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Clinical Summary

Zoster (shingles) represents a reactivation of latent VZV and has been noted as early as the 1st week of life in infants born to mothers who contracted varicella during pregnancy. The lesions present as clustered vesicles or bullae in a dermatomal distribution. The pain of acute neuritis occurs in 75% of patients with herpes zoster. Prodromal pain can be constant or intermittent and burning or stabbing and can precede the lesions by days to weeks. Sometimes pain can persist beyond 1 month after the lesions have disappeared (known as postherpetic neuralgia).

The diagnosis is usually made clinically; however, tissue polymerase chain reaction, cultures, direct fluorescent antibodies, and Tzanck smears can be done from vesicle scrapings for confirmation. Impetigo and cutaneous burns may mimic the appearance of herpetic vesicles. Varicella (chickenpox) is more diffusely spread, although a small crop of lesions may mimic zoster. Zoster also may be confused with herpes simplex virus (HSV) infection, although a close examination should reveal a dermatomal distribution in zoster.

FIGURE 14.34

Herpes Zoster. Vesicles in a classic thoracic dermatomal distribution are seen in this child. (Photo contributor: Frank Birinyi, MD.)

Management and Disposition

Currently, acyclovir (800 mg orally five times per day for 7-10 days initiated within 72 hours of the onset of the rash in children ≥ 12 years) is the treatment of choice for zoster infections in immunocompetent children. Pain relief and prevention of secondary infection are also important. IV antiviral therapy is recommended for immunocompromised patients.


  1. Zoster can occur in children of all ages.

  2. The most common sites for the development of zoster lesions are those supplied by the trigeminal nerve and the thoracic ganglia.

  3. A patient with zoster can transmit chickenpox (varicella) to a nonimmune child or adult.

  4. Herpes zoster ophthalmicus is a sight-threatening condition that presents with hyperesthesia in the effected eye. Vesicular lesions on the nose (Hutchinson sign) are associated with an increased risk of eye involvement.

FIGURE 14.35

Herpes Zoster. Vesicles in a trigeminal nerve distribution. (Photo contributor: Anne W. Lucky, MD.)

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