postherpetic neuralgia (PHN) is pain that persists for longer than a month after the onset of herpes zoster. In the active rash stage, shingles may be confused with herpes simplex, particularly in young adults, if the blisters occur on the buttocks or around the mouth.
A diagnosis may be difficult if herpes zoster takes a non-typical course in the face, such as with Bell's palsy or Ramsay Hunt syndrome, or if it affects the eye or causes fever and delirium.
In most cases of chickenpox and shingles, the symptoms alone are enough for a health care provider to make a diagnosis. The live-virus varicella vaccine (Varivax) produces persistent immunity against chickenpox. The childhood chickenpox vaccine can also be given as part of a combination vaccine (Proquad) that combines measles, mumps, rubella (together called MMR), and varicella in one product. Children most at risk for having chickenpox after having been vaccinated only one time are ages 8 - 12 years and have generally been vaccinated at least 5 years before their current chickenpox infection. People whose immune systems are compromised by disease or drugs (such as after organ transplantation). Patients who cannot be vaccinated but who are exposed to chickenpox receive immune globulin antibodies against varicella virus. Varicella-zoster immune globulin (VariZIG) is a substance that mimics the normal immune response against the varicella-zoster virus.
For these patients, VariZIG should be given within 96 hours of exposure to someone with chickenpox. Acyclovir is an antiviral drug that may be used in adult varicella patients or those of any age with a high risk for complications and severe forms of chickenpox.
Adults may take aspirin or other nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil or other brands). Acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) are approved for shingles. Because herpes zoster tends to resolve fairly quickly in young adults, these drugs are more important for patients at greatest risk for complications or persistent pain. These drugs appear to have little or no harmful effect on healthy cells and can penetrate most body tissues, including cerebrospinal fluid. Possible side effects of nucleoside analogues include rash, headache, fatigue, tremor, nausea and vomiting. Oral corticosteroids, including prednisolone or prednisone, are powerful anti-inflammatory medications.
Unfortunately, tricyclics have side effects that are particularly severe in the elderly, who are also more likely to have PHN. Certain anticonvulsant drugs have effects that block over-excitation of nerve cells and may be helpful for PHN patient.
Side effects include skin rashes, mood swings or thoughts of suicide, headache, dizziness, sleepiness, swelling, and upset stomach.
Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP). Harpaz R, Ortega-Sanchez IR, Seward JF; Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). Nakanishi and colleagues3 studied a mouse model of infection with herpes simplex virus (HSV). Martin, MD, MPH, ABIM Board Certified in Internal Medicine and Hospice and Palliative Medicine, Atlanta, GA. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. When patients with chickenpox cough or sneeze, they expel tiny droplets that carry the virus. In many cases, the immune system has become impaired or suppressed from certain conditions such as AIDS, other immunodeficient diseases, or certain cancers or drugs that suppress the immune system. In such cases, transmission happens during the active phase when blisters have erupted but not formed dry crusts.
Shingles itself can develop only from a reactivation of the varicella-zoster virus in a person who has previously had chickenpox. Before the introduction of the vaccine, about 4 million cases of chickenpox were reported in the U.S.
Some require children to stay home until the skin has completely cleared, although this is not necessary to prevent transmission. Anyone who has had chickenpox has risk for shingles later in life, which means that 90% of adults in the U.S. The risk for herpes zoster increases as people age, and the overall number of cases will undoubtedly increase as the baby boomer generation gets older. People whose immune systems are impaired from diseases such as AIDS or childhood cancer have a risk for herpes zoster that is much higher than those with healthy immune systems.
Patients who take certain drugs that suppress the immune system are at risk for shingles (as well as other infections).
Such disorders include rheumatoid arthritis, systemic lupus erythematosus, diabetes, multiple sclerosis, Crohn's disease, and ulcerative colitis. Children with chickenpox are at much higher risk for this complication than adults are, possibly because they are more likely to scratch. The infection is usually mild, but if it spreads in deep muscle, fat, or in the blood, it can be life threatening.


Encephalitis and meningitis, infections or inflammation in the central nervous systems, have occurred in a few varicella patients, both children and adults.
