Herpes zoster

Last Updated: 2022-03-11

Author(s): Anzengruber F., Navarini A.

ICD11: -


Contagious, segmentally arranged skin disease, which is caused by reactivation of VZV in the spinal and cranial nerve ganglia

Lifetime prevalence: 20%.

  • Incubation period: 1-2 weeks
  • Predisposing factors:
    • Immune suppression
    • Stress
    • Older age

Herpetiform, grouped, segmentally arranged blisters on an erythematous base. In the course of the disease, the blisters burst and crusts form. If there are no more blisters, the patient is no longer classified as infectious. In some cases, there is pain, allodynia, itching, reduced general condition and, rarely, fever.

  • Clinical appearance
  • Tzanck test: swab with cotton swab from the base of the vesicle (press firmly)
    • Smear onto a microscope slide, stain with methylene blue
  • PCR
    • Swab with cotton swab from base of bubble (press firmly). Place cotton swab in virus medium, leave for 15 sec, then remove swab

Unilateral on the body. Mostly thoracic dermatome, second most common in trigeminal area.

Rarely also other localisations, e.g. genital.

  • Postzoster neuralgia
  • CNS involvement of the zoster
  • Pyogenic infections
  • Herpetic keratitis in V.1 infestation

Shingrix vaccination recommended, Zostavax is far less effective.

Vaccination also recommended after clinical course of herpes zoster. Recurrences occur in 6% after zoster, of which approx. 50% occur at the same site.

  • Light protection
  • Contact with pregnant women or young children should be avoided if possible
  • In young patients, exclusion of immunosuppression (especially HIV) is useful
  • Need-oriented analgesic therapy
  • Pain therapy, therapy of postzosteric neuralgia (step-by-step scheme)
    • 1st stage NSAIDs (e.g. ibuprofen, max. 2.4g/d) or paracetamol max. 4d/d
    • 2nd stage additionally weak opioid analgesics (e.g. tramadol 200-400mg/d)
    • 3rd stage (in addition to stage 1) strong opioid analgesics (e.g. oxycodone)
    • 4th stage (in addition to stage 1 or 2) anticonvulsants (e.g. gabapentin max. 3.6g/d), pregabalin max. 600mg/d or antidepressants (e.g. amitriptyline max. 150mg/d); presentation in the pain consultation


  • Therapy
    • 1st line: Valacyclovir, Brivudin, Acyclovir, Famciclovir
    • 2nd line: Pain therapy incl. topical lidocaine patch
    • 3rd line: Adult immunisation, steroids, capsaiscin


Systemic therapy

  • Absolute indications for systemic treatment, ideally within the first 72 hours after infection:
    • Age > 50 years.
    • Extratruncal infestation
    • Moderate or severe pain
    • Extensive local findings
    • Immune suppression
    • Involvement of internal organs
    • Early initiation
    • is essential for any antiviral therapy
    • Start therapy 72 h after the onset of skin symptoms or 72 h after the onset of skin symptoms when new vesicles are formed. In addition, there is an increased risk of secondary bacterial infection




  • Valaciclovir
    • Add.: 1000 mg 3x/d for 7d
    • CI: hypersensitivity, lactation
    • ADVERSE REACTIONS (common): headache, nausea
    • CAVE:
      • Adjustment of dosage in impaired renal function
      • Hydration state


  • Brivudine (tbl.)
    • Administer: 125 mg 1x/d for 7 days
    • WW: 5-fluorouracil preparations (at least 4 weeks apart)
    • NWM (common): nausea
    • KI: 5-fluorouracil- therapy, pregnancy, lactation, hypersensitivity to ingredient, not tested in children and adolescents


  • Aciclovir
    • Administer: 3x 5mg/kg daily i.v. or 5x 800mg/d p.o.;  in immunosuppressed patients 10mg/kg daily i.v.
    • CI: Hypersensitivity, lactation (since transfer to breast milk)
    • ADVERSE REACTIONS (very common): headache, nausea
    • CAVE:
      • In elderly patients, there is an increased risk for the occurrence of reversible neurological disorders
      • Adjust dosage if renal function is impaired
      • Enough fluid intake


  • Famciclovir
    • Application: 500 mg 2x/d
    • In pat. >50, 500mg 3x/d can/should be given
    • to prevent zoster neuralgia
    • Independent of meals
    • Interactions: Probenecid
    • CI: Pregnancy, lactation, hypersensitivity to famciclovir or penciclovir
    • CAVE:
      • In patients at risk of dehydration, especially elderly patients, adequate hydration should be ensured
      • Efficacy may be reduced in black patients


