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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

  • Varicella (chickenpox)

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

    • Occurs typically in children

    • Incubation period is 10–20 days (average 2 weeks)

  • Herpes zoster (shingles) occurs more commonly in elderly or immunocompromised persons

  • Populations at increased risk for varicella-zoster–related diseases include immunosuppressed persons and persons receiving biologic agents


  • Incidence and severity of herpes zoster

    • Affects up to 25% of persons during their lifetime

    • Increases with age due to an age-related decline in immunity against varicella-zoster virus (VZV)

    • More than half of all patients in whom herpes zoster develops are older than 60 years

    • Incidence of herpes zoster reaches 10 cases per 1000 patient-years by age 80 (by which time 50% are infected with VZV)

    • The annual incidence in the United States is 1 million cases and increasing as the population ages

Clinical Findings

Symptoms and Signs

Varicella (chickenpox)

  • Fever and malaise mild in children, marked in adults

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

  • Maculopapules change within a few hours to vesicles that become pustular and eventually form crusts

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

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

  • The crusts slough in 7–14 days, with slightly serrated borders

  • Pitted scars are frequent

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 (Ramsay Hunt syndrome or herpes zoster oticus)


  • Because both infections have characteristic clinical signs, diagnostic testing is usually not necessary

Laboratory Tests

Varicella (chickenpox)

  • Leukopenia often present

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

Herpes zoster (shingles)

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


  • VariZIG reduces the severity of varicella in high-risk children or adults (eg, those ...

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