Updated: 1/31/2020

Varicella Zoster Virus

Review Topic
4 4
5 5
  • A 60-year-old man presents to an urgent care clinic for a rash on his right arm. He reports that this rash suddenly occurred about 1 day ago. He has been in 10/10 pain from this rash. He reports that he had chickenpox during his childhood and that his physician had recommended that he receive a shingles vaccine; however, he had not had a chance to do so. He has not been sleeping well, as he is currently going through a divorce. On physical exam, there is a vesicular rash in a dermatomal distribution on his right upper arm. He is sent home with the appropriate treatment.
  • Classification
    • varicella-zoster virus (VZV)
      • an enveloped, linear, double-stranded DNA virus
      • also known as human herpesvirus-3
      • transmitted via
        • respiratory secretions
        • direct contact with skin lesions
      • causes chickenpox, herpes zoster (shingles), encephalitis, meningitis, and pneumonia
  • Epidemiology
    • demographics
      • herpes zoster in elderly population
      • chicken pox in children
      • encephalitis and pneumonia in the immunocompromised
      • men > women
    • risk factors
      • immunosuppression
      • advanced age
      • previous infection with VZV
  • Pathogenesis
    • the virus infects T-cells
    • the virus is often latent in the dorsal root ganglia or trigeminal ganglia
    • reactivation of the latent virus causes herpes zoster
      • often precipitated by immunocompromise or stress
  • Prevention
    • herpes zoster
      • recombinant vaccine
        • adults > 50 years of age
      • live vaccine
        • adults > 60 years of age
    • chickenpox
      • live vaccine
        • adults and children 1 year or older
  • Prognosis
    • complete healing may take more > 1 month
    • chickenpox is often self-resolving in children
  • Herpes zoster
    • painful unilateral vesicular/pustular skin eruption along a single dermatome
      • does not cross midline
    • preceded by prodrome of itchiness or tingling at the site
    • may involve the eye
      • herpes zoster opthalmicus
      • distribution of cranial nerve V
    • may involve the ear
      • Ramsay-Hunt syndrome or herpes zoster oticus
      • distribution of cranial nerve VII
  • Chicken pox
    • asynchronous vesicular rash
      • very itchy but not painful
      • starts on the head and trunk and spreads to the extremities
      • eventually develops a crust
    • fever and malaise
  • Labs
    • Tzanck smear
      • positive if multinucleated giant cells are seen  
    • polymerase chain reaction
    • direct fluorescent antibody staining
  • Making the diagnosis
    • most cases are clinically diagnosed
    • in atypical cases, laboratory examination may be useful
  • Herpes simplex virus
    • distinguishing factor
      • typically does not present in a dermatomal fashion
  • Contact dermatitis
    • distinguishing factor
      • typically is more itchy than painful
  • Management approach
    • for herpes zoster, antivirals are first-line therapy
    • for chickenpox, treatment is centered around symptomatic relief
  • Conservative
    • soothing creams
      • indication
        • immunocompetent patients with chickenpox
  • Medical
    • oral antivirals
      • indications
        • all patients with shingles
        • immunocompromised patients with chickenpox
      • drugs
        • valacyclovir
        • famciclovir
        • acyclovir
    • intravenous antivirals
      • indication
        • patients with visceral or central nervous system disease
      • drugs
        • acyclovir
    • analgesics
      • indication
        • all patients
      • drugs
        • do not give aspirin for risk of Reye syndrome
  • Disseminated disease
    • in immunocompromised patients
    • often involves the viscera
  • Post-herpetic neuralgia
    • incidence
      • very common
  • Fetal complications
    • blindness
    • scarring
    • limb hypoplasia
  • Vision loss or keratitis
    • from herpes zoster opthalmicus

Please rate topic.

Average 4.7 of 3 Ratings

Questions (4)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M1.MC.13.1) A 68-year-old male presents to his dermatologist with a painful rash above his right nipple as shown in Figure A. Which of the following is the most likely etiology of the patient's rash: Tested Concept

QID: 101304

Excessive fibrosis and collagen deposition




Superficial bacterial skin infection




Autoimmune IgG antibody against desmosomes




Virally mediated epidermal hyperplasia




Reactivation of latent virus



L 1 E

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Evidences (7)
Topic COMMENTS (0)
Private Note