Although stroke in children is extremely rare, a condition called cerebral vasculitis, in which blood vessels in the brain become inflamed, has been associated with varicella-zoster. An immune system may become compromised as a result of diseases such as AIDS, inherited conditions, or certain drugs. Inflammation can also occur in other areas of the body, such as the heart, testicles, liver, joints, or kidney. People who had prodromal symptoms or a severe attack (numerous blisters and severe pain) during the initial shingles episode are also at high risk for PHN.
Some doctors define persistent pain after a herpes zoster attack as subacute herpetic neuralgia if it lasts between 1 - 3 months and as PHN only if it lasts beyond 3 months.
Symptoms include severe ear pain and hearing loss, ringing in the ear, loss of taste, nausea, vomiting, and dizziness.
The condition is temporary but may require a catheter for patients who have trouble urinating. In such cases, visual changes develop within weeks or months after the herpes zoster outbreak has resolved. People with serious illnesses may be at risk for complications of the varicella-zoster virus. Although chickenpox can still be very dangerous in older infants, most are protected by antibodies in breast milk from mothers who have had chickenpox. DiagnosisBoth chickenpox (varicella) and shingles (zoster) can usually be diagnosed by symptoms alone.
Chickenpox, particularly in early stages, may be confused with herpes simplex (the disorder more commonly referred to as "herpes"), or impetigo, insect bites, and scabies. The early prodrome stage of shingles can cause severe pain on one side of the lower back, chest, or abdomen before the rash appears. If the symptoms are not straightforward in some patients, such as those who are immunosuppressed, the doctor performs one or more additional tests to detect the virus itself. A viral culture uses specimens taken from the blister, fluid in the blister, or sometimes spinal fluid.
Immunofluorescence is a diagnostic technique used to identify antibodies to a specific virus. Polymerase chain reaction (PCR) techniques use a piece of the DNA of the virus, which is then replicated millions of times until the virus is detectable. The vaccine can prevent chickenpox or reduce the severity of the illness if it is used within 3 days, and possibly up to 5 days, after exposure to the infection. However, recent data indicate that combining varicella and MMR vaccinations into one shot doubles the risk for febrile (fever-related) seizures in children ages 12 - 24 months compared to giving separate MMR and varicella injections. This second dose can be given at any time as long as it is at least 3 months after the first dose. Centers for Disease Control and Prevention (CDC) recommends that every healthy adult without a known history of chickenpox be vaccinated.
Fewer than 80% of vaccine recipients have pain, swelling, or redness at the injection site. The vaccine may produce a mild rash within about a month of the vaccination, which can transmit chickenpox to others.
Months or even years after the vaccination, some people develop a mild infection called modified varicella-like syndrome (MVLS). Patients with chickenpox do not have to stay in bed unless fever and flu symptoms are severe. Frequent baths are particularly helpful in relieving itching, when used with preparations of finely ground (colloidal) oatmeal.
Patients can apply calamine lotion and similar over-the-counter preparations to the blisters to help dry them out and soothe the skin.
Small children may have to wear mittens so that they don't scratch the blisters and cause a secondary infection.
The drug may also benefit smokers with chickenpox, who are at higher than normal risk for pneumonia.
Antiviral drugs (acyclovir and others), oral corticosteroids, or both are sometimes given to patients with severe symptoms, particularly if they are older and at risk for postherpetic neuralgia (PHN).
Cold compresses soaked in Burrow's solution (an OTC remedy) and cool baths may help relieve the blisters. In general, to prevent or reduce itching, home treatments are similar to those used for chickenpox. The best class of drugs developed against varicella-zoster are those known as nucleoside, or guanosine, analogues. Acyclovir is the oldest, most studied of these drugs, but either famciclovir (Famvir) or valacyclovir (Valtrex), which are both metabolized into acyclovir, are now preferred to treat herpes zoster in most patients because they require fewer daily doses than the five doses needed with acyclovir. They have some benefit for reducing pain in the first 2 weeks or so of an attack, when used with acyclovir or another nucleoside analogue. A patch that contains the anesthetic lidocaine (Lidoderm) is approved specifically for postherpetic neuralgia (PHN). Topical aspirin, known chemically as triethanolamine salicylate (Aspercreme), may bring relief.
