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Herpes zoster (or simply zoster), commonly known as shingles and also known as zona, is a viral disease characterized by a painful skin rash with blisters in a limited area on one side of the body, often in a stripe. Varicella zoster virus can become latent in the nerve cell bodies and less frequently in non-neuronal satellite cells of dorsal root, cranial nerve or autonomic ganglion,[1] without causing any symptoms.[2] Years or decades after a chickenpox infection, the virus may break out of nerve cell bodies and travel down nerve axons to cause viral infection of the skin in the region of the nerve.
In most cases after 1–2 days, but sometimes as long as 3 weeks, the initial phase is followed by the appearance of the characteristic skin rash. Later the rash becomes vesicular, forming small blisters filled with a serous exudate, as the fever and general malaise continue. The causative agent for herpes zoster is varicella zoster virus (VZV), a double-stranded DNA virus related to the Herpes simplex virus group.
Unless the immune system is compromised, it suppresses reactivation of the virus and prevents herpes zoster.
If the rash has appeared, identifying this disease (making a differential diagnosis) requires only a visual examination, since very few diseases produce a rash in a dermatomal pattern (see map). When the rash is absent (early or late in the disease, or in the case of zoster sine herpete), herpes zoster can be difficult to diagnose.[22] Apart from the rash, most symptoms can occur also in other conditions. In a recent study, samples of lesions on the skin, eyes, and lung from 182 patients with presumed herpes simplex or herpes zoster were tested with real-time PCR or with viral culture. In the United Kingdom and other parts of Europe, population-based varicella immunization is not practised. A 2006 study of 243 cases and 483 matched controls found that fresh fruit is associated with a reduced risk of developing shingles–people who consumed less than one serving of fruit a day had a risk three times as great as those who consumed more than three servings, after adjusting for other factors such as total energy intake. The aims of treatment are to limit the severity and duration of pain, shorten the duration of a shingles episode, and reduce complications.
Antiviral drugs inhibit VZV replication and reduce the severity and duration of herpes zoster with minimal side effects, but do not reliably prevent postherpetic neuralgia. Orally administered corticosteroids are frequently used in treatment of the infection, despite clinical trials of this treatment being unconvincing. Treatment for herpes zoster ophthalmicus is similar to standard treatment for herpes zoster at other sites. The rash and pain usually subside within three to five weeks, but about one in five patients develops a painful condition called postherpetic neuralgia, which is often difficult to manage. Eye involvement - trigeminal nerve involvement (as seen in herpes ophthalmicus) should be treated early and aggressively as it may lead to blindness. Another important risk factor is immunocompromise: HIV is an important example of immune compromise[53][54]). Adults with latent VZV infection who are exposed intermittently to children with chickenpox receive an immune boost.[12][56] This periodic boost to the immune system helps to prevent shingles in older adults.
Multiple studies and surveillance data, at least when viewed superficially, demonstrate no consistent trends in incidence in the U.S.
In one study, it was estimated that 26% of patients who contract herpes zoster eventually present with complications. Herpes zoster has a long recorded history, although historical accounts fail to distinguish the blistering caused by VZV and those caused by smallpox,[16] ergotism, and erysipelas.
The first indications that chickenpox and herpes zoster were caused by the same virus were noticed at the beginning of the 20th century.
Until the 1940s, the disease was considered benign, and serious complications were thought to be very rare.[72] However, by 1942, it was recognized that herpes zoster was a more serious disease in adults than in children, and that it increased in frequency with advancing age. The family name of all the herpesviridae is derived from the Greek word herpein ("to creep"),[77] referring to the latent, recurring infections typical of this group of viruses.
Auricular perichondritis is an acute inflammation of the auricular cartilage and its perichondrium It may be due to:1-Infection in auriclar hematoma. Diffuse bacterial otits externa is a diffuse inflammation of the skin of the external auditory canal (EAC).
