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Herpes zoster

Last edited: 4/14/2026

Overview

Herpes zoster (HZ), commonly known as shingles, is caused by the reactivation of varicella-zoster virus (VZV) from a latent state, typically manifesting as a painful vesicular rash along a dermatomal distribution 125.

Diagnosis

  • Clinical Presentation: Characteristic painful vesicular rash localized to a dermatome 5.
  • Laboratory Tests: Not routinely required but may include VZV PCR or serology if atypical presentation or immunocompromised status 12.
  • Imaging: Not typically necessary unless complications like encephalitis or myelitis are suspected 18.

    • Management

  • First-Line Treatments:
    • - Antiviral Therapy: Acyclovir, valacyclovir, or famciclovir (75 mg/kg/day for 7-14 days) to reduce severity and duration of rash 1720. - Pain Management: Nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvant with opioids if necessary 636.
  • Adjunctive Treatments:
    • - Topical Treatments: Lidocaine patches for localized pain relief 36. - Neuropathic Pain: Gabapentin or pregabalin for postherpetic neuralgia (PHN) 3639.

    Special Populations

  • Elderly: Higher risk of HZ and PHN; vaccination recommended 11220.
  • Immunocompromised: Increased susceptibility to severe HZ; consider higher antiviral doses and prolonged therapy 518.
  • Comorbidities: Diabetes and immunosuppression elevate HZ risk and complicate management 2619.

    • Key Recommendations

  • Vaccination: Administer recombinant zoster vaccine (RZV) or live attenuated zoster vaccine (ZVL) for adults ≥50 years to prevent HZ 1812 (Evidence: Strong).
  • Early Antiviral Therapy: Initiate antiviral treatment within 72 hours of rash onset to reduce severity and duration 120 (Evidence: Moderate).
  • Pain Management: Integrate early multimodal pain management strategies including NSAIDs and opioids as needed for acute HZ pain 636 (Evidence: Moderate).
  • PHN Prevention/Management: Use gabapentin or pregabalin for patients at risk of or experiencing PHN 3639 (Evidence: Moderate).
  • Monitor Adverse Events: Vigilantly monitor for adverse events following vaccination, particularly with RZV due to potential reactogenicity 1321 (Evidence: Moderate).

