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Learning Objectives

  • To understand the impact of aging on the incidence of herpes zoster and postherpetic neuralgia (PHN).

  • To recognize typical and atypical presentations of herpes zoster in older adults.

  • To know when to order microbiological testing for the diagnosis of herpes zoster and what tests to order.

  • To employ the appropriate use of different treatments for the management of herpes zoster and PHN.

  • To summarize Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC), recommendations for the use of the zoster vaccine.

Key Clinical Points

  1. All cases of herpes zoster are caused by the reactivation of endogenous varicella-zoster virus (VZV) from latent infection of dorsal sensory or cranial nerve ganglia and not by exogenous transmission of VZV from an individual with herpes zoster or varicella.

  2. Increasing age and impaired cellular immunity are the strongest risk factors for herpes zoster; other risk factors include white race, female sex, psychological stress, and physical trauma.

  3. Increasing age is the strongest risk factor for postherpetic neuralgia (PHN); other risk factors include the presence of prodromal pain, severe pain during the acute phase of herpes zoster, and greater rash severity.

  4. Although the diagnosis can be made on clinical grounds in the majority of cases with a typical dermatomal vesicular rash and pain, laboratory diagnostic testing is indicated when differentiating herpes zoster from HSV, for suspected organ involvement, and for atypical presentations, particularly in the immunocompromised host; polymerase chain reaction (PCR) of vesicular fluid is the preferred diagnostic test.

  5. The goal of the treatment of herpes zoster in older adults is to decrease the length of the acute attack and to reduce pain by the use of early antiviral therapy (acyclovir, famciclovir, valacyclovir), scheduled analgesia, and if the pain is not adequately controlled, adjunctive agents.

  6. Lidocaine patch 5%, gabapentin, pregabalin, opioids, and tricyclic antidepressants constitute first-line therapies for the management of PHN.

  7. Zoster vaccine is recommended for all immunocompetent adults 60 years of age and older by ACIP for the prevention of herpes zoster and PHN.


Herpes zoster is a neurocutaneous disease that is caused by the reactivation of varicella-zoster virus (VZV) from a latent infection of dorsal sensory or cranial nerve ganglia following primary infection with VZV earlier in life. Herpes zoster is characterized by unilateral, dermatomal pain and rash. Postherpetic neuralgia (PHN) is pain 90 or more days after rash onset.


VZV Transmission

Varicella-zoster virus is a double-stranded DNA herpesvirus that is transmitted from person to person via direct contact or airborne or droplet nuclei when a virus-naive individual is exposed to the vesicular rash of varicella or herpes zoster. These exposed individuals may then develop varicella. Health care workers and staff in nursing homes and hospitals and children who have not received the varicella vaccine may not have had VZV primary infection ...

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