Mathews Journal of Dermatology


Previous Issues Volume 1, Issue 1 - 2016

Review Article Abstract PDF  

Risk Factors and Complications of Herpes Zoster

Manahel Mahmood AlSabbagh

MB BCh BAO (NUI), Clinical Dermatology, Kingdom of Bahrain.

Corresponding Author: Manahel Mahmood AlSabbagh, MB BCh BAO (NUI), Clinical Dermatology, Kingdom of Bahrain.  Tel: 00973 39729242; E-Mail:

Received Date: 31 May 2016   

Accepted Date: 07 Jun 2016   

Published Date: 17 Jun 2016

Copyright © 2016 AlSabbagh MM

Citation: AlSabbagh MM. (2016). Risk Factors and Complications of Herpes Zoster. Mathews J  Dermatol. 1(1): 006.


Herpes zoster is a viral infection that is prevalent among 20-30% of people. Though it is unclear, the underlying pathophysiology can be attributed to cellular immunity dysfunction. Potential risk factors may involve routine procedures like biopsies and teeth extraction. Herpes zoster usually follows a very benign course that is most commonly complicated with post herpetic neuralgia; however, serious systemic complications including heart block and cerebral angiitis are frequently reported in immunocompromised cases. This article reviews publications on this topic and aims to highlight the potential risk factors and documented complications.


Herpes zoster is a reactivation of varicella-zoster virus, a member of the Herpesviridae that remains dormant within the dorsal root or cerebral nerve ganglion after a primary varicella infection [1-3]. (Herpes) and (Zoster) are Greek words mean Creeping Girdle [4].  This article aims to review publications on herpes zoster, with a special focus on potential risk factors and reported complications.


Herpes zoster typically presents as a vesicular eruption proceeded by pain, erythema, local edema or abnormal sensation. Pain might be burning, shooting, stapping, itching or aching. It usually follows a ganglion distribution, typically on the thoracic region; however, immunocompromised patients might have disseminated herpes zoster [1, 5-7]. Young patients usually present with an erythematous form, whereas elderly or ill patients present with hemorrhagic or necrotic forms [8].


Herpes zoster is incident among one million, or 4 per 1000 population, per year in the United States and twenty to thirty percent of people will get herpes zoster in their life [6, 9, 10]. It dominates in old age; and rarely, it reactivates during infancy with primary foetal/early infantile infection or during childhood [11-29]. It is still controversial whether it has a sporadic reactivation or it is a seasonal disease [1, 30].


Exact risk factors of reactivation are not well-known; yet, cellular immunity is thought to have a key role [31]. This role is well illustrated in old age due to normal age-related decline in cellular immunity; Plasmodium/malaria infection due to transient depression of cellular immunity and immune suppression in cases of immune deficiencies, human immunodeficiency infection or HIV disease and immunosuppressants [1, 2, 5, 32-44]. The role of genetics and family history is still controversial [41, 45-47].

Table 1: Potential Risk Factors of Herpes Zoster.

Publication Potential Risk factors
(Hamaguchi, 2015) [48] (EVIK, 2013) [49] (Herrero, 2004) [50] Abdominal Liver transplant   
(Moquete, 2012) [51] Splenectomy
(Eryilmaz, 2008) [52] Abdominoplasty/td>
(Levy, 2002) [53] Routine liver biopsy
Sires, 2008) [54] Dermatological Radiesse injection
(Clayton, 2005) [55] Pulsed-dye laser
(Lee, 2005) [56] Post cryosurgery
(Gatti, 2010) [41] (Cvjetkovic, 1999) [1] Psychological Stress; psychological stress and hard work
(Korber, 2007) [57] Ophthalmic Cataract operation
(Jarade, 2002) [58] Laser in situ keratomileusis
(Su, 2011) [59] Others Hematopoietic stem cell transplantation
(Gatti, 2010) [41] Mechanical trauma; facial trauma
(Simms, 2007) [60] Microvascular decompression
(Godfrey, 2006) [61]  (Weiss, 1989) [62] Spinal surgery
(Ramchandani, 2004) [63] Routine removal of third molars
(Su, 1976) [64] Accidental inoculation

Risk of rheumatoid and connective tissue diseases is debateable. It is difficult to attribute the risk of reactivation to the disease per sae; especially that patients are frequently on immunosuppressant medications. Some publications suggest luck of association between herpes zoster and the disease and/or the medication, whereas other researchers propose a possible relationship [65-72].

Other co-existing diseases are diabetes mellitus, essential hypertension, dyslipidaemia, chronic venous diseases, other skin diseases, and malignancies including breast cancer, lung cancer, prostate cancer, lymphoma, lymphatic leukaemia, multiple myeloma and Hodgkins disease with bone marrow transplant [5, 11, 73-78].