    • References

    1 Cai H, Jia B, Song Z, Wang L, Zhao S. Real-world safety of herpes zoster vaccines: A pharmacovigilance study based on the vaccine adverse event reporting system (may 2006-december 2024). Vaccine 2025. link 2 Sun X, Zhang L, Zhang T, Sun J, Xu Y, Liu L et al.. Surveillance on the coverage of herpes zoster vaccine and post-marketing adverse events in Jiangsu province, China. Human vaccines & immunotherapeutics 2025. link 3 Li H, Xie M, Qiu X, Kang X, Li F, Xu A et al.. Real-world study: Analysis of post-marketing safety for recombinant zoster vaccine in Shandong, China. Human vaccines & immunotherapeutics 2025. link 4 Ding S, Wen S, Kang H, Zhang H, Guo H, Li Y. Association of the incidence of postherpetic neuralgia with early treatment intervention of herpes zoster and patient baseline characteristics: A systematic review and meta-analysis of cohort studies. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases 2024. link 5 Tao BK, Soor D, Micieli JA. Herpes zoster in neuro-ophthalmology: a practical approach. Eye (London, England) 2024. link 6 Iseki M, Yamamoto T, Ogawa Y, Majima Y, Abe Y, Watanabe D et al.. Efficacy and safety of intravenous fosphenytoin for patients with acute herpes zoster-associated pain: A placebo-controlled randomized trial. The Journal of dermatology 2024. link 7 Fang R, Zhou Y, Han L, Chen W, Guan N, Li J. Pharmacovigilance study of famciclovir in the Food and Drug administration adverse event reporting system database. Scientific reports 2024. link 8 Muttucumaru R, Lau CL, Leeb A, Mills DJ, Wood N, Furuya-Kanamori L. Post-marketing surveillance of 10,392 herpes zoster vaccines doses in Australia. Vaccine 2024. link 9 Blumstein AJ, Fayne R, Eshaq M. Persistent 'postherpetic neuralgia' and well-demarcated plaque. The Journal of family practice 2023. link 10 Guenther L. Prevention of Shingles in Dermatology Patients on Systemic Medications. Skin therapy letter 2023. link 11 Singh RB, Parmar UPS, Ichhpujani P, Jeng BH, Jhanji V. Herpetic Eye Disease After SARS-CoV-2 Vaccination: A CDC-VAERS Database Analysis. Cornea 2023. link 12 Okoli GN, Al-Yousif Y, Reddy VK, Lê ML, Neilson CJ, Abou-Setta AM. The Number Needed to Vaccinate (NNV) against herpes zoster: a systematic review with meta-analysis. Infectious diseases (London, England) 2022. link 13 Chu CW, Jiesisibieke ZL, Yang YP, Wu PC, Lin HL, Tung TH. Association of COVID-19 vaccination with herpes zoster: a systematic review and meta-analysis. Expert review of vaccines 2022. link 14 Maranini B, Ciancio G, Cultrera R, Govoni M. Reply to: "Herpes zoster seven days after SARS-CoV-2 vaccination in a patient with ankylosing spondylitis under adalimumab" by Josef Finsterer. Reumatismo 2022. link 15 Finsterer J. Herpes zoster seven days after SARS-CoV-2 vaccination in a patient with ankylosing spondylitis under adalimumab. Reumatismo 2022. link 16 Lin LY, Mathur R, Mulick A, Smeeth L, Langan SM, Warren-Gash C. Association between vitamin D and incident herpes zoster: a UK Biobank study. The British journal of general practice : the journal of the Royal College of General Practitioners 2022. link 17 Gringeri M, Battini V, Cammarata G, Mosini G, Guarnieri G, Leoni C et al.. Herpes zoster and simplex reactivation following COVID-19 vaccination: new insights from a vaccine adverse event reporting system (VAERS) database analysis. Expert review of vaccines 2022. link 18 Shiraki K, Toyama N, Tanaka K, Ito A, Yamamoto J. Effect of universal varicella vaccination and behavioral changes against coronavirus disease 2019 pandemic on the incidence of herpes zoster. Journal of dermatological science 2021. link 19 Bongers LD, Navarini A, Berger CT, Mueller SM. Complications and cost estimations in herpes zoster - a retrospective analysis at a Swiss tertiary dermatology clinic. Swiss medical weekly 2021. link 20 Klaric JS, Beltran TA, McClenathan BM. An Association Between Herpes Zoster Vaccination and Stroke Reduction Among Elderly Individuals. Military medicine 2019. link 21 Hesse EM, Shimabukuro TT, Su JR, Hibbs BF, Dooling KL, Goud R et al.. Postlicensure Safety Surveillance of Recombinant Zoster Vaccine (Shingrix) - United States, October 2017-June 2018. MMWR. Morbidity and mortality weekly report 2019. link 22 Miller ER, Lewis P, Shimabukuro TT, Su J, Moro P, Woo EJ et al.. Post-licensure safety surveillance of zoster vaccine live (Zostavax®) in the United States, Vaccine