Clinical and Epidemiological Profile of

Research Herpes Zoster; A Cross-Sectional Study

from Tertiary Hospital

Paudel Vikash*1,5, Pandey Buddhi Raj1, Tripathee Richa1, Tripathee Rishabh Dev2, Sitaula
Shreema3, Dhakal Prabin4, Shrestha Dwarika Prasad5

1
Department of Dermatology, Venereology and Leprosy, National Medical College, Birgunj, Parsa, Nepal
2
Stupa Community Hospital, Bauddha, Kathmandu, Nepal
3
Alka Hospital, Jawalakhel, Kathmandu, Nepal
4
Department of Dermatology, Manmohan Memorial Medical College, Kathmandu, Nepal
5
Department of Dermatology and Venereology, Institute of Medicine, Kathmandu, Nepal

Date of Submission : March 04, 2018

Received in Revised Form : March 19, 2018
Date of Acceptance : April 09, 2018
Date of Publishing : July 30, 2018

ABSTRACT Twenty-five percent had local complication at

Background: Herpes zoster is dermatomal the time of presentation. Fifty two percent had
neuropathic disease caused by reactivation of themselves identified the lesion as herpes zoster.
varicella zoster virus, characterized by vesico- However, only 10 had some knowledge about
bullous eruptions. Although, being a common it. Twelve percent had visited traditional healers
cause of morbidity, there are few clinic- prior to hospital arrival.
epidemiological studies and the studies regarding
the knowledge and practice among the patients Conclusions: The results show varied clinico-
are nominal. epidemiologic patterns of herpes zoster. Major
patient have less knowledge about it. A larger
Methods: This was descriptive observational study would be necessary for better clinical,
study which included 100 consecutive patients epidemiological and social behavioral data.
with herpes zoster who presented to Department Because of ignorance and tradition, awareness
of Dermatology and Venereology in a Teaching program should be conducted to reduce potential
Hospital, Kathmandu during the period from July complications.
2014 to June 2015.
Keywords: Epidemiology; Herpes Zoster;
Results: The annual incidence was 0.55%. Knowledge, Nepal
Seventy two percent were males and 28 percent
were females with the M: F=2.5:1. The average *Corresponding Author: Dr Vikash Paudel,
age of patients and mean duration of disease National Medical College, Birgunj-15, Nepal, luck_
was 40.4 years and 5.5 days respectively. Ninety vik@hotmail.com, vikashpoudel@iom.edu.np
five percent were managed at OPD and 5 % of
them needed hospitalization. Most common INTRODUCTION
dermatome involved was thoracic (50%) followed Herpes zoster (HZ), also known as Shingles,
by cervical (20%). Twelve percent had one or is a benign localized viral neuro-dermopathic
more provocative features including diabetes, disease caused by varicella zoster virus (VZV).1
steroid use, chemotherapy, surgical trauma etc. VZV is a ubiquitous, double-stranded DNA
Twenty patients had definite history chicken pox. herpes virus with a genome that contains at least

60 MED PHoenix : An Official Journal of NMC, Birgunj, Nepal, Volume (3), Issue (1), July, 2018, 60-65
 Clinical and Epidemiological Profile

70 gene products.2 It is clinically characterized disease. All the patients were asked about
by a grouped vesiculo-bullous eruptions knowledge about herpes zoster, their
confined to dermatomes. In Nepali language, it causative factor and practice of visiting
is termed as JANAI KHATIRA i.e. holy thread traditional healers. A complete dermatological
wound, because of the pattern of herpes zoster examination regarding morphology, pattern
in thoracic region is like as the holy thread of the lesions, the segment of involvement,
worn. (Figure 1) The current concept of the laterality, dissemination of the lesions etc. were
development of the lesion as postulated by Hope- noted. Similarly, any changes in the periphery
Simpson in 1965, that primary infection presents were also noted. Whenever necessary, opinion
as chicken-pox (CP), and HZ is a reactivation from other specialists was sought. All the
of the latent virus established in one or more details were recorded in preformed proforma
sensory root ganglia during primary clinical or and analyzed statistically.
subclinical infection early in life or occasionally
in utero. 3,4 Although, HZ being a common cause RESULTS
of morbidity, there are very few studies on the The annual incidence of herpes zoster was 0.55%.
epidemiology, clinical profiles and the studies Out of 100 cases, 72 % were males and 28 %
regarding the knowledge and awareness among were females (M: F = 2.5:1). The mean age of the
the patients with HZ in South Asia. 5 Here-in, we patients was 40.4 years which ranged from 2–80
describe a hospital-based study of herpes zoster years. The distribution of age and gender is given
in a central hospital of Nepal in Table 1.

