Last updated: November 27, 2023

Summarytoggle arrow icon

Shingles (herpes zoster) is a dermatomal rash with painful blistering that is caused by the reactivation of the varicella-zoster virus (VZV). The initial infection with VZV usually occurs early in life, presenting as chickenpox (varicella), after which the virus remains dormant in the dorsal root ganglia. Immunocompromised individuals are at increased risk of VZV reactivation. Shingles is generally a clinical diagnosis, although further testing (e.g., PCR) may be indicated in unclear cases. Treatment with antiviral drugs, such as acyclovir, is usually effective. Potential complications include encephalitis and, particularly in the elderly population, painful postherpetic neuralgia. VZV may also affect the cranial nerves. Involvement of the trigeminal nerve may cause visual impairment up to blindness (herpes zoster opthalmicus), while involvement of the facial and vestibulocochlear nerves can cause facial paralysis and hearing loss (herpes zoster oticus). These presentations, in particular, require urgent medical attention to prevent serious complications. The recombinant zoster vaccine is recommended for the prevention of herpes zoster in all individuals ≥ 50 years of age and immunocompromised individuals ≥ 19 years of age.

Epidemiologytoggle arrow icon

  • Incidence [1]
    • Overall: 2.5–4/1,000 per year in the US [2]
    • Among individuals ≥ 60 years old: 10/1,000 per year in the US
    • Incidence of recurrence: unknown
  • Prevalence: increasing among adults in the US [1][3]
  • Sex: > [2]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Pathophysiologytoggle arrow icon

Clinical featurestoggle arrow icon

Subtypes and variantstoggle arrow icon

Herpes zoster ophthalmicus (HZO) [9]

Herpes zoster oticus [13]

Herpes zoster, herpes zoster oticus, and herpes zoster ophthalmicus present with identical rashes.

Diagnosticstoggle arrow icon

Clinical presentation is usually sufficient for a diagnosis. [10][14]

Treatmenttoggle arrow icon

Approach [10][14][16]

Patients seeking care for suspected shingles should be placed on both airborne precautions and contact precautions to prevent transmission to other at-risk individuals (e.g., VZV-naive or immunocompromised individuals) until all lesions have crusted over. [17]

Antiviral therapy for herpes zoster [10][14][16]

Antiviral therapy speeds up the resolution of lesions, reduces viral shedding, reduces the formation of new lesions, and decreases pain. It is most effective if administered within approx. 72 hours or while new lesions are erupting.

Antiviral therapy should be initiated as early as possible since the effectiveness of antiviral treatment decreases as the disease progresses.

Anti-inflammatory and analgesic therapy [10][14][19]

Pain control is vital to maintain patients' quality of life and prevent postherpetic neuralgia.

Corticosteroids [10]

Admission criteria and consultations [10]

Acute management checklisttoggle arrow icon

Complicationstoggle arrow icon

Postherpetic neuralgia [14][20][21]

Herpes zoster encephalitis [10]

Additional complications [10]

We list the most important complications. The selection is not exhaustive.

Preventiontoggle arrow icon

Routine chickenpox immunization and shingles vaccination (see also “Immunization schedule”) are recommended for all eligible individuals. [23][24]

Shingles vaccination [24][25]

  • General principles
    • Consists of 2 doses of recombinant zoster vaccine (RZV) administered 2–6 months apart [24][25]
    • At-risk individuals should begin an RZV immunization series regardless of previous shingles outbreak or vaccination. [24]
  • Indications
  • Special considerations
    • Avoid vaccination of patients with active herpes zoster infection until symptoms improve. [24]
    • Consider deferring vaccination in pregnant individuals until after delivery. [27]

RZV is different from the varicella vaccine and should not be administered for the prevention of chickenpox. [24]

Screening for evidence of immunity to varicella is not routinely required prior to shingles vaccination. [28]