Adverse Event Reporting System (VAERS), 2006-2015. Human vaccines & immunotherapeutics 2018. link 23 Sabzwari SR, Afzal A, Nanji K. Mimicking rashes: Use of moulage technique in undergraduate assessment at the aga khan university, Karachi. Education for health (Abingdon, England) 2017. link 24 Gustafson CJ, Woodard M, Hanke CW. A Unique Case of Herpes Zoster Within One Week of Varicella Zoster Vaccination. Journal of drugs in dermatology : JDD 2016. link 25 Zarei MR, Chamani G. Atypical Presentation of Zoster Mimicking Headache and Temporomandibular Disorder: A Case Report. Journal of the California Dental Association 2016. link 26 Pickering G, Gavazzi G, Gaillat J, Paccalin M, Bloch K, Bouhassira D. Is herpes zoster an additional complication in old age alongside comorbidity and multiple medications? Results of the post hoc analysis of the 12-month longitudinal prospective observational ARIZONA cohort study. BMJ open 2016. link 27 Pasternak J. Vaccine against herpes zoster. Einstein (Sao Paulo, Brazil) 2013. link 28 Sy A, McLeod SD, Cohen EJ, Margolis TP, Mannis MJ, Lietman TM et al.. Practice patterns and opinions in the management of recurrent or chronic herpes zoster ophthalmicus. Cornea 2012. link 29 Kanbayashi Y, Onishi K, Fukazawa K, Okamoto K, Ueno H, Takagi T et al.. Predictive factors for postherpetic neuralgia using ordered logistic regression analysis. The Clinical journal of pain 2012. link 30 Tseng HF, Liu A, Sy L, Marcy SM, Fireman B, Weintraub E et al.. Safety of zoster vaccine in adults from a large managed-care cohort: a Vaccine Safety Datalink study. Journal of internal medicine 2012. link 31 Guenther LC, Lynde CW. A refresher on herpes zoster, current status on vaccination, and the role of the dermatologist. Journal of cutaneous medicine and surgery 2011. link 32 Gabutti G, Serenelli C, Sarno O, Marconi S, Corazza M, Virgili A. Epidemiologic features of patients affected by herpes zoster: database analysis of the Ferrara University Dermatology Unit, Italy. Medecine et maladies infectieuses 2010. link 33 Wu CY, Hu HY, Huang N, Pu CY, Shen HC, Chou YJ. Do the health-care workers gain protection against herpes zoster infection? A 6-year population-based study in Taiwan. The Journal of dermatology 2010. link 34 Gnann JW. Vaccination to prevent herpes zoster in older adults. The journal of pain 2008. link 35 Irwin MR, Olmstead R, Oxman MN. Augmenting immune responses to varicella zoster virus in older adults: a randomized, controlled trial of Tai Chi. Journal of the American Geriatrics Society 2007. link 36 Tyring SK. Management of herpes zoster and postherpetic neuralgia. Journal of the American Academy of Dermatology 2007. link 37 Chidiac C, Bruxelle J, Daures JP, Hoang-Xuan T, Morel P, Leplège A et al.. Characteristics of patients with herpes zoster on presentation to practitioners in France. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2001. link 38 Landow K. Acute and chronic herpes zoster. An ancient scourge yields to timely therapy. Postgraduate medicine 2000. link 39 di Luzio Paparatti U, Arpinelli F, Visonà G. Herpes zoster and its complications in Italy: an observational survey. The Journal of infection 1999. link90079-8) 40 Schmader K. Herpes zoster in the elderly: issues related to geriatrics. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 1999. link 41 Okuda T, Oh-i T, Koga M. Evaluation of acceleration plethysmograms in dermatology--efficacy of lipo PGE1 preparations against herpes zoster and neuralgia following herpes. The Journal of dermatology 1997. link 42 Manabe H, Dan K, Higa K. Continuous epidural infusion of local anesthetics and shorter duration of acute zoster-associated pain. The Clinical journal of pain 1995. link 43 McElvanney AM, Murray PI. Multifocal choroidal lesions. A rare complication of herpes zoster ophthalmicus. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society 1994. link 44 Stubbings JM, Goodfield MJ. An unusual distribution of an acneiform rash due to herpes zoster infection. Clinical and experimental dermatology 1993. link 45 Foster O, Askaria A, Lanham J, Perry D. Algoneurodystrophy following herpes zoster. Postgraduate medical journal 1989. link 46 Manzie PP. Herpes zoster. The gp view. Australian family physician 1982. link 47 Epstein S. Herpes zoster of the chest wall and gynaecomastia. A case report. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 1978. link

