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

Herpes zoster - Oral Mucosal Lesion

See also in: Overview,Cellulitis DDx,Anogenital,Hair and Scalp
Contributors: Susan Burgin MD, Whitney A. High MD, JD, MEng, Carl Allen DDS, MSD, Sook-Bin Woo MS, DMD, MMSc
Other Resources UpToDate PubMed


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.

Oral findings of zoster may be secondary to involvement of the maxillary or mandibular branch of the trigeminal nerve (V2 or V3 respectively). Intraoral zoster may be preceded by facial pain, toothache, or intraoral tingling. The upper cutaneous lip, palate, and upper gingiva may manifest grouped vesicles, which rupture rapidly if intraoral, eventuating into erosions. The remainder of the V2 dermatome, including the cheek and temple, may also be involved. In V3 zoster, the tongue, lower gingiva, buccal mucosa, floor of the mouth, and the lower cutaneous lip may be affected. Cutaneous involvement of V3 includes the chin, lower cheek over the mandible, preauricular area, and temporal scalp. With oral involvement, complete loss of or altered taste may occur.

Ramsay-Hunt syndrome occurs when VZV affects the geniculate ganglion of the facial nerve, typically giving rise to ipsilateral facial weakness, ear pain, vesicles of the external auditory canal and other parts of the ear, and hearing loss. The trigeminal nerve may be affected in this syndrome, in which case, the anterior two-thirds of the tongue, the palate, and/or the lips may be involved.

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. Disseminated zoster, defined as more than 20 vesicles outside of the primary and adjacent dermatomes, is chiefly a problem of immunocompromised patients (patients with 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. In the mouth, complications include periodontal inflammation, osteonecrosis, and loss of teeth.

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. Osteonecrosis and associated loss of teeth are reported to occur more frequently in HIV-positive individuals.


B02.9 – Zoster without complications

4740000 – Herpes zoster

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Differential Diagnosis & Pitfalls

  • 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.
  • Oral cytomegalovirus infection – Single or multiple, 1- to 3-cm, painful ulcers that are slowly progressive and persistent in an immunocompromised individual.
  • 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.
  • Traumatic eosinophilic granuloma – Usually a single, slowly enlarging, painless ulcer.
  • Chemotherapy-induced mucositis – Ulceration and hemorrhage on multiple mucosal surfaces that develop within 1-2 weeks of the initiation of chemotherapy.
  • Mucormycosis – Rapidly progressive ulceration can be seen on the nasal turbinates, septum, and palate with an adherent black eschar.
  • Histoplasmosis – In chronic disseminated histoplasmosis, oral ulcers are a common finding, including palatal ulcers.
  • Tertiary syphilis – Gummas may affect the palate, where they appear as punched-out ulcers.

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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:07/01/2018
Last Updated:10/11/2021
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Herpes zoster - Oral Mucosal Lesion
See also in: Overview,Cellulitis DDx,Anogenital,Hair and Scalp
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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