Referencestoggle arrow icon

  1. Sampathkumar P, Drage LA, Martin DP. Herpes Zoster (Shingles) and Postherpetic Neuralgia. Mayo Clinic Proceedings. 2009; 84 (3): p.274-280.doi: 10.4065/84.3.274 . | Open in Read by QxMD
  2. Cohen JI. Herpes Zoster. N Engl J Med. 2013; 369 (3): p.255-263.doi: 10.1056/nejmcp1302674 . | Open in Read by QxMD
  3. Shin BS, Na CH, Song IG, Choi KC. A case of human immunodeficiency virus infection initially presented with disseminated herpes zoster.. Annals of dermatology. 2010; 22 (2): p.199-202.doi: 10.5021/ad.2010.22.2.199 . | Open in Read by QxMD
  4. Dado D, Chernev I. Gastrointestinal varicella zoster infection. Dissemination or reactivation of a latent virus in the gut?. Endoscopy. 2013; 45 (08): p.678-678.doi: 10.1055/s-0032-1326632 . | Open in Read by QxMD
  5. Mohsen AH, McKendrick M. Varicella pneumonia in adults. European Respiratory Journal. 2003; 21 (5): p.886-891.doi: 10.1183/09031936.03.00103202 . | Open in Read by QxMD
  6. LIESEGANG T. Herpes Zoster OphthalmicusNatural History, Risk Factors, Clinical Presentation, and Morbidity. Ophthalmology. 2008; 115 (2): p.S3-S12.doi: 10.1016/j.ophtha.2007.10.009 . | Open in Read by QxMD
  7. Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the Management of Herpes Zoster. Clinical Infectious Diseases. 2007; 44 (Supplement_1): p.S1-S26.doi: 10.1086/510206 . | Open in Read by QxMD
  8. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  9. Tuft S. How to manage herpes zoster ophthalmicus. Community Eye Health. 2020; 33 (108): p.71-72.
  10. Gondivkar S, Parikh V, Parikh R. Herpes zoster oticus: A rare clinical entity. Contemporary Clinical Dentistry. 2010; 1 (2): p.127-9.doi: 10.4103/0976-237X.68588 . | Open in Read by QxMD
  11. Saguil A, Kane S, Mercado M, Lauters R. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management.. Am Fam Physician. 2017; 96 (10): p.656-663.
  12. Laboratory Testing for VZV. . Accessed: January 26, 2020.
  13. Sauerbrei A. Diagnosis, antiviral therapy, and prophylaxis of varicella-zoster virus infections. European Journal of Clinical Microbiology & Infectious Diseases. 2016; 35 (5): p.723-734.doi: 10.1007/s10096-016-2605-0 . | Open in Read by QxMD
  14. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. 2007; 35 (10): p.S65-S164.doi: 10.1016/j.ajic.2007.10.007 . | Open in Read by QxMD
  15. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Updated: August 18, 2020. Accessed: December 18, 2020.
  16. Bates D, Schultheis BC, Hanes MC, et al. A Comprehensive Algorithm for Management of Neuropathic Pain. Pain Medicine. 2019; 20 (Supplement_1): p.S2-S12.doi: 10.1093/pm/pnz075 . | Open in Read by QxMD
  17. Harpaz R, Ortega-Sanchez IR, Seward JF, Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC).. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP).. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports. 2008; 57 (RR-5): p.1-30; quiz CE2-4.
  18. Johnson RW, Rice ASC. Postherpetic Neuralgia. N Engl J Med. 2014; 371 (16): p.1526-1533.doi: 10.1056/nejmcp1403062 . | Open in Read by QxMD
  19. Nagel MA, Bubak AN. Varicella Zoster Virus Vasculopathy.. J Infect Dis. 2018; 218 (suppl_2): p.S107-S112.doi: 10.1093/infdis/jiy425 . | Open in Read by QxMD
  20. AAP Committee on Infectious Diseases. Red Book: 2021–2024 Report of the Committee on Infectious Diseases. American Academy of Pediatrics ; 2021
  21. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018; 67 (3): p.103-108.doi: 10.15585/mmwr.mm6703a5 . | Open in Read by QxMD
  22. Anderson TC, Masters NB, Guo A, et al. Use of Recombinant Zoster Vaccine in Immunocompromised Adults Aged ≥19 Years: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep. 2022; 71 (3): p.80-84.doi: 10.15585/mmwr.mm7103a2 . | Open in Read by QxMD
  23. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV: 2021 update. Updated: June 22, 2021. Accessed: August 18, 2021.
  24. Adult Immunization Schedule by Medical Condition and Other Indication. Updated: August 1, 2022. Accessed: August 24, 2022.
  25. Berger S, Kunerl A, Wasmuth S, Tierno P, Wagner K, Brügger J. Menstrual toxic shock syndrome: case report and systematic review of the literature. Lancet Infect Dis. 2019; 19 (9): p.e313-e321.doi: 10.1016/s1473-3099(19)30041-6 . | Open in Read by QxMD
  26. Shingles (Herpes Zoster). Updated: August 19, 2016. Accessed: December 28, 2016.
  27. Opstelten W, Van Essen GA, Schellevis F, Verheij TJM, Moons KGM. Gender as an Independent Risk Factor for Herpes Zoster: A Population-Based Prospective Study. Ann Epidemiol. 2006; 16 (9): p.692-695.doi: 10.1016/j.annepidem.2005.12.002 . | Open in Read by QxMD
  28. Leung J, Harpaz R, Molinari N-A, Jumaan A, Zhou F. Herpes Zoster Incidence Among Insured Persons in the United States, 1993–2006: Evaluation of Impact of Varicella Vaccination. Clinical Infectious Diseases. 2011; 52 (3): p.332-340.doi: 10.1093/cid/ciq077 . | Open in Read by QxMD

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