Herpes simplex virus infection of the presents with fever as in viral influenza and skin vesicles in the EAC and the drum which rupture & heal without scar formation. Bullous otitis externa presents with sudden severe ear pain and bloody or serosanguinous discharge which appears after rupture of the bulla. The same varicella-zoster virus that causes chickenpox also causes shingles, which involves only a segment of the skin. In a child with no antibodies to the chickenpox virus the virus travels to the whole skin surface causing the typical chickenpox lesions all over the body. Usually there is a prodromal stage where there is shooting pain in the skin dermatome, which will be breaking out later in the shingles rash. A) In ophthalmic herpes zoster (=herpes zoster ophthalmicus) one of the facial branches (ophthalmic, maxillary or mandibular branch of the trigeminal nerve) is affected.
B) Ramsey Hunt’s syndrome or herpes zoster oticus is due to invasion of the varicella-zoster virus of the 8th cranial nerve and a ganglion of the facial nerve. The diagnosis is mostly made clinically although in occasional cases special blood tests (ELISA titer) might have to be done to confirm the diagnosis. This involves that blood for serum is drawn early into the disease and at the time of complete recovery. Most of the time the prognosis is good meaning that the patient recovers without any consequences.
There has been a breakthrough with the introduction of acyclovir (brand name: Zovirax) with respect to the recovery time from shingles as well as with respect to the recovery from chickenpox. Often the overall time of disease is cut in half and complications such as postherpetic neuralgia or bacterial superinfection are diminished significantly. As mentioned above treatment of ophthalmic herpes zoster should be supervised by an ophthalmologist.
Treatment of herpes zoster oticus should be supervised by an ENT specialist, although there are not too many options for effective treatment.

In AIDS patients who developed herpes zoster ongoing antiviral suppression therapy must be considered as otherwise herpes zoster would reoccur repeatedly. This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor. The varicella zoster virus is a type of herpes simplex virus (HSV) but is not the same as the herpes simplex virus that causes genital herpes.
Herpes zoster is not a virus but a syndrome that arises with reactivation of the varicella zoster virus (VZV) years or even decades after chickenpox. Herpes zoster is the same as shingles, an alternative and commonly used name for this condition.
Herpes zoster is more likely to occur in a person with a depressed immune system and the elderly. Herpes zoster, commonly known as just zoster or shingles, is a condition caused by the reactivation of the varicella zoster virus (VZV). Shingles is the syndrome where a painful skin rash marked by the presence of tiny blisters usually forms on a dermarcated area on the skin surface of the head or trunk. Once the virus reactivates, it causes inflammation of the nerves and is therefore also known as acute posterior ganglionitis.
However, shingles often arises for no known reason even in a person without any of these contributing factors. The main symptoms of herpes zoster (shingles) is an itchy skin rash and pain which has been discussed in detail below. Herpes zoster mainly affects sensory nerves but motor nerves that control muscles may also be affected. Pain that lasts for longer than a month, even after the rash clears, is most likely a complication of shingles known as post-herpetic neuralgia.
All images have been sourced from the Dermatology Atlas (2) courtesy of Samuel Freire da Silva, M.D. Tricyclic antidepressants, anticonvulsants and corticosteroids along with anesthetics may be needed for post-herpetic neuralgia. Treatment should be commenced immediately once a diagnosis of shingles is made, preferably within the first few days of the onset of the rash. Zoster vaccine to prevent shingles and should be considered only for a person older than 60 years of age.
Please note that any information or feedback on this website is not intended to replace a consultation with a health care professional and will not constitute a medical diagnosis.
The initial infection with varicella zoster virus (VZV) causes the acute (short-lived) illness chickenpox which generally occurs in children and young people. The virus may spread from one or more ganglia along nerves of an affected segment and infect the corresponding dermatome (an area of skin supplied by one spinal nerve) causing a painful rash.[3][4] Although the rash usually heals within two to four weeks, some sufferers experience residual nerve pain for months or years, a condition called postherpetic neuralgia. The pain and rash most commonly occurs on the torso, but can appear on the face, eyes or other parts of the body. Herpes zoster ophthalmicus involves the orbit of the eye and occurs in approximately 10–25% of cases.
