Skip to main content

Herpes Zoster (Shingles)

Edwin Y. Choi, MD, Lea S. Choi, DO and Shane L. Larson, MD Reviewed 06/2019

Send Email

Recipient(s) will receive an email with a link to 'Herpes Zoster (Shingles)' and will have access to the topic for 7 days.

Subject: Herpes Zoster (Shingles)

(Optional message may have a maximum of 1000 characters.)




  • Results from reactivation of latent varicella-zoster virus (VZV) (human herpesvirus type 3) infection

  • Postherpetic neuralgia (PHN) is defined as pain persisting at least 1 month after rash has healed. The term zoster-associated pain is more clinically useful.

  • Usually presents as a painful unilateral vesicular eruption with a dermatomal distribution

  • System(s) affected: nervous; integumentary; exocrine

  • Synonym(s): shingles



  • Incidence increases with age—2/3 of cases occur in adults age ≥50 years. Incidence is increasing overall as the U.S. population ages.

  • Herpes zoster: 4/1,000 person-years

  • PHN: 18% in adult patients with herpes zoster; 33% in patients ≥79 years of age

  • Individual lifetime risk of 30% in the United States


~1 million new cases of herpes zoster annually in the United States 
Pregnancy Considerations

May occur during pregnancy

Geriatric Considerations
  • Increased incidence of zoster outbreaks

  • Increased incidence of PHN

Pediatric Considerations
  • Occurs less frequently in children

  • Has been reported in newborns infected in utero



Reactivation of VZV from dorsal root/cranial nerve ganglia. Upon reactivation, the virus replicates within neuronal cell bodies, and virions are carried along axons to dermatomal skin zones, causing local inflammation and vesicle formation. 


  • Increasing age

  • Immunosuppression (malignancy or chemotherapy)

  • Physical trauma

  • Female

  • HIV infection

  • Spinal surgery


  • Herpes zoster vaccination (Shingrix) is approved and recommended by the CDC for adults 50 years and older (1).

  • Shingrix is recommended for adults who previously received Zostavax and is the preferred vaccine.

  • Live VZV vaccine (Zostavax) (recommended for >60 years) is contraindicated in immunosuppressed persons, patients with HIV and CD4 counts <200, patients undergoing cancer treatment, and patients with hematologic or lymphatic (1),(2).

  • Patients with active zoster may transmit disease-causing varicella virus—typically through direct contact.


Immunocompromised states, HIV infection, posttransplantation, immunosuppressive drugs, and malignancy 



  • Prodromal phase (sensory changes over involved dermatome prior to rash)

    • Tingling, paresthesias

    • Itching

    • Boring “knife-like” pain

    • Allodynia and hyperalgesia

  • Acute phase

    • Constitutional symptoms (e.g., fatigue, malaise, headache, low-grade fever) are variable.

    • Dermatomal rash


  • Acute phase

    • Rash: initially erythematous and maculopapular; evolves to characteristic grouped vesicles usually in one dermatome but may affect two to three adjacent dermatomes

    • Thoracic and lumbar dermatomes are most commonly involved sites (2).

    • Vesicles become pustular and/or hemorrhagic in 3 to 4 days.

    • Weakness in distribution of rash (1%)

    • Rash crusts and resolves by 14 to 21 days.

  • Possible sine herpete (zoster without rash) and other chronic disorders associated with VZV without the typical rash

    • Herpes zoster ophthalmicus (HZO). Vesicles on tip of the nose (Hutchinson sign) indicate involvement of the external branch of cranial nerve V; associated with increased incidence of HZO

  • Chronic phase

    • PHN is the most common complication (15% overall; increases with age).

    • 1–5% of cases may affect the motor nerves, causing weakness (zoster motorius), facial nerve (e.g., Ramsay Hunt syndrome), spinal motor radiculopathies.

    • Lesions usually heal 2 to 4 weeks after onset, but scarring and pigmentation changes are common (2).


  • Herpes simplex virus

  • Coxsackievirus

  • Contact dermatitis

  • Superficial pyoderma


Initial Tests (lab, imaging)

Rarely necessary. Clinical appearance is distinct. 

Follow-Up Tests & Special Considerations

  • Viral culture

  • Tzanck smear (does not distinguish from herpes simplex, and false-negative results occur)

  • Polymerase chain reaction

  • Immunofluorescent antigen staining

  • Varicella-zoster–specific IgM

Test Interpretation

  • Multinucleated giant cells with intralesional inclusion

  • Lymphatic infiltration of sensory ganglia with focal hemorrhage and nerve cell destruction



  • Treat to control symptoms and prevent complications.

  • Antiviral therapy decreases viral replication; lessens inflammation, nerve damage; and reduces the severity and duration of long-term pain.

  • Prompt analgesia may shorten the duration of zoster-associated pain.

  • Calamine and colloidal oatmeal may help reduce itching and burning.


First Line

  • Acute treatment

    • Antiviral agents initiated within 72 hours of skin lesions help relieve symptoms, speed resolution, and prevent or mitigate PHN (3)[A].

    • Antivirals do not significantly reduce the incidence of PHN (4)[A].

    • Valacyclovir: 1,000 mg PO TID for 7 days

    • Famciclovir: 500 mg PO TID for 7 days

    • Acyclovir: 800 mg q4h (5 doses daily) for 7 days

    • In children, oral acyclovir is the drug of choice.

  • Analgesics (acetaminophen, NSAIDs)

  • Corticosteroids do not prevent PHN but may accelerate resolution of acute neuritis.

