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For further information, see CMDT Part 32-01: Human Herpesviruses

Key Features

Essentials of Diagnosis

  • Varicella rash: pruritic, centrifugal, papular, changing to vesicular ("dewdrops on a rose petal"), pustular, and finally crusting

  • Zoster rash: tingling, pain, eruption of vesicles in a dermatomal distribution, evolving to pustules and then crusting

General Considerations

  • Chickenpox is spread by inhalation of infective droplets or by contact with skin lesions


  • Disease manifestations include

    • Chickenpox (varicella), which occurs typically in children

    • Shingles (zoster), which occurs more commonly in elderly or immunocompromised persons

Clinical Findings

Symptoms and Signs

Varicella (chickenpox)

  • Fever and malaise mild in children, marked in adults

  • Vesicular eruptions often first involve oropharynx

  • Rash involves face, scalp, and trunk and then moves out to the extremities

  • Lesions erupt over 1–5 days so all stages of eruption present simultaneously

  • Vesicles and pustules are superficial, elliptical, with slightly serrated borders

  • Multinucleated giant cells on Tzanck smear of materials from vesicle bases

Herpes zoster (shingles)

  • Pain is often severe and precedes the lesions

  • Lesions follow any nerve route distribution (thoracic and lumbar most common)

  • Vesicular skin lesions resemble varicella

  • Lesions on tip of nose, inner corner of eye, and root and side of nose (Hutchinson sign) indicate potential ophthalmic involvement

  • Facial palsy, vertigo, tinnitus, deafness, or external ear lesions suggest geniculate ganglion involvement

  • Associations between recent attacks of zoster and the development of multiple sclerosis and Guillain Barré syndrome are recognized

Differential Diagnosis

Varicella (chickenpox)

  • Herpes simplex (cold or fever sore; genital herpes)

  • Herpes zoster (shingles)

  • Contact dermatitis

  • Scabies

  • Atopic dermatitis (eczema) (acute)

  • Miliaria (heat rash)

  • Photodermatitis

  • Smallpox

  • Rickettsialpox

  • Hand, foot, and mouth disease

Herpes zoster (shingles)

  • Contact dermatitis (eg, poison oak or ivy)

  • Herpes simplex

  • Varicella (chickenpox)

  • Erysipelas

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


Laboratory Tests

  • Leukopenia often present in varicella

  • Zoster symptoms and signs often highly characteristic, not requiring further diagnostic testing

  • When diagnosis remains in doubt, direct fluorescent antibody (DFA) testing, viral culture, and polymerase chain reaction (PCR) testing can be helpful

Diagnostic Findings

  • Most patients with a history of exposure and clinical symptoms and signs of varicella do not need further diagnostic testing


  • VariZIG reduces the severity of varicella in high-risk children or adults (eg, those with impaired immunity, pregnant women, and infants exposed peripartum) if given within 4 days of exposure



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