This document discusses Herpes zoster, also known as shingles. It is caused by reactivation of the varicella zoster virus, which also causes chickenpox. Herpes zoster causes a painful rash and is characterized by inflammation of nerve ganglia and vesicles on the skin in the affected dermatome. It most commonly occurs in older adults and can be triggered by factors that weaken the immune system. Complications can include postherpetic neuralgia, in which pain continues after the rash clears. Treatment focuses on antiviral medication to accelerate healing and reduce pain. A vaccine is available to help prevent occurrence in older adults.

1.  Guided by :- Dr. Alpesh Patel
Dr. Uday Patel
 Produced by :- Nancy Hirpara
Bhakti Jivani
Monali Joshi

2.  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.

4.  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

6.  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.

7.  HIV infection
 Cytotoxic or treatment with immuno-
suppressive drugs
 Radiation
 Presence of malignancies
 Old age
 Alcohol abuse
 Stress ( emotional and physical )
 Dental manipulation

8.  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.

9.  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

10.  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.

11.  Approximately 10% of affected individuals
will exhibit no pro-dermal pain.
 The pain may be
-sensitive teeth
-otitis media
-migraine headache
- myocardial infraction or appendicitis,
depending upon which dermatome is
affected

12.  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).

13.  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.

14.  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.

16.  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 osteo-
necrosis may be secondary to damage of
the blood vessels supplying the alveolar
ridges and teeth, leading to focal ischemic
necrosis.

17.  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.

18.  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 with hoarseness,tinnitus,vertigo
and occasional oter dtsterbences.

20.  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.

21.  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.

22.  The virus causes acantholysis, the
formation of numerous free-floating
tzanck cells which exhibit nuclear
margination of chromatin and occational
multinucleation.

23.  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.

24.  Fever should be treated with antipyretics
that do not contain aspirin.
 Antipruritics 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 accelarate healing of the
cutaneous and mucosal lesions.

25.  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.