Fitzpatrick's Dermatology In General Medicine (Two Vol.

Set) 6th edition (May 23,

2003) : by Irwin M. Freedberg
(Editor), Arthur Z. Eisen (Editor), Klauss Wolff (Editor), K. Frank Austen (Editor), Lowell
A. Goldsmith (Editor), Stephen
Katz (Editor) By McGraw-Hill Professional
By OkDoKeY

Fitzpatrick's Dermatology In General Medicine

CONTENTS
Editors
Contributors
Preface
Notice

Part One: Introduction

Part Two: Biology and Development of Skin
Part Three: Disorders Presenting in the Skin and Mucous Membranes
Part Four: Dermatology and Medicine
Part Five: Diseases Due to Microbial Agents, Infestations, Bites, and Stings
Part Six: Therapeutics

Chapter 194. Varicella and Herpes Zoster

Kenneth E. Schmader; Michael N. Oxman
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Varicella and Herpes Zoster at a Glance

Varicella (chickenpox) and herpes zoster (shingles) are distinct clinical entities caused by
a single member of the herpesvirus family, varicella-zoster virus (VZV).

Varicella, an acute, highly contagious exanthem that occurs most often in childhood, is
the result of primary VZV infection of a susceptible individual.

The rash usually begins on the face and scalp and spreads rapidly to the trunk, with
relative sparing of the extremities. Lesions are scattered rather than clustered, and
progress from rose-colored macules to papules, vesicles, pustules, and crusts. In
varicella, in contrast to smallpox, lesions in all stages are usually present on the body at
the same time.

In normal children, systemic symptoms are usually mild and serious complications are
rare. In adults and immunologically compromised persons of any age, varicella is more
likely to be associated with life-threatening complications.

Where use of varicella vaccine in susceptible children and adults is widespread, the
incidence of varicella is markedly reduced, although breakthrough varicella may occur.

Herpes zoster is characterized by unilateral, dermatomal pain, and rash that results from
reactivation and multiplication of endogenous VZV that had persisted in latent form
within sensory ganglia following an earlier attack of varicella.

The erythematous, maculopapular, and vesicular lesions of herpes zoster are clustered
rather than scattered because virus reaches the skin via sensory nerves rather than
viremia.

Herpes zoster is most common in older adults and immunosuppressed individuals.

Pain is an important clinical manifestation of herpes zoster, and the most common
debilitating complication is chronic pain or postherpetic neuralgia (PHN).

Antiviral therapy and analgesics reduce acute pain; lidocaine patch (5%), high dose
capsaicin patch, gabapentin, pregabalin, opioids, and tricyclic antidepressants may
reduce the pain of PHN.

A live attenuated zoster vaccine reduces the incidence of herpes zoster by one-half and
the incidence of PHN by two-thirds.

Epidemiology of Varicella
Varicella is distributed worldwide, but its age-specific incidence differs in temperate versus
tropical climates, and in populations that have received varicella vaccine. In temperate climates
in the absence of varicella vaccination, varicella is endemic, with a regularly recurring seasonal
prevalence in winter and spring, and periodic epidemics that depend upon the accumulation of
susceptible persons. In Europe and North America in the prevaccination era, 90% of cases
occurred in children younger than 10 years of age and fewer than 5% in individuals older than
the age of 15.1 From 1988 to 1995, there were approximately 11,000 hospitalizations and 100
deaths caused by varicella each year in the United States.24 The risk of hospitalization and death
was much higher in infants and adults than in children, and most varicella-related deaths
occurred in previously healthy people.5 In tropical and semitropical countries, the mean age of
varicella is higher and susceptibility among adults to primary VZV infection is significantly
greater than in temperate climates. High levels of susceptibility to varicella among adult
immigrants from tropical climates are well ...
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