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Herpes zoster infection

BMJ 2019; 364 doi: (Published 10 January 2019) Cite this as: BMJ 2019;364:k5095
  1. Phuc Le, assistant professor,
  2. Michael Rothberg, vice chair for research
  1. Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, USA
  1. Correspondence to Phuc Le lep{at}

What you need to know

  • A typical history for herpes zoster might include neuropathic pain for around three days followed by a vesicular rash in a dermatomal distribution

  • Consider treatment with an antiviral for those over 50, or with evidence of trigeminal nerve involvement (ideally within 72 hours of symptoms), and refer those who are immunocompromised and/or have eye involvement

  • The rash takes around two weeks to resolve and can scar

  • Post-herpetic neuralgia is the most common complication and is more likely in older people, where it can take six months or more to resolve

  • In some areas a new recombinant zoster vaccine has been licensed; there is variation in whether the new or previous vaccine is recommended

Herpes zoster is caused by reactivation of a primary infection with varicella zoster virus.1 After a primary infection, the virus lies dormant in dorsal root or cranial nerve ganglia. Reactivation causes the typical dermatomal pain and vesicular rash (fig 1).

Fig 1

Vesicular rash caused by herpes zoster

Varicella zoster (commonly known as chickenpox) and herpes zoster (commonly known as shingles) are caused by the same herpes virus. Varicella follows the initial infection and causes a generalised rash, whereas herpes zoster occurs after reactivation, years later, and symptoms are usually localised to a specific dermatome.

The overall annual incidence of herpes zoster in the UK is estimated to be 1.85-3.9 cases per 1000 population,2 increasing with age from fewer than two cases per 1000 among people under 50 to 11 cases per 1000 among people aged 80 or older. In the US, incidence ranges from 1.2 to 3.4 cases per 1000 person years, increasing with age to 3.9 to 11.8 cases per 1000 person years among people aged 65 or older.34

Who is at risk?

Over 90% of adults in the US have serological evidence of primary varicella …

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