    • Tricyclic antidepressants (TCAs); amitriptyline 10 to 25 mg at bedtime and other low-dose TCAs relieve pain acutely and may reduce pain duration; dose may be titrated up to 75 to 150 mg/day as tolerated.

    • Lidocaine patch 5% (Lidoderm) applied over painful areas (limit three patches simultaneously or trim a single patch) for up to 12 hours may be effective.

    • Gabapentin: 300 to 600 mg TID for pain; limited by adverse effects

    • Capsaicin cream and other analgesics may be useful adjuncts. Use opioids sparingly.

    • Capsaicin 8% patch or plaster provides pain relief for patients with PHN (5)[C]; better tolerated when initially applied with topical anesthetic

    • Pregabalin: 150 to 300 mg/day divided BID or TID reduces pain; use is limited by side effects.

  • Prevention of PHN and zoster-associated pain: Nothing prevents PHN entirely, but treatment may shorten duration and/or reduce severity.

    • Antiviral therapy with valacyclovir, famciclovir, or acyclovir given during acute skin eruption may decrease the duration of pain.

    • Low-dose amitriptyline (25 mg at bedtime) started within 72 hours of rash onset and continued for 90 days may reduce PHN incidence/duration.

    • Paravertebral blockade: Nerve blocks during the acute phase shorten the duration of pain; somatic blocks, paravertebral blocks, and repeated/continuous epidural blocks can be used to prevent PHN (6)[A].

    • Insufficient evidence to suggest that corticosteroids reduce incidence, severity, or duration of PHN

  • Precautions

Second Line

Numerous therapies have been advocated, but supporting evidence to routinely recommend is lacking. 


Cupping therapy (traditional Chinese medicine) shows potential benefit, but evidence is conflicting. 


  • Outpatient treatment, unless disseminated or occurring as complication of serious underlying disease requiring hospitalization

  • Consultation with ophthalmology for ophthalmic involvement (VZO).



Refer to ophthalmology if concern that ophthalmic branch of the trigeminal nerve is involved. 

Patient Monitoring

Follow duration of symptoms—particularly PHN. Consider hospitalization if symptoms are severe; patients are immunocompromised; >2 dermatomes are involved; serious bacterial superinfection, disseminated zoster, or meningoencephalitis develops. 


No special diet 


  • The rash typically lasts 2 to 3 weeks.

  • Encourage good hygiene and proper skin care.

  • Warn of potential for dissemination (dissemination must be suspected with constitutional illness signs and/or spreading rash).

  • Warn of potential PHN.

  • Warn of potential risk of transmitting illness (chickenpox) to susceptible persons.

  • Seek medical attention if any eye involvement.


  • Immunocompetent individuals should experience spontaneous and complete recovery within a few weeks.

  • Acute rash typically resolves within 14 to 21 days.

  • PHN may occur in patients despite antiviral treatment.


  • PHN

  • HZO: 10–20%

  • Superinfection of skin lesions

  • Meningoencephalitis

  • Disseminated zoster

  • Hepatitis; pneumonitis; myelitis

  • Cranial and peripheral nerve palsies

  • Acute retinal necrosis


Centers for Disease Control and Prevention. Shingles (herpes zoster). Accessed October 18, 2018. Accessed October 18, 2018. ??[View Abstract on OvidMedline]
Saguil A, Kane S, Mercado M, et al. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician.  2017;96(10):656–663. [View Abstract on OvidMedline]
McDonald EM, de Kock J, Ram FS. Antivirals for management of herpes zoster including ophthalmicus: a systematic review of high-quality randomized controlled trials. Antivir Ther.  2012;17(2):255–264. [View Abstract on OvidMedline]
Chen N, Li Q, Zhang Y, et al. Vaccination for preventing postherpetic neuralgia. Cochrane Database Syst Rev.  2011;(3):CD007795. [View Abstract on OvidMedline]
Massengill JS, Kittredge JL. Practical considerations in the pharmacological treatment of postherpetic neuralgia for the primary care provider. J Pain Res.  2014;7:125–132. [View Abstract on OvidMedline]
Kim HJ, Ahn HS, Lee JY, et al. Effects of applying nerve blocks to prevent postherpetic neuralgia in patients with acute herpes zoster: a systematic review and meta-analysis. Korean J Pain.  2017;30(1):3–17. [View Abstract on OvidMedline]


Langan SM, Smeeth L, Margolis DJ, et al. Herpes zoster vaccine effectiveness against incident herpes zoster and post-herpetic neuralgia in an older US population: a cohort study. PLoS Med.  2013;10(4):e1001420. [View Abstract on OvidMedline] 


  • Bell Palsy; Chickenpox (Varicella Zoster); Herpes Eye Infections; Herpes Simplex

  • Algorithm: Genital Ulcers



  • B02.9 Zoster without complications

  • B02.29 Other postherpetic nervous system involvement


  • 053.9 Herpes zoster without mention of complication

  • 053.10 Herpes zoster with unspecified nervous system complication


  • 4740000 Herpes zoster (disorder)

  • 2177002 Postherpetic neuralgia (disorder)


  • Antiviral therapy within 72 hours of the onset of rash is most effective.

  • Patients with active herpes zoster can transmit clinically active disease (chickenpox) to susceptible individuals.

  • Shingrix is the recommended vaccine for healthy adults 50 years and older, including those who previously received Zostavax, to prevent shingles and related complications.