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Key Features

Essentials of Diagnosis

  • Dermatomal pain followed by painful grouped vesicular lesions

  • Involvement is unilateral; some lesions (fewer than 20) may occur outside the affected dermatome

  • Lesions are usually on trunk or face

  • Direct fluorescent antibody positive, especially of fluid from vesicular lesions

General Considerations

  • An acute vesicular eruption due to the varicella-zoster virus

  • Usually occurs in adults

  • With rare exceptions, patients suffer only one attack

  • Dermatomal herpes zoster does not imply the presence of a visceral malignancy

  • Generalized disease, however, raises the suspicion of an associated immunosuppressive disorder such as HIV infection

  • Early (within 72 h after onset) and aggressive antiviral treatment of herpes zoster reduces the severity and duration of postherpetic neuralgia


  • HIV-infected patients are 20 times more likely to develop zoster, often before other clinical findings of HIV disease are present

Clinical Findings

Symptoms and Signs

  • Pain usually precedes the eruption by 48 h or more and may persist and actually increase in intensity after the lesions have disappeared (post-herpetic neuralgia)

  • Zoster lesions consist of grouped, tense, deep-seated vesicles distributed unilaterally along a dermatome ("shingles")

  • The most common distributions are on the trunk or face

  • Up to 20 lesions may be found outside the affected dermatomes, even in immunocompetent persons

  • Regional lymph nodes may be tender and swollen

Differential Diagnosis

  • Contact dermatitis (eg, poison oak or ivy)

  • Herpes simplex virus, type 1 or 2, infection

  • Erysipelas

  • Prodromal pain mimics angina pectoris, peptic ulcer, appendicitis, biliary or renal colic


  • Clinical, including obtaining a history of HIV risk factors

Laboratory Testing

  • HIV testing should be considered when appropriate, especially in zoster patients under 55 years of age



Table 6–2.Useful topical dermatologic therapeutic agents.

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