Varicella–zoster virus (VZV) is the etiologic agent for two diseases: varicella (chickenpox) and herpes zoster (shingles). Chickenpox is a very common contagious disease that mostly affects children 2 to 10 years of age and is usually benign; however, chickenpox in adults or immunocompromised persons can have visceral complications and can be fatal (15%). Second attacks of varicella may occur, but these attacks are usually mild and more common in immunocompromised persons. Herpes zoster is caused by a reactivation of the latent VZV and most frequently affects immunocompromised individuals and older people (>50 years of age).

• Exposure to VZV at school, at home, or in the hospital
• Depression of cellular immunity to VZV leads to herpes zoster

• Infected family member or close contact with an infected person
• Immunosuppression (e.g., with cancer, chemotherapy, radiation, immunosuppressive medication, lymphoma)
• Surgery or insult to the spinal cord
• Lack of vaccination

The typical rash of chickenpox is characterized by maculopapules, vesicles, and scabs in various stages of development on the trunk, scalp, face, and extremities. The typical rash of herpes zoster is unilateral with a dermatomal distribution; lesions begin as maculopapules, then progress to vesicles and scabs on the face (trigeminal ganglia), trunk (thoracic ganglia), shoulders and neck (cervical ganglia), and lower extremities (lumbar or sacral ganglia).

• Varicella: low-grade fever, malaise (fatigue), headache, loss of appetite, rash, and pruritus
• Zoster: rash with dermatomal distribution (T3 to L3), tingling and itching progressing to severe pain, zoster ophthalmicus (if the ophthalmic branch of the trigeminal nerve is involved), erythematous maculopapular rash, acute neuritis, postherpetic neuralgia

Chickenpox has a characteristic rash with lesions in all different stages of development and a history of recent exposure. In contrast, herpes zoster may be very difficult to diagnose without serologic testing in the prodromal stage. Appropriate differential diagnosis of herpes zoster must exclude:

• Disseminated herpes simplex virus
• Rickettsialpox
• Impetigo
• Disseminated coxsackievirus infection
• Dermatitis herpetiformis and eczema herpeticum
• Stevens–Johnson syndrome

Chickenpox can be easily recognized clinically by the following.

• Maculopapular rash along with fever; mild constitutional symptoms
• Progression of macules to papules, vesicles, and pustules, which eventually crust
• Crops of lesions in all phases of development
• White shallow ulcers in the mouth

Herpes zoster usually presents with the following.

• Unilateral rash within a dermatome
• Maculopapules that progress to vesicles and eventually crust
• Moderate to severe neuralgia

• Restriction endonuclease analysis—to determine the molecular identity of the VZV
• In situ hybridization and polymerase chain reaction (PCR)—to detect viral DNA in vesicular fluid
• Fluorescent antibody to membrane antigen (FAMA)—to detect VZV antibodies and immune status
• Latex agglutination (LA) test—to make a serologic diagnosis
• Enzyme-linked immunosorbent assay (ELISA)—to make a serologic diagnosis and to determine immune status
• Radioimmunoassay (RIA)—to determine immune status

• Ballooning degeneration of epidermal cells
• Multinucleated giant cells on Tzanck smear
• Eosinophilic intranuclear inclusions
• Invasion (of lesions) by polymorphonuclear leukocytes
• Hemorrhage, edema, and lymphocytic infiltration in ganglia during herpes zoster virus infection

• Biopsy for immunofluorescence testing

Shorten the duration of the current infection and make the patient as comfortable as possible. Because chickenpox is benign in most children, there are no recommendations for treatment other than over-the-counter lotions to relieve itching. However, a vaccine is available for healthy children, and postexposure prophylaxis is recommended for high-risk groups.

• For immunocompetent children who have never been infected—live attenuated varicella vaccine
• For immunocompromised children, adults, or children with AIDS—varicella–zoster immune globulin (VZIG) or intravenous zoster immune plasma (ZIP) (given within 96 hours of exposure to be effective)

• Acetaminophen—for fever (aspirin is contraindicated in children)
• Acyclovir (800 mg five times/day for five to seven days, for adolescents and adults with chickenpox; 800 mg five times/day for 7 to 10 days, for patients with herpes zoster; 10 to 12.5 mg/kg intravenously every eight hours for seven days—for varicella in immunocompromised patients; 800 mg orally qid, for varicella in a woman in the third trimester of pregnancy)
• Valacyclovir (1 g tid for 7 to 10 days)—to accelerate healing of herpes zoster
• Prednisone (60 mg/day for seven days, then 30 mg/day for seven days, then 15 mg/day for seven days)—for pain relief of herpes zoster in normal host (to be taken with acyclovir)
• Antipruritic drugs—usually topical agents
• Capsaicin cream (from cayenne pepper), amitriptyline hydrochloride, and fluphenazine hydrochloride—for pain relief of herpes zoster or post-herpetic neuralgia

May be helpful in reducing the duration and severity of the disease.

