Fast Five Quiz: How Much Do You Know About Shingles?

William James, MD; Camila K. Janniger, MD


March 09, 2017

The clinical manifestations of herpes zoster can be divided into the following three phases:

  • Pre-eruptive phase (preherpetic neuralgia)

  • Acute eruptive phase

  • Chronic phase (PHN)

The pre-eruptive phase is characterized by the following:

  • Sensory phenomena along one or more skin dermatomes, lasting 1-10 days (average, 48 hours)

  • Phenomena usually are noted as pain or, less commonly, itching or paresthesias

  • Pain may simulate headache, iritis, pleurisy, brachial neuritis, cardiac pain, appendicitis or other intra-abdominal disease, or sciatica

  • Other symptoms, such as malaise, myalgia, headache, photophobia, and, uncommonly, fever

The acute eruptive phase is marked by the following:

  • Patchy erythema, occasionally accompanied by induration, in the dermatomal area of involvement

  • Regional lymphadenopathy, either at this stage or subsequently

  • Grouped herpetiform vesicles developing on the erythematous base (the classic finding)

  • Cutaneous findings that typically appear unilaterally, stopping abruptly at the midline of the limit of sensory coverage of the involved dermatome

  • Vesicular involution: Vesicles initially are clear but eventually cloud, rupture, crust, and involute

  • After vesicular involution, slow resolution of the remaining erythematous plaques, typically without visible sequelae

  • Scarring can occur if deeper epidermal and dermal layers have been compromised by excoriation, secondary infection, or other complications

  • Almost all adults experience pain, typically severe

  • A few experience severe pain without a vesicular eruption (ie, zoster sine herpete)

  • Symptoms tend to resolve over 10-15 days

  • Complete healing of lesions may require up to a month

PHN is characterized by the following:

  • Persistent or recurring pain lasting 30 or more days after the acute infection or after all lesions have crusted (9%-45% of all cases)

  • Pain usually is confined to the area of original dermatomal involvement

  • The pain can be severe and incapacitating

  • Pain can persist for weeks, months, or years

  • Slow resolution of pain is especially common in the elderly

  • PHN is observed more frequently after cases of herpes zoster ophthalmicus and in instances of upper-body dermatomal involvement

  • Less common postherpetic sequelae include hyperesthesia or, more rarely, hypoesthesia or anesthesia in the area of involvement

For more on the clinical manifestation of herpes zoster, read here.


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