Most people are infected with this virus as children, and suffer from an episode of chickenpox.
The virus has not been recovered from human nerve cells by cell culture and the location and structure of the viral DNA is not known. Why this suppression sometimes fails is poorly understood,[6] but herpes zoster is more likely to occur in people whose immune system is impaired due to aging, immunosuppressive therapy, psychological stress, or other factors.[19] Upon reactivation, the virus replicates in the nerve cells, and virions are shed from the cells and carried down the axons to the area of skin served by that ganglion. This newly infected individual may then develop chickenpox, but will not immediately develop shingles. In this comparison, viral culture detected VZV with only a 14.3% sensitivity, although the test was highly specific (specificity=100%). Topical lotions containing calamine can be used on the rash or blisters and may be soothing. Of these drugs, acyclovir has been the standard treatment, but the new drugs valaciclovir and famciclovir demonstrate similar or superior efficacy and good safety and tolerability.[36] The drugs are used both as prophylaxis (for example in AIDS patients) and as therapy during the acute phase. Nevertheless, one trial studying immunocompetent patients older than 50 years of age with localized herpes zoster, suggested that administration of prednisone with aciclovir improved healing time and quality of life.[40] Upon one-month evaluation, aciclovir with prednisone increased the likelihood of crusting and healing of lesions by about twofold, when compared to placebo. In some patients, herpes zoster can reactivate presenting as zoster sine herpete: pain radiating along the path of a single spinal nerve (a dermatomal distribution), but without an accompanying rash.
When routine chickenpox vaccination was introduced in the US, the concern was that because older adults would no longer receive this natural, periodic boost, this would result in an increase in the incidence of shingles in the US.
It was only in the late eighteenth century that William Heberden established a way to differentiate between herpes zoster and smallpox,[69] and only in the late nineteenth century that herpes zoster was differentiated from erysipelas.
Physicians began to report that cases of herpes zoster were often followed by chickenpox in the younger people who lived with the shingles patients. Shingles is the popular term, in medical circles this condition is known as  herpes zoster.
In an adult who had prior exposure to the varicella-zoster virus there is a latent infection in the dorsal root ganglia of the spinal cord. Factors such as stress weakening the immune system (often in college or university students) or a weakened immune system due to AIDS or due to immunosuppression (in transplant patients or patients who had chemotherapy for cancer) can allow the varicella-zoster virus to migrate along the nerve fibers to the associated skin segment. Most often the patients get herpes zoster only once, only less than 4% of patients might get a recurrence of it.
If the ophthalmic branch is affected the varicella-zoster virus will often affect the cornea and there is a danger of corneal perforation. This causes severe pain in the ear, dizziness (vertigo), hearing loss and palsy of the affected facial nerve.
However, with ophthalmic herpes zoster not infrequently postherpetic neuralgia develops, which is a painful condition in the affected dermatome with chronic pain and exaggerated skin hypersensitivity.

Frequent examinations with a slit lamp and topical applications of antiviral eye drops in combination with oral antiviral therapy are essential.
After the active phase of the infection resolves, the virus stays dormant at the spinal nerve root, specifically the dorsal root ganglion.
It mainly affects the sensory nerves but can sometimes involve the motor nerves a€“ those nerves that control muscles in the body. These symptoms usually settle after 10 to 15 days but can take up to one month to resolve completely.
