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A 14-year-old boy presents with deep burning pain and a vesicular eruption in a band starting at the left chest and ending just across the midline of the back (Figure 124-1). The varicella-zoster virus (VZV) leaves the dorsal root ganglion to travel down the spinal nerves to the cutaneous nerves of the skin. The vesicles do cross the midline by a few centimeters because the posterior primary ramus of the spinal nerve includes a small cutaneous medial branch that reaches across the midline.1 The boy was treated with analgesics and an antiviral medication. The zoster healed with scarring.

Figure 124-1

A 14-year-old boy with severe case of herpes zoster in a thoracic distribution. (Courtesy of Richard P. Usatine, MD.)

Herpes zoster (shingles) is a syndrome characterized by a painful, usually unilateral vesicular eruption that develops in a restricted dermatomal distribution (Figures 124-1 and 124-2).2,3

Figure 124-2

Close-up of herpes zoster lesions. Note grouped vesicles on a red base. (Courtesy of Richard P. Usatine, MD.)


  • According to the Centers for Disease Control and Prevention (CDC), 32% of persons in the United States will experience zoster during their lifetimes accounting for about 1 million cases annually.4 Older age groups account for the highest incidence of zoster. Approximately 4% of patients will experience a second episode of herpes zoster.5
  • More zoster cases have been observed among women, even when controlling for age.6
  • Herpes zoster occurs more frequently and more severely in immunosuppressed patients, including transplantation patients.

  • After primary infection with either chickenpox or vaccine-type VZV, a latent infection is established in the sensory dorsal root ganglia. Reactivation of this latent VZV infection results in herpes zoster (shingles).
  • Both sensory ganglia neurons and satellite cells surrounding the neurons serve as sites of VZV latent infection. During latency, the virus only expresses a small number of viral proteins.
  • How the virus emerges from latency is not clearly understood. Once reactivated, virus spreads to other cells within the ganglion. The dermatomal distribution of the rash corresponds to the sensory fields of the infected neurons within the specific ganglion.3
  • Loss of VZV-specific cell-mediated immune response is responsible for reactivation.3
  • The pain associated with zoster infections and postherpetic neuralgia (PHN) is thought to result from injury to the peripheral nerves and altered central nervous system processing.
  • The most common complications are PHN and bacterial superinfection that can delay healing and cause scarring of the zoster lesions.
  • Approximately 19% of patients develop complications that may include:7
    • PHN—The most common complication is seen in 10% at 90 days7 (see below).
    • Ocular complications, including uveitis and keratitis (seen in 4%)7 (see Chapter 125, Zoster Ophthalmicus).
    • Bell palsy and ...

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