From the Guidelines
Zoster without vesicles, also known as zoster sine herpete (ZSH), is a relatively rare condition, but its exact prevalence is not specified in the provided evidence. However, it is known that herpes zoster (HZ) is a painful, vesicular, cutaneous eruption from reactivation of varicella zoster virus (VZV), which can lead to potentially debilitating complications 1. The lifetime risk of HZ is estimated to be 20%–30% in the general population, with an increased risk in the elderly and immunocompromised populations 1.
Key Points
- Zoster sine herpete (ZSH) presents with dermatomal pain but lacks the typical vesicular rash, making diagnosis challenging.
- Diagnosis typically relies on clinical suspicion and can be confirmed with PCR testing of skin swabs or serological testing showing a rise in varicella-zoster virus antibodies.
- Treatment follows standard herpes zoster protocols, including antiviral medications.
- Early treatment is crucial to reduce the risk of postherpetic neuralgia, which can occur even in cases without visible lesions.
Given the lack of specific information on the prevalence of ZSH in the provided evidence, it is essential to prioritize early recognition and treatment of herpes zoster, regardless of the presence of vesicles, to reduce the risk of complications and improve patient outcomes. The most effective strategy to prevent HZ and its complications is by vaccination, with two types of HZ vaccines, zoster vaccine live and recombinant zoster vaccine, approved for use 1.
From the Research
Definition and Diagnosis of Zoster Sine Herpete
- Zoster sine herpete (ZSH) is a variant of shingles without the typical vesicular rash, making diagnosis challenging due to the absence of visual cues 2.
- The diagnosis of ZSH can be confirmed using varicella-zoster virus (VZV) DNA polymerase chain reaction (PCR) analysis of intact skin scrapings 2.
- ZSH can cause variable symptoms, such as neuralgia, neuropathic pain, Bell palsy, and Ramsay Hunt syndrome, but does not display the characteristic zoster rash 3.
Prevalence and Epidemiology
- There is limited information available on the prevalence of ZSH, but it is considered an atypical clinical manifestation of herpes zoster (HZ) 3.
- HZ itself is estimated to occur in approximately 1 million cases in the United States annually, with an individual lifetime risk of 30% 4.
- Patients with conditions that decrease cell-mediated immunity are 20 to 100 times more likely to develop HZ, which may also increase the risk of ZSH 4.
Clinical Implications and Treatment
- Prompt initiation of antiviral therapy is crucial for minimizing the duration and severity of radicular pain in ZSH cases 2.
- The misdiagnosis of ZSH and delayed antiviral treatment may lead to severe ZSH sequelae, including postherpetic neuralgia and fatal complications such as VZV encephalitis and stroke 3.
- Larger studies are needed to further evaluate the utility of VZV DNA PCR analysis for accurately diagnosing ZSH and to establish guidelines for its diagnosis and treatment 2, 3.