Can Varicella-Zoster Virus Cause Symptoms in Hands and Feet?
Yes, varicella-zoster virus (VZV) can definitively cause symptoms in the hands and feet, though this occurs less commonly than the classic dermatomal distribution of shingles. VZV reactivation can lead to peripheral neuropathy affecting the extremities, presenting as pain, numbness, tingling, or burning sensations in a glove-and-stocking distribution 1.
Mechanisms of VZV-Related Hand and Foot Symptoms
VZV causes nerve damage through multiple pathways that can affect the extremities:
Direct nerve inflammation and damage: When VZV reactivates from dorsal root ganglia, it travels along nerve pathways causing inflammation that can extend to peripheral nerves supplying the hands and feet 1, 2.
Peripheral neuropathy patterns: VZV can cause cranial and peripheral nerve palsies, with approximately 5% of zoster patients developing these complications 3, 2.
Small fiber sensory polyneuropathy: The virus can damage small nerve fibers, leading to burning sensations, tingling, and pain in the extremities 4.
Clinical Presentations in Hands and Feet
The symptoms manifest in several distinct patterns:
Postherpetic neuralgia (PHN): Patients may describe "cold burning pain" in a glove-and-stocking distribution affecting both hands and feet, which can be particularly incapacitating in immunocompromised individuals 1.
Sensory symptoms: Numbness, paresthesias, tingling, and burning sensations are the most common manifestations, typically affecting the feet more than the hands 4.
Zoster sine herpete: VZV can cause peripheral nerve symptoms without the characteristic rash, making diagnosis more challenging 2, 5, 3.
Diagnostic Approach
When VZV-related extremity symptoms are suspected:
Look for dermatomal distribution first: Most VZV reactivation follows specific dermatomes, but peripheral nerve involvement can occur 2, 6.
Consider rash-free presentations: If no rash is present but neurological symptoms exist, examine cerebrospinal fluid for VZV DNA by PCR and anti-VZV IgG/IgM antibodies 2, 6.
Electrophysiological testing: Nerve conduction studies can reveal sensory axonal polyneuropathy with low amplitude sensory action potentials 4.
Important Clinical Caveats
Timing matters: Neurological symptoms from VZV often have delayed onset of weeks to months after initial infection, and pain in extremities can actually worsen over time rather than improve 4.
Immunocompromised patients at higher risk: Those with HIV, cancer, or on immunosuppressive therapy experience more severe manifestations and increased risk of peripheral nerve complications 1, 2.
Duration is variable: While skin lesions resolve in 1-2 weeks, complete cessation of nerve pain typically takes 4-6 weeks, though PHN can persist indefinitely 7, 2.
Treatment Considerations
For established VZV-related neuropathic pain in extremities:
First-line pharmacological therapy: Tricyclic antidepressants (amitriptyline, nortriptyline, doxepin), gabapentin, pregabalin, or topical lidocaine patches 1, 7, 2.
Acute treatment: Intravenous acyclovir is indicated for VZV vasculopathy, meningoencephalitis, and myelitis, particularly in immunocompromised patients 2, 5.
Prevention is paramount: Vaccination with recombinant zoster vaccine or zoster vaccine live remains the most effective strategy to prevent both shingles and its neurological complications, including peripheral neuropathy 8, 1.