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Herpes zoster (shingles)
Herpes zoster is reactivation of the varicella virus in a sensory ganglion — a painful vesicular rash in a single dermatome; antiviral treatment within 72 hours shortens the illness, and the common complication is lasting nerve pain.
Why it matters in the exam
The exam describes an older woman with vesicles on one side of the chest or forehead and asks about treatment, eye involvement (a vesicle at the tip of the nose), facial palsy with ear vesicles, and pain lasting months after the rash. Other questions test contagion: who may catch what.
Remember that a person with zoster can infect an unvaccinated person — with chickenpox, not with shingles — and that the recombinant vaccine is also given to someone who has already had zoster.
Zoster is very common over the age of 50, and the nerve pain left behind badly harms the quality of life of older people — so both early treatment and vaccination are part of the family doctor's role.
Zoster in a healthy young person without a clear reason raises the question of immunosuppression and HIV. It is also important to tell the patient to cover the lesions until they crust.
Key points
- A painful vesicular rash in one dermatome that does not cross the midline.
- Antiviral treatment within 72 hours: valaciclovir for 7 days.
- Tip of the nose (Hutchinson) — ophthalmologist today.
- Pain over 3 months — postherpetic neuralgia; gabapentinoids and tricyclics.
- Recombinant vaccine from 50, even after the disease.
Summary table
| Condition | Presentation | Treatment | Exam note |
|---|---|---|---|
| Ordinary herpes zoster | Pain followed by vesicles in one dermatome that do not cross the midline | Valaciclovir 1 g three times a day for 7 days (or aciclovir 800 mg five times a day) | Within 72 hours; later too if new vesicles appear |
| Ophthalmic involvement (zoster ophthalmicus) | Forehead and eyelid; a vesicle at the tip of the nose (Hutchinson's sign) | Antiviral treatment and same-day ophthalmology referral | Risk of keratitis and uveitis |
| Ramsay Hunt syndrome | Ear vesicles, facial nerve palsy, hearing loss | Antiviral treatment and sometimes steroids | Worse prognosis than Bell's palsy |
| Disseminated zoster or zoster in an immunosuppressed patient | More than 3 dermatomes, spread over the body | Intravenous aciclovir | Think of HIV in a young person without a reason |
| Postherpetic neuralgia | Pain lasting more than 3 months | Gabapentin or pregabalin, tricyclic antidepressants, lidocaine plaster | The strongest predictor: older age |
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Sources
- CDC, 2024 — Clinical overview of shingles (herpes zoster) and recommendations for recombinant zoster vaccine
- Werner RN et al., European consensus-based (S2k) guideline, J Eur Acad Dermatol Venereol, 2017 — Management of herpes zoster
- Goroll AH, Mulley AG. Primary Care Medicine, 8th edition (2020) — Management of herpes zoster and postherpetic neuralgia
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.