Herpes Zoster (Shingles) : Muhammad Abdullah Dept. of Dermatology DHQ Hospital Faisalabad

Herpes Zoster (shingles)
Muhammad Abdullah
Dept. Of Dermatology DHQ Hospital
Faisalabad
INTRODUCTION
 Herpes zoster is an acute infectious viral disease.

 It is extremely painful and having incapacitating nature.
 It is characterised by inflammation of dorsal root ganglia or
extra-medullary cranial nerve ganglia , associated with
vesicular eruptions of the skin or mucous membrane in areas
supplied by sensory nerves.
VIRICELLA-Z0STER VIRUS (VZV ; HHV-3
)
 Viricella zoster virus is simillar to herpes simplex
virus(HSV) in many respects.
 Chicken pox represents the primary infection with VZV

latency ensures and recurrence is possible as HERPES
ZOSTER
 This disease is most common in adult life and affects male
and female with equal frequency.
 Although rare it does occur in children.
 The infection period is 10 - 21 days with an average of 15

days.
PREDISPOSING FACTORS FOR
REACTIVATION
 HIV infection
 Cytotoxic or treatment with immunosuppressive drugs
 Radiation
 Presence of malignancies
 Old age
 Alcohol abuse
 Stress ( emotional and physical)
 Dental manipulation
PATHOGENESIS
 After the initial infection with VZV ( chicken pox ), the virus
is transported up the sensory nerves and presumably
establishes latency in dorsal spinal ganglia.
 Simillar eosinophilic intra-nuclear inclusion bodies ,

indicative of viral infection occur in both the cases
 Herpes zoster rash has healed , a debilitating complications
known as post herpatic neuralgia(PHN).
 The incidense and severity of herpes zoster and PHN

increase with age in association with an age related decline in
cell-mediated immunity to VZV
CINICAL FEATURES
 It can be grouped into three phases
prodrome
acute
chronic
 During initial viral replication , active ganglionitis develops
with resultant neuronal necrosis and sever neuralgia
 As the virus travels down the nerve, pain intensifies and has
been described as burning, tingling, itching, boring, prickly,
or knifelike.
 Approximately 10% of affected individuals will exhibit no
pro-dermal pain.
 The pain may be

1) sensitive teeth
2) otitis media
3) migraine headache
4) myocardial infraction
5) appendicitis
 depending upon which dermatome is affected

ZOSTER SINE
 Conversely on occasion there may be recurrence in the
absence of vesiculation of the skin or mucosa.
 This pattern is called zoster sine (zoster with out rash)
 The acute phase begins as the involved skin develops clusters of
vesicles set on an erythmatous base.
 within 3 to 4 days the vesicles becomes pustular and ulcerate
with crusts developing after 7 to 10 days.

ORAL LESIONS
 Oral lesions occur with trigeminal nerve involvement and
may be present on the movable or bound mucosa.
 The lesions often extend to the mid-line and frequently are
present on conjuction with involvement of skin overlying the
affected quardant.
 Individual lesions manifest as 1 to 4 mm, white, opaque
vesicles that rupture to form shallow ulcerations.
 Involvement of maxilla may be associated with devitalization
of the teeth in the affected area.
 Several reports have documented significant bone necrosis
with loss of teeth in areas involved with herpes zoster.
 It is postulated that the gnathic osteonecrosis may be
secondary to damage of the blood vessels supplying the
alveolar ridges and teeth, leading to focal necrosis.
 Of the reported cases there is almost an equal distribution
between maxilla and mandible with both sexes similarly.
 Ocular involvement is not unusual and can be the source of
significant morbidity, including permanent blindness.
JAMES RAMSAY HUNT’S
SYNDROME
 A special form of zoster infection of the geniculate ganglion,
with the involvement of the external ear and oral mucosa,
has been termed hunte’s syndrome.
 Clinical manifestation
- facial paralysis
- pain of external auditory meatus and pinna of ear.
 vesicular eruption occur in oral cavity and oropharynx wth
hoarseness,tinnitus,vertigo and occasional oter disterbences.
ORAL MANIFESTATION
 Herpes zoster may involve the face by infection of trigeminal
nerve.
 This usually consist of unilateral involvement of skin areas
supplied by either the opthalmic , maxillary or mandibular
nerves.
 Lesions of the oral mucosa are fairly common , and
extremely painful vesicles may be found on the buccal
mucosa , tongue, uvula, pharynx and larynx.
 This generally rupture to leave areas of erosion.
 One of the characteristics clinical features of the disease
involving the face and oral cavity is the unilaterality of the

lesions.
 Typically, when large, the lesions will extend upto the
midline and stop abruptly

HISTOPATHOLOGIC
FEATURES
 The virus may cause acantholysis, the formation of numerous
free floating tzanck cells which exhibit nuclear margination
of chromatin and occasional multinucleaon.
Diagnosis
 Viral cultural can confirm the clinical impression but takes
atleast 24 hours.
 A rapid diagnosis can be obtain through the use of direct
staining of cytologic smears with fluorescent monoclonal
antibodies for VZV.
 This technique gives positive results in almost 80% of cases.
 Molecular techniques such as dotblot hybridization and PCR
also can be used to detect VZV.
Treatment and prognosis
 Fever should be treated with antipyretics that do not contain
aspirin.
 Antipruritic such as diphenhydramine can be administrated
to reduce etching.
 Early therapy with appropriate antiviral medications such as
acyclovir, valacyclovir and famciclovir has been found to
accelerate healing of the cutaneous and mucosal lesions.
 This medications are most effective if initiated within 72
hours after development of first vesicle.
 One topical treatment, capsaicin has had significant success
with 80% of patients.
 A live attenuated VZV vaccine has been approved for use in
adults, 60 years of age or older.
 Zostavax is 14 times more potent than varivax.

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Herpes Zoster (shingles)

 Herpes zoster is an acute infectious viral disease.

 Chicken pox represents the primary infection with VZV

 Although rare it does occur in children.

 The infection period is 10 - 21 days with an average of 15

 Simillar eosinophilic intra-nuclear inclusion bodies ,

 The incidense and severity of herpes zoster and PHN

 The pain may be

 depending upon which dermatome is affected

vesicles set on an erythmatous base.

 within 3 to 4 days the vesicles becomes pustular and ulcerate

with crusts developing after 7 to 10 days.

 One of the characteristics clinical features of the disease

involving the face and oral cavity is the unilaterality of the

 Typically, when large, the lesions will extend upto the

midline and stop abruptly

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