This gives rise to symptoms such as paralysis of the diaphragm, bladder and bowel problems, cranial nerve palsies and muscle weakness. A dermatome is an area of the skin which is innervated by nerves from a single spinal root. However, if the infection occurs in a vaccinated person it is usually less severe and shorter in duration. Once an episode of chickenpox has resolved, the virus is not eliminated from the body but can go on to cause shingles—an illness with very different symptoms—often many years after the initial infection. Virus-specific proteins continue to be made by the infected cells during the latent period, so true latency, as opposed to a chronic low-level infection, has not been proven.[2][17] Although VZV has been detected in autopsies of nervous tissue,[18] there are no methods to find dormant virus in the ganglia in living people. Antiviral treatment is recommended for all immunocompetent individuals with herpes zoster over 50 years old, preferably given within 72 hours of the appearance of the rash.[39] Complications in immunocompromised individuals with herpes zoster may be reduced with intravenous acyclovir. This trial also evaluated the effects of this drug combination on quality of life at one month, showing that patients had less pain, and were more likely to stop the use of analgesic agents, return to usual activities and have uninterrupted sleep.
This condition may involve complications that affect several levels of the nervous system and cause multiple cranial neuropathies, polyneuritis, myelitis, or aseptic meningitis.
The idea of an association between the two diseases gained strength when it was shown that lymph from a sufferer of herpes zoster could induce chickenpox in young volunteers. 3-Postoperative (in case of absence of antiseptic precaution or if stitches pass through cartilage) 4-Idiopathic. It is there where the disease breaks out and affects one dermatome on one side of the body. However, these patients warrant a thorough workup for cancer that might be hidden, but weaken the immune system.
An emergency assessment and treatment by an ophthalmologist is required to abort the disease. If the eye-specialist sees keratitis (involvement of the cornea of the eye) treatment with topical corticosteroid eye drops would be given. Antiviral antibiotics are also administered to shorten the overall duration of the disease. Shingles can affect any age group but is more commonly seen in the elderly and those with depressed immune defenses.
Although the peripheral nerves to the trunk is commonly affected, the virus may cause inflammation of any part of the nervous system, even the brain (encephalitis), meninges (meningitis) or both (meningoencephalitis). Herpes zoster is not the same disease as herpes simplex despite the name similarity (both the varicella zoster virus and herpes simplex virus belong to the same viral subfamily Alphaherpesvirinae).
In a few patients, symptoms may include conjunctivitis, keratitis, uveitis, and optic nerve palsies that can sometimes cause chronic ocular inflammation, loss of vision, and debilitating pain.[14] Herpes zoster oticus, also known as Ramsay Hunt syndrome type II, involves the ear.
However, when comparing cessation of herpes zoster-associated pain or post herpetic neuralgia, there was no difference between aciclovir plus prednisone and simply aciclovir alone. There is hypersensitivity to touch in the affected dermatome and multiple skin blisters (vesicles) appear in the same region. This is quite different from herpes simplex keratitis, where topical corticosteroids are contraindicated for fear of perforation of the cornea.
However, no evidence is available to show reliably that hearing loss or loss of tongue sensitivity would be improved by these therapeutic measures. The varicella zoster virus causes the common childhood infection known as chickenpox which resolves after a few weeks.
The virus targets certain nerves with symptoms such as the rash and pain being isolated to those areas of the skin supplied by a single spinal nerve.
It is thought to result from the virus spreading from the facial nerve to the vestibulocochlear nerve.
Most commonly it is in the skin of the lumbar and thoracic region that is affected and the rash is confined to one side. Signs of mild meningitis and encephalitis and involvement of other cranial nerves can be found associated with this. Decompression surgery to free the sensory branch of the facial nerve sometimes improves facial paralysis. However, the virus remains dormant for long periods of time in the body and may sometimes reactivate to cause inflammation of the nerve roots. Although shingles resolves within a month, it can sometimes lead to complications or the pain can persist for months thereafter (post-herpetic neuralgia).
Dizziness is treated symptomatically with diazepam, pain is treated with codeine or other narcotics. This does not happen in every person who had chickenpox and is more frequently seen in diminished immune states.
Vaccines provide an effective albeit not guaranteed protection against developing shingles.

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