  • Foscarnet
    • In immunosuppression and aciclovir resistance
    • Administration: 3 x 40 mg/kg bw/d i.v.
    • KI: hypersensitivity, pregnancy, lactation
    • Side effects (very common): granulocytopenia, anorexia, hypokalaemia, hypomagnesaemia, hypocalcaemia, paraesthesias, headache, dizziness, nausea, vomiting, diarrhoea, rash, increased serum creatinine, fever, fatigue, chills, asthenia
    • CAVE:
      • Adjust dosage if renal function is impaired
      • Enough fluid intake


  • Systemic glucocorticoids
    Note: Although systemic glucocorticoids are sometimes used, the data supporting this strategy are rather weak. Although studies have been conducted that showed a positive effect of glucocorticoids with regard to quality of life and a reduction in cases with postzoster neuralgia, these data could not be confirmed in a meta-analysis.


  • Topical therapy
    • Tanning agents / Lsg. several times a day


  1. Beutner, K.R., et al., Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrobial Agents and Chemotherapy, 1995. 39(7): p. 1546-1553.
  2. Chanan-Khan, A., et al., Analysis of Herpes Zoster Events Among Bortezomib-Treated Patients in the Phase III APEX Study. Journal of Clinical Oncology, 2008. 26(29): p. 4784-4790.
  3. Doan, K., K. Stoler, and K. Logan, Herpes Zoster of the Third Division of the Trigeminal Nerve. A Clinical Pathologic Conference. N Y State Dent J, 2015. 81(6): p. 50-4.
  4. Domingo, P., et al., Herpes zoster as an immune reconstitution disease after initiation of combination antiretroviral therapy in patients with human immunodeficiency virus type-1 infection. The American Journal of Medicine, 2001. 110(8): p. 605-609.
  5. Dworkin, R.H., et al., A randomized, placebo-controlled trial of oxycodone and of gabapentin for acute pain in herpes zoster. Pain, 2009. 142(3): p. 209-217.
  6. Glesby, M.J., R.D. Moore, and R.E. Chaisson, Clinical Spectrum of Herpes Zoster in Adults Infected with Human Immunodeficiency Virus. Clinical Infectious Diseases, 1995. 21(2): p. 370-375.
  7. Gnann, J.W. and R.J. Whitley, Herpes Zoster. New England Journal of Medicine, 2002. 347(5): p. 340-346.
  8. Gross, G., et al., Herpes zoster guideline11Established by an Expert Group on the occasion of a symposium on ‘Zoster and Zoster pain’ held on 9th December 2000 in Rostock (Germany) consisting of H. Schöfer, Frankfurt a. M.; S. Wassilew, Krefeld (Dermatology and Venereology); K. Friese (Gynaecology and Obstetrics); H.W. Pau (Otorhinolaryngology); A. Timm, R. Guthoff (Ophthalmology); A. Wree (Anatomy), Rostock; J.P. Malin (Neurology), Bochum; H.W. Doerr, Frankfurt a. M., (Virology); P. Wutzler, Jena, (Virology); under the leadership of G. Gross, Rostock (Dermatology and Venereology). of the German Dermatology Society (DDG). Journal of Clinical Virology, 2003. 26(3): p. 277-289.
  9. Helgason, S., Prevalence of postherpetic neuralgia after a first episode of herpes zoster: prospective study with long term follow up. BMJ, 2000. 321(7264): p. 794-794.
  10. Hicks, L.D., et al., Family History as a Risk Factor for Herpes Zoster. Arch Dermatol, 2008. 144(5).
  11. Ibanez, J.P., et al., Sirolimus in chronic allograft nephropathy in pediatric recipients. Pediatr Transplant, 2007. 11(7): p. 777-80.
  12. Lapolla, W., Incidence of Postherpetic Neuralgia After Combination Treatment With Gabapentin and Valacyclovir in Patients With Acute Herpes Zoster. Arch Dermatol, 2011. 147(8): p. 901.
  13. Lin, H.C., C.W. Chien, and J.D. Ho, Herpes zoster ophthalmicus and the risk of stroke: A population-based follow-up study. Neurology, 2010. 74(10): p. 792-797.
  14. Mahler, V. and G. Schuler, Therapie von Varizella-Zoster- und Herpes-simplex-Virus-bedingten Erkrankungen. Der Hautarzt, 2001. 52(5): p. 464-473.
  15. Martinez, E., et al., High Incidence of Herpes Zoster in Patients with AIDS Soon After Therapy with Protease Inhibitors. Clinical Infectious Diseases, 1998. 27(6): p. 1510-1513.
