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Herpes zoster - Oral Mucosal Lesion
See also in: Overview,Cellulitis DDx,Anogenital,Hair and Scalp
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Herpes zoster - Oral Mucosal Lesion

See also in: Overview,Cellulitis DDx,Anogenital,Hair and Scalp
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Contributors: Susan Burgin MD, Whitney A. High MD, JD, MEng, Carl Allen DDS, MSD, Sook-Bin Woo MS, DMD, MMSc
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Herpes zoster (shingles) is reactivation of a latent infection with the varicella-zoster virus (VZV). After primary infection (chickenpox), the virus lays dormant in dorsal root ganglia for life. Reactivation may be triggered by immunosuppression, certain medications, other infections, or physical or emotional stress. The individual lifetime risk of developing herpes zoster is 1 in 3.

Cutaneous herpes zoster usually begins with a 1-3 day prodrome of burning pain or paresthesias in the affected dermatome, followed by eruption of erythematous papules and vesicles in the same distribution.

Involvement of a thoracic dermatome may simulate acute myocardial infarction. 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. Disseminated zoster, defined as >20 vesicles outside of the primary and adjacent dermatomes, is chiefly a problem of immunocompromised patients (patients with human immunodeficiency virus [HIV], patients with cancer, and those on immunosuppressive drugs). Some patients may suffer acute segmental neuralgia, known as zoster sine herpete, without ever developing a visible skin eruption. Regional adenopathy may be seen.

Zoster may be accompanied by pain acutely. Additionally, a major concern after a zoster outbreak is postherpetic neuralgia, defined as pain and neuropathic symptoms that persist in a dermatome one month beyond resolution of the rash. Risk factors for postherpetic neuralgia include older age, female sex, presence of a prodrome, greater rash severity, and acute pain. Postherpetic neuralgia can be intractable and debilitating, and prevention is an important goal. Other less frequently encountered post-zoster sequelae include herpes zoster granulomatous dermatitis (where a granulomatous eruption develops weeks to months after zoster resolution) and skin infiltration of the site of healed zoster by cells from an underlying hematologic malignancy (so-called isotopic response).

Cerebrovascular accidents, peripheral motor neuropathies, neurogenic bladder, and diaphragmatic paralysis have been associated with zoster. Herpes zoster encephalitis usually appears in the first 2 weeks after the onset of lesions and it has a 10%-20% mortality rate. Lesions may also be at risk for bacterial superinfection. In extreme cases, necrotizing fasciitis may occur.


B02.9 – Zoster without complications

4740000 – Zoster

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Ramsay-Hunt syndrome – Dissemination can occur, particularly in the immunocompromised. This syndrome consists of vertigo, ipsilateral facial weakness, and deafness (with auditory nerve involvement). Involvement of the nasociliary branch of the ophthalmic nerve increases the risk of ocular complications such as conjunctivitis, lid ulcerations, keratitis, glaucoma, optic neuritis, optic atrophy, and panophthalmitis.
  • Herpes simplex virus (HSV) – Lesions may cross the midline and present with similar shallow ulcerations but with more focal involvement. They present extraorally on the skin or vermilion zone of the lip (herpes labialis) and intraorally on the gingiva and hard palate and dorsum of tongue.
  • Aphthous ulcer (canker sore) – Presents as single or multiple painful intraoral ulcerations limited to movable, nonkeratinized mucosa. They may have a unilateral distribution but will not be found on the hard palate or attached gingiva.
  • Herpangina – Ulcers are generally located in the posterior oral cavity and oropharynx; with fever and malaise typical for a viral infection.
  • Hand-foot-and-mouth disease – Patients present with involvement of the hands and feet; with fever and malaise.
  • Pemphigus vulgaris – Bilateral ulcerations that do not correspond to the distribution of the nerve.
  • Paraneoplastic pemphigus – Severe ulcerations of the oral cavity, bilateral, with hemorrhagic scabs of the lips and concomitant underlying malignancy.
  • Necrotizing sialometaplasia – Unilateral single ulcer of the hard or soft palate resulting from ischemia, with a specific histopathology.

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: 07/02/2018
Last Updated: 11/14/2019
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Herpes zoster - Oral Mucosal Lesion
See also in: Overview,Cellulitis DDx,Anogenital,Hair and Scalp
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Herpes zoster : Grouped configuration, Painful skin lesions, Umbilicated vesicle
Clinical image of Herpes zoster
Grouped vesicles on an erythematous base in the T3 distribution.
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