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Herpes zoster in Child

See also in: Cellulitis DDx,Anogenital,Hair and Scalp,Oral Mucosal Lesion
Contributors: Susan Burgin MD, Craig N. Burkhart MD, Dean Morrell MD
Other Resources UpToDate PubMed


Zoster, or shingles, is a reactivation of a latent infection with varicella-zoster virus (VZV). Annual incidence is less than 1/1000 in children aged younger than 10 years. Maternal varicella infection during pregnancy, infection during the first year of life, and immunocompromised status are risk factors for zoster development in childhood.

Involvement of the ophthalmic branch of the trigeminal nerve may lead to herpes zoster ophthalmicus. Herpes zoster oticus (Ramsay-Hunt syndrome) occurs with involvement of the vestibulocochlear nerve. Herpes zoster duplex is the simultaneous occurrence of zoster in 2 noncontiguous dermatomes and herpes zoster multiplex refers to this phenomenon occurring in more than 2 dermatomes. While most patients with herpes zoster duplex or multiplex are adults, children affected by this condition have also been reported.

Although the onset of cutaneous zoster in adults typically involves a 1- to 3-day prodrome of burning pain or tingling in the affected dermatome, this is rarely observed in children. Postherpetic neuralgia is also rare in children. Other less frequently encountered post-zoster sequelae include herpes zoster granulomatous dermatitis.

If it occurs, zoster encephalitis usually appears in the first 2 weeks after the onset of lesions and has a 10%-20% mortality rate. Disseminated zoster occurs 5-10 days after the onset of dermatomal disease. It is defined as more than 20 lesions outside the initial dermatome of involvement.

Immunocompromised patient considerations: Immunocompromised patients have a higher risk of disseminated zoster. In patients with HIV and AIDS, multidermatomal, necrotic, or recurrent zoster may occur. Persistent ulcers and chronic hyperkeratotic zoster are further manifestations. A strong association of herpes zoster multiplex with underlying malignancy (especially lymphoma) was reported in one retrospective study.


B02.9 – Zoster without complications

4740000 – Herpes zoster

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Herpes simplex virus infection occurring within a dermatomal distribution is the primary differential diagnosis. Serology, viral culture, or polymerase chain reaction (PCR) may be necessary to distinguish this diagnosis from zoster.
  • Allergic contact dermatitis  may present as a well-defined vesicular plaque. A dermatomal distribution suggests zoster.
  • Molluscum contagiosum , when inflamed, can be confused with varicella-zoster. Cases are typically of longer duration, and VZV PCR studies are negative. The presence of coexisting noninflamed molluscum lesions is a helpful diagnostic clue.
  • Cellulitis or Erysipelas
  • Folliculitis
  • Herpangina
  • Arthropod bite or sting
  • Other poxviruses (Cowpox, Mpox)
  • Pyoderma gangrenosum
  • Primary Varicella infection and Disseminated herpes zoster
  • Urticaria
  • Bullous Fixed drug eruption
  • Eczema herpeticum
  • Vasculitis

Best Tests

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Management Pearls

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Reviewed:04/11/2018
Last Updated:09/05/2023
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Herpes zoster in Child
See also in: Cellulitis DDx,Anogenital,Hair and Scalp,Oral Mucosal Lesion
A medical illustration showing key findings of Herpes zoster : Grouped configuration, Painful skin lesions, Umbilicated vesicle, Dermatomal distribution
Clinical image of Herpes zoster - imageId=128116. Click to open in gallery.  caption: 'Grouped vesicles on an erythematous base in the T3 distribution.'
Grouped vesicles on an erythematous base in the T3 distribution.
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