  16. Mehta, Satish K., et al., VaricellaZoster Virus in the Saliva of Patients with Herpes Zoster. The Journal of Infectious Diseases, 2008. 197(5): p. 654-657.
  17. Oaklander, A.L., et al., Herpes zoster itch: preliminary epidemiologic data. The Journal of Pain, 2003. 4(6): p. 338-343.
  18. Oxman, M.N., et al., A Vaccine to Prevent Herpes Zoster and Postherpetic Neuralgia in Older Adults. New England Journal of Medicine, 2005. 352(22): p. 2271-2284.
  19. Oxman, M.N., et al., A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med, 2005. 352(22): p. 2271-84.
  20. Ragozzino, M.W., et al., Population-Based Study of Herpes Zoster and Its Sequelae. Medicine, 1982. 61(5): p. 310-316.
  21. Rappersberger, K., Infections with herpes simplex and varicella-zoster virus in pregnancy: clinical manifestations in the mother, fetus and newborn – therapeutic options. Hautarzt, 1999. 50(10): p. 706.
  22. Requena, et al., Cutaneous reactions at sites of herpes zoster scars: an expanded spectrum. Br J Dermatol, 1998. 138(1): p. 161-168.
  23. Satyaprakash, Anita K., et al., Viremia in Acute Herpes Zoster. The Journal of Infectious Diseases, 2009. 200(1): p. 26-32.
  24. Sauerbrei, A. and P. Wutzler, Herpes simplex and varicella-zoster virus infections during pregnancy: current concepts of prevention, diagnosis and therapy. Part 2: Varicella-zoster virus infections. Med Microbiol Immunol, 2006. 196(2): p. 95-102.
  25. Schmader, K.E., et al., Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years. Clin Infect Dis, 2012. 54(7): p. 922-8.
  26. Simberkoff, M.S., Safety of Herpes Zoster Vaccine in the Shingles Prevention Study. Annals of Internal Medicine, 2010. 152(9): p. 545.
  27. Tseng, H.F., Herpes Zoster Vaccine in Older Adults and the Risk of Subsequent Herpes Zoster Disease. JAMA, 2011. 305(2): p. 160.
  28. Tyring, S., et al., A Randomized, Double-Blind Trial of Famciclovir Versus Acyclovir for the Treatment of Localized Dermatomal Herpes Zoster in Immunocompromised Patients. Cancer Investigation, 2001. 19(1): p. 13-22.
  29. Tyring, S.K., Antiviral Therapy for Herpes Zoster: Randomized, Controlled Clinical Trial of Valacyclovir and Famciclovir Therapy in Immunocompetent Patients 50 Years and Older. Archives of Family Medicine, 2000. 9(9): p. 863-869.
  30. Wassilew, S.W., Brivudin compared with famciclovir in the treatment of herpes zoster: effects in acute disease and chronic pain in immunocompetent patients. A randomized, double-blind, multinational study. Journal of the European Academy of Dermatology and Venereology, 2005. 19(1): p. 47-55.
  31. Wauters, O., E. Lebas, and A.F. Nikkels, Chronic mucocutaneous herpes simplex virus and varicella zoster virus infections. Journal of the American Academy of Dermatology, 2012. 66(6): p. e217-e227.
  32. Weiss, H., et al., Acyclovir with and without prednisone for the treatment of herpes zoster: a randomized, placebo-controlled trial. American Journal of Ophthalmology, 1997. 123(5): p. 723.
  33. Whitley, R.J., Acyclovir with and without Prednisone for the Treatment of Herpes Zoster. Annals of Internal Medicine, 1996. 125(5): p. 376.
  34. Wood, M.J., et al., A Randomized Trial of Acyclovir for 7 Days or 21 Days with and without Prednisolone for Treatment of Acute Herpes Zoster. New England Journal of Medicine, 1994. 330(13): p. 896-900.
  35. Wutzler, P., Antiviral Therapy of Herpes simplex and Varicella-zoster Virus Infections. Intervirology, 1997. 40(5-6): p. 343-356.
  36. Wutzler, P., et al., Oral brivudin vs. intravenous acyclovir in the treatment of herpes zoster in immunocompromised patients: A randomized double-blind trial. J. Med. Virol., 1995. 46(3): p. 252-257.
  37. Yoshikawa, T.T. and K. Schmader, Herpes Zoster in Older Adults. Clinical Infectious Diseases, 2001. 32(10): p. 1481-1486.