Ethyl chloride (Chloroethane) and fluori-methane are chemicals that cool the blood vessels in the skin. These drugs not only relieve depression, which can be common in PHN sufferers, but certain tricyclics specifically block sodium channels, which play a role in causing pain in PHN.
Desipramine and nortriptyline have fewer side effects than amitriptyline and are preferred for older patients. Some people have visual disturbances, ringing in the ears, agitation, or odd movements when drug levels are at their peak.
Patients with severe pain that does not respond to tricyclic antidepressants may need powerful painkilling opioid drugs.
Researchers are investigating whether treatment with antiviral drugs may help reduce the pain associated with postherpetic neuralgia.
Certain surgical techniques in the brain or spinal cord attempt to block nerve centers associated with postherpetic neuralgia. A number of relaxation and stress-reduction techniques may be helpful for managing chronic pain.
Behavioral cognitive therapy is showing benefit in enhancing patients' beliefs in their own abilities for dealing with pain.
Prevention of varicella: recommendations for use of varicella vaccines in children, including a recommendation for a routine 2-dose varicella immunization schedule.
A new product (VariZIG) for postexposure prophylaxis of varicella available under an investigational new drug application expanded access protocol. Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. Physician attitudes regarding breakthrough varicella disease and a potential second dose of varicella vaccine. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). Improvement of postherpetic neuralgia after treatment with intravenous acyclovir followed by oral valacyclovir. Risk of herpes zoster in patients with rheumatoid arthritis treated with anti-TNF-alpha agents. They show that CD4+ helper T cells are required to promote entry of CD8+ cytotoxic lymphocytes (CTLs) into infected vaginal tissue. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites.
Researchers now know that they are both caused by a single virus of the herpes family, known as varicella-zoster virus (VZV).
If a person who has never had chickenpox or never been vaccinated inhales these particles, the virus enters the lungs. Chickenpox is extremely contagious, and can be spread by direct contact, droplet transmission, and airborne transmission. Risk FactorsThe varicella-zoster virus is responsible for both chickenpox and herpes zoster, but its method of infection is different in both diseases. In other words, shingles itself is never transmitted from one person to another either in the air or through direct exposure to the blisters.
One study estimated that a person who reaches age 85 has a 50% chance of having herpes zoster. At highest risk are those with Hodgkin's disease (13 - 15% of these patients develop shingles). Children who catch chickenpox from family members are likely to have a more severe case than if they caught it outside the home. However, people who have had mild infections may be at greater risk for a breakthrough infection later on. With this illness, the middle ear becomes red, swollen, and inflamed because of bacteria trapped in the eustachian tube.
Infection can cause serious conditions, such as necrotizing fasciitis (the so-called flesh-eating bacteria) and toxic shock syndrome (TSS). Pregnant women, smokers, and those with serious medical conditions are at higher risk for pneumonia if they have chickenpox.
Infection in the pregnant woman in the first trimester also poses a 1 - 2% chance for infecting the developing fetus, which is an extremely serious condition.
For example, disseminated varicella occurs in up to 35% of children with chickenpox who are undergoing cancer chemotherapy.
Symptoms include rash, vomiting, and confusion beginning about a week after the onset of the disease. People with impaired immune systems do not seem to be at any higher risk for persistent PHN than those with normal immune systems.
There is some indication that this syndrome may suggest a reactivation of herpes zoster, even if no rash appears.
In rare cases, particularly in patients with impaired immune systems, it can be severe and even life threatening. Although this complication usually follows a herpes outbreak in the face, it can occur after an outbreak in any part of the body. Patients with diseases, such as Hodgkin's disease, who receive bone marrow or stem cell transplants are at higher risk for herpes zoster and its complications.
More serious defects include a smaller than normal head, eye problems, low birth weight, and mental retardation.
The patient often develops fever, headache, swollen glands, and other flu-like symptoms before the typical rash appears.
They become larger within a few hours and spread quickly (sprout), eventually forming small blisters on a red base.