MATERIALS AND METHODS Table 1: Age and gender distribution of Herpes

This cross sectional observational study was Zoster
conducted department of dermatology, and Age and gender Sex
distribution Male Female Total
venereology, university teaching hospital,
Age Less than 10 2 2 4
Kathmandu, Nepal, during the period of
10-19 6 6 12
one year from July 2014 to June 2015. Non- 20-29 20 4 24
probability purposive sampling was the method 30-39 12 2 14
40-49 4 0 4
of sampling. All the patients with clinical 50-59 8 6 14
diagnosis of herpes zoster as determined by 60-69 12 6 18
dermatologist were taken as a case. Ethical 70-79 6 2 8
80-89 2 0 2
approval was taken prior the commencement Total 72 28 100
of the study. Informed consent was obtained
from patients or their guardians for enrollment The maximum incidence was in the age group
into the study and taking clinical photographs. of 20–29 years (24%), which is followed 60-69
Total number of patients was 100 who were years (18%). Minimum incidence was observed
consecutively enrolled in the study. The in the age group of 80-89 years and 1–10 years
general demographic profiles such as age, which were 2% and 4% respectively. Mean
gender, address, religion and occupation were duration of disease was 5.5 days with range of
noted. A complete history about the prodromal 1-25 days and mean prodromal duration was
features, symptoms, types and pattern of skin 2.8 days with range of 1-10 days. Prodromal
lesions, nature, intensity and duration of pain symptoms were present in half of the patients
were noted. Similarly, previous history of which were burning sensation (28%), followed
chicken pox and past attack of herpes zoster by pain (10%), redness (10%) and hyperesthesia
were elicited. They were also inquired about (2%). The common presenting symptoms were
history of provocative risk factors such as vesiculations (90%), pain (88%), myalgia (24%),
drugs, trauma, surgery, immunosuppressive watering from eyes (16%) and headache (12%).
and cytotoxic chemotherapy or radiotherapy,
HIV infections, diabetes mellitus, tuberculosis, The dermatomal distribution of zoster is given
asthma or chronic obstructive pulmonary in Table 2. Thoracic dermatome was commonly

MED PHoenix : An Official Journal of NMC, Birgunj, Nepal, Volume (3), Issue (1), July, 2018, 60-65 61
Paudel et al.

affected (50%) and among thoracic, T4 Table 2: Dermatome involvement according to

segment was the commonest. It was followed gender in herpes zoster
by the cervical nerve (20) and trigeminal 18 Dermatomes and gender Gender
distribution Male Female Total
[ophthalmic branch (16), maxillary (2)]. (Figure Ophthalmic 12 4 16
1, 2 and 3) Two patients had disseminated Maxillary 0 2 2
lesions with involvement of more than two Dermatomes
Cervical 16 4 20
Thoracic 38 12 50
dermatome. Majority of the patient had right Lumbar 4 6 10
sided lesion (58) and forty two cases on the left Sacral 2 0 2
side. Total 72 28 100

Being the benign nature and course of disease, 95

% were managed on out-patient basis, whereas
five were hospitalized. Among hospitalized
ones, majority was elderly patient (4), two
had disseminated herpes zoster and three had
ophthalmic zoster. The disseminated zoster was
present in patient under immuno-suppressive
drug for connective tissue disease. (Figure 3)
Seventy percent patients had zoster associated
pain (ZAP), which was moderate to severe in
intensity.

Figure 1: Herpes Zoster

(janai khatira, holy thread rash)

Figure 3 : Disseminated Herpes Zoster, immuno-

suppressed patient

Local complication was seen in one quarter of the

patients which were necrosis or ulceration of skin
(10%), irritant contact dermatitis (5%), keratitis
(5%), super-added bacterial infection (4%), and
keloid formation (1%). Post herpetic neuralgia
was seen in 15% of patients. The systemic
complications were not seen in any patients.
Figure 2: Herpes zoster ophthalmicus Out of 100 cases, only 10 had definite history of
chicken pox and none had past history of herpes

62 MED PHoenix : An Official Journal of NMC, Birgunj, Nepal, Volume (3), Issue (1), July, 2018, 60-65
 Clinical and Epidemiological Profile

zoster. Only, twelve patients had one or more his similar with the studies from Nepal7, India9
suspected provoking factors. Among them, six and Sri Lanka.10 The finding is contrast to
were diabetic, four were on steroids, one patient global estimates where female preponderance
had cancer with chemotherapy and one had done is more common.11 This could be probably due
hysterectomy just prior to HZ. to male predominance of society, frequent visit
to hospital.
Fifty two patients themselves had identified the
lesion as HZ. Among them; only 10 had some HZ is described as commonly occurring in the
short of knowledge about it. Twelve of the patients elderly and the immuno-compromised patients
had visited traditional healer prior to presentation and the incidence is said to increase with age.12
whereas in eight of them, the traditional healer This study, however showed majority of cases in
had applied herbal medicines and painted some the age group of 21–30 years with a mean age of
animals in the periphery of lesion with the belief 40 years. The results are similar with that from
of resolution. (Figure 4) Nepal 7, India 9 and Srilanka.10