    Original source

    1. [1]
      Real-world safety of herpes zoster vaccines: A pharmacovigilance study based on the vaccine adverse event reporting system (may 2006-december 2024). — Cai H, Jia B, Song Z, Wang L, Zhao S Vaccine (2025)
    2. [2]
      Surveillance on the coverage of herpes zoster vaccine and post-marketing adverse events in Jiangsu province, China. — Sun X, Zhang L, Zhang T, Sun J, Xu Y, Liu L et al. Human vaccines & immunotherapeutics (2025)
    3. [3]
      Real-world study: Analysis of post-marketing safety for recombinant zoster vaccine in Shandong, China. — Li H, Xie M, Qiu X, Kang X, Li F, Xu A et al. Human vaccines & immunotherapeutics (2025)
    4. [4]
      Association of the incidence of postherpetic neuralgia with early treatment intervention of herpes zoster and patient baseline characteristics: A systematic review and meta-analysis of cohort studies. — Ding S, Wen S, Kang H, Zhang H, Guo H, Li Y International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases (2024)
    5. [5]
      Herpes zoster in neuro-ophthalmology: a practical approach. — Tao BK, Soor D, Micieli JA Eye (London, England) (2024)
    6. [6]
      Efficacy and safety of intravenous fosphenytoin for patients with acute herpes zoster-associated pain: A placebo-controlled randomized trial. — Iseki M, Yamamoto T, Ogawa Y, Majima Y, Abe Y, Watanabe D et al. The Journal of dermatology (2024)
    7. [7]
      Pharmacovigilance study of famciclovir in the Food and Drug administration adverse event reporting system database. — Fang R, Zhou Y, Han L, Chen W, Guan N, Li J Scientific reports (2024)
    8. [8]
      Post-marketing surveillance of 10,392 herpes zoster vaccines doses in Australia. — Muttucumaru R, Lau CL, Leeb A, Mills DJ, Wood N, Furuya-Kanamori L Vaccine (2024)
    9. [9]
      Persistent 'postherpetic neuralgia' and well-demarcated plaque. — Blumstein AJ, Fayne R, Eshaq M The Journal of family practice (2023)
    10. [10]
      Prevention of Shingles in Dermatology Patients on Systemic Medications. — Guenther L Skin therapy letter (2023)
    11. [11]
      Herpetic Eye Disease After SARS-CoV-2 Vaccination: A CDC-VAERS Database Analysis. — Singh RB, Parmar UPS, Ichhpujani P, Jeng BH, Jhanji V Cornea (2023)
    12. [12]
      The Number Needed to Vaccinate (NNV) against herpes zoster: a systematic review with meta-analysis. — Okoli GN, Al-Yousif Y, Reddy VK, Lê ML, Neilson CJ, Abou-Setta AM Infectious diseases (London, England) (2022)
    13. [13]
      Association of COVID-19 vaccination with herpes zoster: a systematic review and meta-analysis. — Chu CW, Jiesisibieke ZL, Yang YP, Wu PC, Lin HL, Tung TH Expert review of vaccines (2022)
    14. [14]
      Reply to: "Herpes zoster seven days after SARS-CoV-2 vaccination in a patient with ankylosing spondylitis under adalimumab" by Josef Finsterer. — Maranini B, Ciancio G, Cultrera R, Govoni M Reumatismo (2022)
    15. [15]
      Herpes zoster seven days after SARS-CoV-2 vaccination in a patient with ankylosing spondylitis under adalimumab. — Finsterer J Reumatismo (2022)
    16. [16]
      Association between vitamin D and incident herpes zoster: a UK Biobank study. — Lin LY, Mathur R, Mulick A, Smeeth L, Langan SM, Warren-Gash C The British journal of general practice : the journal of the Royal College of General Practitioners (2022)
    17. [17]
      Herpes zoster and simplex reactivation following COVID-19 vaccination: new insights from a vaccine adverse event reporting system (VAERS) database analysis. — Gringeri M, Battini V, Cammarata G, Mosini G, Guarnieri G, Leoni C et al. Expert review of vaccines (2022)
    18. [18]
      Effect of universal varicella vaccination and behavioral changes against coronavirus disease 2019 pandemic on the incidence of herpes zoster. — Shiraki K, Toyama N, Tanaka K, Ito A, Yamamoto J Journal of dermatological science (2021)
    19. [19]
      Complications and cost estimations in herpes zoster - a retrospective analysis at a Swiss tertiary dermatology clinic. — Bongers LD, Navarini A, Berger CT, Mueller SM Swiss medical weekly (2021)
    20. [20]
      An Association Between Herpes Zoster Vaccination and Stroke Reduction Among Elderly Individuals. — Klaric JS, Beltran TA, McClenathan BM Military medicine (2019)
    21. [21]
      Postlicensure Safety Surveillance of Recombinant Zoster Vaccine (Shingrix) - United States, October 2017-June 2018. — Hesse EM, Shimabukuro TT, Su JR, Hibbs BF, Dooling KL, Goud R et al. MMWR. Morbidity and mortality weekly report (2019)
    22. [22]
      Post-licensure safety surveillance of zoster vaccine live (Zostavax®) in the United States, Vaccine Adverse Event Reporting System (VAERS), 2006-2015. — Miller ER, Lewis P, Shimabukuro TT, Su J, Moro P, Woo EJ et al. Human vaccines & immunotherapeutics (2018)