The pain may be experienced as sharp, aching, piercing, tearing, or similar to an electric shock. Healing takes even longer in patients who have impaired immune systems, and, in such cases, the blisters may last for months. Symptoms include burning or shooting pain, numbness, tingling, itching, headache, fever, chills, and nausea. If a diagnosis is still unclear after a physical examination, diagnostic tests may be required. It therefore may be mistaken for disorders, such as gallstones, that cause acute pain in internal organs. They are sent to a laboratory, where it takes 1 - 14 days to detect the virus in the preparation made from the specimen.
In the case of herpes zoster, the technique uses ultraviolet rays applied to a preparation composed of cells taken from the zoster blisters. Doctors pushed for the new second-dose policy due to a number of recent chickenpox outbreaks among previously vaccinated schoolchildren. These reactions include seizures, pneumonia, anaphylactic reaction, encephalitis, Stevens-Johnsons syndrome, neuropathy, herpes zoster, and blood abnormalities. Individuals who have recently been vaccinated should avoid close contact with anyone who might be susceptible to severe complications from chickenpox until the risk for a rash passes. The condition appears to be less contagious and has fewer complications than naturally acquired chickenpox. Study results suggest that the zoster vaccine can prevent about half of all shingles cases and two-thirds of postherpetic neuralgia cases. To relieve discomfort, a child can take acetaminophen (Tylenol), with doses determined by the doctor. Commercial preparations (Aveeno) are available in drugstores, or one can be made at home by grinding or blending dry oatmeal into a fine powder. Some doctors recommend its use for children who catch chickenpox from other family members because such patients are at risk for more serious cases. In addition, psychological therapies aimed at coping and reducing the effects of pain may be useful. Patients can try antihistamines (particularly Benadryl), oatmeal baths, and calamine lotion. The earlier they are given the more effective these drugs are, but they can be helpful even if treatment is started after 3 days. Patients with AIDS or other diseases that compromise the immune system are at increased risk for kidney damage and blood clots. It is used in cases of VZV strains that have become resistant to acyclovir and similar drugs. Sprays that contain these chemicals are not anesthetics, but they are used to inactivate the sensitive areas.
Nortriptyline (Pamelor, Aventyl), amitriptyline (Elavil, Endep), and desipramine (Norpramin) are standard drugs.
They do not work as well in patients who have burning pain or allodynia (pain that occurs with normally non-painful stimulus, such as a light touch or wind).
Side effects include dry mouth, blurred vision, constipation, dizziness, difficulty urinating, disturbances in heart rhythms, and an abrupt drop in blood pressure when standing up. Studies suggest significant pain relief in patients with PHN and reduction in the use of opioids.
These methods carry risk for permanent damage, however, and should be used only as a last resort when all other methods have failed and the pain is intolerable. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that it is a manageable experience. Please let us know about the age of the cat, breed, when any cat skin symptoms began, is the problem in one or both eyes, have the symptoms changed over time, is your cat primarily indoor or outdoor, the presence of other pets, changes in your cats routine, bathing routine, or anything else that will help us understand your cat's medical history, including any tests and results. The word herpes is derived from the Greek word "herpein," which means "to creep," a reference to a characteristic pattern of skin eruptions.
Symptoms range from fever, headache, stomach ache, or loss of appetite before breaking out in the classic pox rash.
Human herpes viruses include herpes simplex virus 1 (HSV-1), which causes cold sores, and herpes simplex virus 2 (HSV-2), which causes genital herpes.
It is so contagious that few nonimmunized people escape this common disease when they are exposed to someone else with the disease.
Shingles occurs, however, in 10 - 20% of these adults over the course of their lives, so certain factors must exist to increase the risk for such outbreaks.
The risk for postherpetic neuralgia (PHN) is also highest in older people with the infection and increases dramatically after age 50. Certain drugs used for HIV, called protease inhibitors, may also increase the risk for herpes zoster.
About 7 - 9% of patients with lymphomas, and 1 - 3% of patients with other cancers, have herpes zoster. Children with no immune problems but who had chickenpox before they were 1 year old also have a higher risk for shingles. Possible ComplicationsChickenpox (varicella) rarely causes complications, but it is not always harmless. Because of the strong warnings against children taking aspirin, this condition is, fortunately, very rare.