• Avoid foods that inhibit immune activity and stimulate inflammation, such as saturated fats, refined foods, sugars, and juice.
• Beta-carotene (50,000 to 100,000 IU/day), zinc (30 to 50 mg/day), vitamin C (1,000 to 1,500 mg tid to qid), vitamin E (400 to 800 IU/day) promote immune function and healing of the lesions.
• Calcium (1,000 to 1,500 mg/day), magnesium (200 mg bid to tid), and B complex (50 to 100 mg/day) protect nerve integrity.
• Additional B12 (500 to 1,000 mcg) may be required, especially with post-herpetic neuralgia.
• Vitamin A (200,000 to 300,000 IU/day for 3 days, then 100,000 to 150,000 IU/day for 3 days, then 50,000 IU/day for three days) helps decrease severity and length of symptoms. Contraindicated in pregnancy and liver disease.

Herbs are generally a safe way to strengthen and tone the body's systems. Ascertain a diagnosis first. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Topical cream applications of concentrated extract of glycyrrhizic acid (from licorice root) can provide symptomatic relief. A poultice made from powdered slippery elm (Ulmus fulva), comfrey (Symphytum officinale), and goldenseal root (Hydrastis canadensis) is soothing, aids healing, and reduces the likelihood of secondary infection.
• Internal treatment supports antiviral activity and immune function. For acute infection, combine equal parts of the following herbs in a tincture (30 to 60 drops tid to qid) or a tea (3 to 4 cups/day): coneflower (Echinacea purpurea), licorice root (Glycyrrhiza glabra), burdock root (Arctium lappa), lemon balm (Melissa officinalis), chamomile (Matricaria recutita), and St. John's wort (Hypericum perforatum). Licorice is contraindicated in hypertension.
• For pain relief and post-herpetic neuralgia combine equal parts tincture of Jamaica dogwood (Piscidia piscipula), wild lettuce (Lactuca virosa), valerian (Valeriana officinalis), marigold (Calendula officinalis), and St. John's wort with ˝ part yellow jasmine (Gelsemium sempervirens). Take 30 to 60 drops tid to qid.

An experienced homeopath should select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Lachesis for herpes zoster across left side of back with flushes of heat
• Mezereum for herpes zoster of the face with headaches and facial neuralgias
• Petroleum for herpes zoster with intense itching that is worse at night

Tepid oatmeal baths may provide relief from itching and burning. Use Aveeno, as commercially available, or place 1 cup of oats in a sock and let soak in tub. Squeeze the sock to release the soothing oat milk. Prepare a tea from peppermint leaf (Mentha piperita), cool and place in a spray bottle. Spray on lesions for temporary pain relief.

Immune function may be stimulated with acupuncture treatments, decreasing the duration and intensity of herpes zoster and post-herpetic neuralgia.

During an outbreak of either varicella or herpes zoster, patients should be monitored for secondary bacterial infections. VZV lies dormant for many years after initial presentation as chickenpox. No further treatment is necessary unless the virus is reactivated as shingles.

Varicella is uncomplicated in most children, usually conferring lifelong immunity. A vaccine is now available for healthy children who have never been exposed to varicella. However, rigid isolation and prophylaxis is recommended for high-risk groups such as immunocompromised children, and adults.

Central nervous system (CNS) involvement of chickenpox, including benign cerebellar ataxia, aseptic meningitis, encephalitis, transverse myelitis, Guillain–Barré syndrome, and Reye's syndrome, is usually benign. Varicella pneumonia can be serious and is more common in adults. Aspirin should not be given to manage elevated temperatures in children because of the association with Reye's syndrome. Severe varicella infections are seen in children treated with cancer chemotherapy or corticosteroids and children with AIDS. CNS involvement of herpes zoster includes meningoencephalitis, granulomatous angiitis (rare), transverse myelitis.

Most cases resolve in two to three weeks. Immunity usually results after one episode. Severe and often fatal infections may occur in newborn infants and patients receiving corticosteroids, cancer chemotherapy, or radiation. VZV resistance to acyclovir has been reported in HIV-positive patients.

High doses of vitamins are contraindicated. Topical applications may be used for symptomatic relief.

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