Though it usually follows a benign course, herpes zoster is most commonly complicated by post herpetic neuralgia (Table 2). It is proposed that different organopathies are due to either direct infiltration of the virus or indirect hematogenous infection [79].

Table 2: Complications of Herpes Zoster.

Publication Potential Risk factors
(Kalender, 2016) [80] Cardiac Heart block
(Ma, 2007) [81] Pleuropericarditis
(Bricout, 2015) [82] Psychological and functional Decline in functionality and loss of independence
(Chen, 2014) [83] Depression
(Albietz, 2014) [8] Ophthalmic Band keratopathy
(Khalafallah, 2013) [77] (Liesegang, 2008) [84] (McPherson, 1997) [85] (Krimmer, 1994) [86] Herpes zoster ophthalmicus in 10-25%
(Cvjetkovic, 1999) [1] Keratitis, iridocyclitis, secondary glaucoma and loss of sight
(Yeo, 1986) [87] Acute retinal necrosis
(Ellis, 2014) [88] (Eskiizmir, 2009) [89] (Sigaloff, 2007) [90] Neurological Encephalitis in 0.1-0.2%
(Kayipmaz, 2013) [2] (Johnson, 2010) [10] (Brunton, 1995) [91] ost herpetic neuralgia in 20% of patients and in 50% of those older than 60
(EVIK, 2013) [49] (Straube, 1996) [79] Myelitis
(Bessho, 2010) [92] (Young-Barbee, 2009) [93] rown-Sequard syndrome
(Braun-Falco, 2009) [94] Meningoencephalitis
(Straube, 1996) [79] Cerebral angiitis, meningitis
(Gondivkar, 2010) [61] (Bkenkamp, 1990) [23] (Yeo, 1986) [87] Motor Facial nerve palsy
(Jeevarethinam, 2009) [95] Unilateral brachial plexitis
(Cvjetkovic, 1999) [1] Guillain-Barre syndrome
(Flamholc, 1996) [96] Focal muscle paralysis and contralateral hemiplegia
(Braverman, 1986) [97] Focal limb muscle weakness
(Cvjetkovic, 1999) [1] Dermatological Secondary bacterial infection
(Leung, 1986) [98] Scarring
(Spiess, 1986) [99] Obstetric Abortion, embryopathies and organic lesions
(Ellis, 2014) [88] (Nair, 2014) [100] Dermatological Disseminated zoster particularly in immunocompromised patients. It is defined as having greater than twenty vesicles outside the primary or adjacent dermatome or as involvement of three or more dermatomes.
(Ling, 2014) [101] Hepatitis, viral pneumonia and neurogenic chronic cough
(Rudd, 2014) [102] Osteonecrosis
(AlSardar, 2013) [103] Cystitis and penile numbness
(Mahima, 2010) [104] Alveolar bone necrosis and exfoliation of teeth
(Biddlestone, 2009) [105] Acute urinary retention complicated by constipation
(Paudyal, 2006) [106] Diaphragmatic motor weakness
(Tola-Arribas, 1997) [107] Horners syndrome
(Straube, 1996) [79 ] Myositis


Herpes zoster can be confused with similar skin lesions; varicella, erysipelas, impetigo, enteroviral infections, and herpes simplex infections. These diseases are excluded by detailed history-taking and physical examination, laboratory findings, virus isolation and commercially available serological tests. Other differentials are odontalgia, sciatica, and lateral pontomedullary syndrome [1, 108-110].


Herpes zoster per sae is a benign disease in the majority of cases. The main aim of management is to control pain, to prevent new eruptions, to reduce duration and complications and to prevent dissemination [111]. It is commonly managed with anti-viral medication (acyclovir or famciclovir), preferably within 72 hours of rash eruption. Different types of pain associated with herpes should not be confused. Acute herpetic pain is managed with antivirals, non-steroidal anti-inflammatories, opioids and sympathetic nerve blockade. This is different to post herpetic neuralgia, a neuropathic pain commonly treated with antidepressants (amitriptyline, nortriptyline or desipramine,), anticonvulsants (pregabalin or gabapentin) or antiarrhythmic medications [112]. Antibiotics and corticosteroids can be used when required. Rehabilitation program and resting splints are of benefit if needed [1, 2, 6, 7, 92, 99, 113, 114].

On the other hands, surgical nerve decompression, which needs extensive research, was implied by some researchers [115].


Though it is thought to result from cellular immunity decline, herpes zoster was reported following routine procedures. It is classically a benign disease, where post herpetic neuralgia is the most common complication. Yet, physicians should suspect systemic complications in immunocompromised patients.


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