Unfortunately, when PHN is severe and treatments have not been very effective, the persistent pain and abnormal sensations can be profoundly frustrating and depressing for patients. Prompt treatment with acyclovir can often halt its progress, at least in people with healthy immune systems.
It is also sometimes used in vaccinated patients to determine if a varicella-like infection is caused by a natural virus or by the vaccine.
The specific characteristics of the light as seen through a microscope will identify the presence of the antibodies. The CDC recommends that all adults age 60 years and older who have intact immune systems should receive this vaccine. A child should never be given aspirin, or medications containing aspirin, as aspirin increases the risk for a dangerous condition called Reye syndrome.
None of these drugs can actually destroy the virus and cure the disease, but they can significantly reduce the severity of the attack, hasten healing, and reduce the duration. Patients with suppressed immune systems are also more likely to have viral resistance to these drugs.
Corticosteroids do not appear to prevent a further shingles attack or reduce the risk for PHN.
In general, however gabapentin is safer than tricyclic antidepressants for elderly patients. These techniques may apply to patients with severe pain from acute infection or persistent long-term postherpetic neuralgia. There are two types of herpes simplex virus; HSV1, which causes infections of the nose, mouth and face, and HSV2, which infects the genitals. The rash can consist of several hundred small, itchy, fluid-filled blisters over red spots on the skin. Cytomegalovirus (CMV), which causes mononucleosis and retinitis, and Epstein-Barre Virus (EBV), another cause of mononucleosis, are also human herpes viruses. Pneumonia that is caused by varicella can result in lung scarring, which may impair oxygen exchange over the following weeks, or even months. Rarely, however, the pain of herpes zoster affects sleep, mood, work, and overall quality of life. Severity of hearing loss varies from partial to total; however, this too usually always goes away. Either acyclovir or valacyclovir, a similar drug, may prevent other eye complications, such as conjunctivitis (pink eye), inflammation of the cornea, and pain. If the face is affected, there is a danger that the infection can spread to the eye or mouth.
Some evidence suggests that some cases of Bell's palsy (in which part of the face becomes paralyzed) might actually be an indication of zoster sine herpete. Patients should wear loose clothing and use clean loose gauze coverings over the affected areas. Side effects of corticosteroids can be severe, and patients should take oral steroids at as low a dose, and for as short a time, as possible. Patients should not use capsaicin until the blisters have completely dried out and are falling off the skin.
Gabapentin is also showing promise in combination with valacyclovir for reducing pain from an acute herpes zoster attack. Studies suggest it might be very helpful for PHN patients, particularly those with heart problems or other conditions that restrict tricyclic antidepressants. There is no cure for the herpes simplex infection, but symptomatic outbreaks can be treated with the antiviral drug acyclovir (trade name Zovirax). Fortunately, since the introduction of the vaccine in 1995, hospitalizations have declined by nearly 90%, and there have been few fatal cases of chickenpox. Acetaminophen (Tylenol) is the preferred drug for fever or pain in patients younger than age 18 years. This can lead to fatigue, loss of appetite, depression, social withdrawal, and impaired daily functioning. A rash that follows the side of the nose is a warning that the cornea of the eye is in danger.
The vaccine does not appear to not work well in patients age 80 years and older and is generally not recommended for this age group. They should handle capsaicin ointment using a glove, and apply it to affected areas three or four times daily. Any duplication or distribution of the information contained herein is strictly prohibited. Please include information such as breed, age, sex, history, changes in behavior, products used etc.We will try and respond as quickly as possible.
The patient will usually feel a burning sensation when the drug is first applied, but this sensation diminishes with use. Once PHN develops, a patient may need a multidisciplinary approach that involves a pain specialist, psychiatrist, primary care physician, and other health care providers. It may take up to 6 weeks for the patient to feel the ointment's full effect, and about a third of patients cannot tolerate the burning sensation.
Usually separate crops of blisters occur over 4 - 7 days, the entire disease process lasting 7 - 10 days.



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