Hope-Simpson and Ragozzino et al believed

that HZ is classically associated with physical
stress.3,13 In ours, except for twelve individuals,
others were in state of good health. The common
provocative factors were diabetes mellitus (6%),
systemic steroids (4%), chemotherapy (1%) and
post-operative stress (1%). The risk factors or
the provocative factors were similar to the other
studies whereas none of our patient had HIV
unlike other studies.12

The presenting symptoms vesiculations, pain,

muscle pain, watering from eyes, headache were
common as revealed in metaanalysis. 12 The
presence of zoster associated pain (ZAP) has
been reported in 95% and 94.6% of cases.12,14 The
most common dermatome was thoracic (50%)
Figure 4 : Herpes zoster, thoracic dermatome followed by cervical (20%), cranial (18%) and
(painting of animal in periphery) lumbosacral. (Table 2) This is which is similar
to various prospective and retrospective studies.
DISCUSSION 9, 14, 15

Herpes zoster is recognized since ancient times

and described in early medical literature.6 But, we The common complications were irritant contact
lack epidemiological and clinical data because of dermatitis, ulceration, secondary infections,
self-resolution of disease and limited studies, in keratitis, post herpetic neuralgia, keloid formation
our part of the world. etc. The post herpetic neuralgia was present in
15% of patient and more common in elderly. 8,16
The present study was conducted to find the More than half (52%) of the patient had
epidemiological, clinical and social parameters diagnosed the rash as that of herpes zoster but
of HZ. The incidence of HZ was 0.55% which a few (10%) patients had knowledge about
was less than the previous study in Nepal,7 herpes zoster. This was similar to a survey
The incidence rate of HZ ranged between 3 conducted which showed higher knowledge
and 5/1000 person-years in North America, in developed countries and poor knowledge
Europe and Asia-Pacific.8 There was slightly in developing ones. 5 Twelve percent of the
male preponderance with M:F= 2.6:1 which patients were initially handled by traditional

MED PHoenix : An Official Journal of NMC, Birgunj, Nepal, Volume (3), Issue (1), July, 2018, 60-65 63
Paudel et al.

healers, with a belief on them, who used to 2. Cohen JI. The varicella-zoster virus
apply herbal medicines and draw animal figure genome. Curr Top Microbiol Immunol.
in the periphery of lesions. Some of the visitors 2010;342:1-14.
believed that the circumferential involvement 3. Hope-Simpson RE. The Nature of Herpes
of herpes zoster is fatal. Visiting the traditional Zoster: A Long-Term Study and a New
healer for herpes zoster is also common in Hypothesis. Proc R Soc Med. 1965; 58:9-
some places. 17,18 This is believed to delay 20.
in diagnosis & timely treatment, ultimately 4. Oxman MN. Herpes Zoster Pathogenesis
contributing in various complications.19 and Cell-Mediated Immunity and
Immunosenescence. J Am Osteopath
The limitation of the study was lesser number Assoc. 2009; 109(6_suppl_2):S13-S17.
of participants. Being a hospital based study, the 5. Paek E, Johnson R. Public awareness and
study did not give the true incidence of the herpes knowledge of herpes zoster: results of a
zoster in the community. There was difficulty in global survey. Gerontology. 2010; 56(1):20-
obtaining the knowledge among the participants 31.
about the herpes zoster because of the medical 6. Muehlenbachs A. Viruses and Man: A
terminologies involved. History of Interactions. Clin Infect Dis.
2015 Jun 15;60(12):1877-8.
CONCLUSION 7. Kayastha B, Shrestha P, Shrestha R, Lama
The results and patterns were almost similar with L. Changing Profile of Herpes Zoster in
the Asian studies and different from Western Nepal: A Hospital-Based Study. Nepal
and European ones.This could probably be due Journal of Dermatology, Venereology &
to the younger population or a true incidence Leprology. 2009; 8(1):1-4.
in Asians. Though being common nature 8. Kawai K, Gebremeskel BG, Acosta
of problem and its associated considerable CJ. Systematic review of incidence and
economic burden and health morbidity, clinic- complications of herpes zoster: towards a
epidemiological data are lacking. Because global perspective. BMJ Open. 2014; 4(6).
of the poor knowledge about the HZ and 9. Aggarwal SK, Radhakrishnan S. A clinico-
traditional faith among patients, awareness epidemiological study of herpes zoster.
program should be conducted regarding Armed Forces Med J India. 2016;72(2):175-
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broader study would be necessary formore epidemiological study of herpes zoster.
accurate results on clinical, epidemiological The Ceylon Journal of Medical Science.
and social behaviors of HZ. 1999;36 (1), 1-7.
11. Yawn BP, Gilden D. The global
ACKNOWLEDGEMENT epidemiology of herpes zoster. Neurology.
We are thankful to all the patients who participated 2013;81(10):928-930.
in the study, faculties and staffs of department of 12. Kawai K, Yawn BP. Risk factors for herpes
dermatology-TUTH and Dr. Deepa Chudal for zoster: a systematic review and meta-analysis.
her constant secretarial support. Mayo Clin Proc. 2017;92:1806–1821.
13. Ragozzino M, Melton L, Kurland L, Chu C,
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