    23. [23]
      Mimicking rashes: Use of moulage technique in undergraduate assessment at the aga khan university, Karachi. — Sabzwari SR, Afzal A, Nanji K Education for health (Abingdon, England) (2017)
    24. [24]
      A Unique Case of Herpes Zoster Within One Week of Varicella Zoster Vaccination. — Gustafson CJ, Woodard M, Hanke CW Journal of drugs in dermatology : JDD (2016)
    25. [25]
      Atypical Presentation of Zoster Mimicking Headache and Temporomandibular Disorder: A Case Report. — Zarei MR, Chamani G Journal of the California Dental Association (2016)
    26. [26]
      Is herpes zoster an additional complication in old age alongside comorbidity and multiple medications? Results of the post hoc analysis of the 12-month longitudinal prospective observational ARIZONA cohort study. — Pickering G, Gavazzi G, Gaillat J, Paccalin M, Bloch K, Bouhassira D BMJ open (2016)
    27. [27]
      Vaccine against herpes zoster. — Pasternak J Einstein (Sao Paulo, Brazil) (2013)
    28. [28]
      Practice patterns and opinions in the management of recurrent or chronic herpes zoster ophthalmicus. — Sy A, McLeod SD, Cohen EJ, Margolis TP, Mannis MJ, Lietman TM et al. Cornea (2012)
    29. [29]
      Predictive factors for postherpetic neuralgia using ordered logistic regression analysis. — Kanbayashi Y, Onishi K, Fukazawa K, Okamoto K, Ueno H, Takagi T et al. The Clinical journal of pain (2012)
    30. [30]
      Safety of zoster vaccine in adults from a large managed-care cohort: a Vaccine Safety Datalink study. — Tseng HF, Liu A, Sy L, Marcy SM, Fireman B, Weintraub E et al. Journal of internal medicine (2012)
    31. [31]
      A refresher on herpes zoster, current status on vaccination, and the role of the dermatologist. — Guenther LC, Lynde CW Journal of cutaneous medicine and surgery (2011)
    32. [32]
      Epidemiologic features of patients affected by herpes zoster: database analysis of the Ferrara University Dermatology Unit, Italy. — Gabutti G, Serenelli C, Sarno O, Marconi S, Corazza M, Virgili A Medecine et maladies infectieuses (2010)
    33. [33]
      Do the health-care workers gain protection against herpes zoster infection? A 6-year population-based study in Taiwan. — Wu CY, Hu HY, Huang N, Pu CY, Shen HC, Chou YJ The Journal of dermatology (2010)
    34. [34]
      Vaccination to prevent herpes zoster in older adults. — Gnann JW The journal of pain (2008)
    35. [35]
      Augmenting immune responses to varicella zoster virus in older adults: a randomized, controlled trial of Tai Chi. — Irwin MR, Olmstead R, Oxman MN Journal of the American Geriatrics Society (2007)
    36. [36]
      Management of herpes zoster and postherpetic neuralgia. — Tyring SK Journal of the American Academy of Dermatology (2007)
    37. [37]
      Characteristics of patients with herpes zoster on presentation to practitioners in France. — Chidiac C, Bruxelle J, Daures JP, Hoang-Xuan T, Morel P, Leplège A et al. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America (2001)
    38. [38]
      Acute and chronic herpes zoster. An ancient scourge yields to timely therapy. — Landow K Postgraduate medicine (2000)
    39. [39]
      Herpes zoster and its complications in Italy: an observational survey. — di Luzio Paparatti U, Arpinelli F, Visonà G The Journal of infection (1999)
    40. [40]
      Herpes zoster in the elderly: issues related to geriatrics. — Schmader K Clinical infectious diseases : an official publication of the Infectious Diseases Society of America (1999)
    41. [41]
      Evaluation of acceleration plethysmograms in dermatology--efficacy of lipo PGE1 preparations against herpes zoster and neuralgia following herpes. — Okuda T, Oh-i T, Koga M The Journal of dermatology (1997)
    42. [42]
      Continuous epidural infusion of local anesthetics and shorter duration of acute zoster-associated pain. — Manabe H, Dan K, Higa K The Clinical journal of pain (1995)
    43. [43]
      Multifocal choroidal lesions. A rare complication of herpes zoster ophthalmicus. — McElvanney AM, Murray PI Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society (1994)
    44. [44]
      An unusual distribution of an acneiform rash due to herpes zoster infection. — Stubbings JM, Goodfield MJ Clinical and experimental dermatology (1993)
    45. [45]
      Algoneurodystrophy following herpes zoster. — Foster O, Askaria A, Lanham J, Perry D Postgraduate medical journal (1989)
    46. [46]
      Herpes zoster. The gp view. — Manzie PP Australian family physician (1982)
    47. [47]
      Herpes zoster of the chest wall and gynaecomastia. A case report. — Epstein S South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde (1978)
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