Herpes zoster physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; L. Katie Morrison, MD; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Jesus Rosario Hernandez, M.D. [3], Dima Nimri, M.D. [4].


The characteristic physical examination finding of herpes zoster is the maculopapular rash. The rash in typically unilateral and its distribution is confined to one or two adjacent dermatomes. As the rash crusts and heals in 7-10 days, a post-inflammatory hyperpigmentation of the skin may result. Other findings, such as cranial and peripheral nerves involvement depend on the location of the dorsal root ganglia involved.

Physical Examination

Physical examination findings of herpes zoster depend on the location of the rash, as well as the stage of the disease:


The rash of herpes zoster virus is typically unilateral and does not cross the midline. It follows the distribution of one or two adjacent dermatomes. The rash can involve any area of the body, but the most common sites are the face (ophthalmic division of trigeminal nerve), neck (cervical dorsal root ganglia) or chest (thoracic dorsal root ganglia). The rash is initially an erythematous, maculopapular rash, but over the next 7-10 days, it progresses to pustules and ulceration, with crusts, scabbing or both. Post-inflammatory hyperpigmentation may develop along the affected dermatome(s) as part of the healing process. In the immunocompromised individuals, the rash may be complicated by skin necrosis and scarring.[1][2]

Herpes zoster ophthalmicus

When the rash involves the ophthalmic division of the trigeminal nerve, the same characteristic rash will be present in addition to several occular and head and neck findings which may or may not accompany the rash. These include[1][3][4][5]:

  • Hutchinson's sign: a rash on the tip of the nose is a strong predictor of eye involvement
  • Blepharoconjunctivitis: edema and inflammation of the outer eyelids
  • Keratitis: presents with signs of corneal inflammation, which presents with eye pain, redness and photophobia
  • Uveitis: presents with eye redness and elevated intraocular pressure
  • Cranial nerve palsies: herpes zoster virus may involves cranial nerves III, VI and less commonly, IV. Involvement of these cranial nerves may present with pain on eye movement (ophthalmoplegia), as well as pupillary dilatation with a sluggish reaction to light when cranial nerve III is involved.[3][4]

Ramsay Hunt Syndrome

Rarely, herpes zoster may present with a maculopapular rash in the external auditory canal (zoster opticus) or the tympanic membrane. Ramsay Hunt Syndrome refers to zoster rash in the external auditory canal, the tympanic membrane, the ipsilateral anterior two-thirds of the tongue or hard palate, associated with ipsilateral weakness or paralysis of the facial muscles, due to involvement of cranial nerve VII. Syndrome may be associated with signs of hearing loss, involuntary eye movements and nystagmus.[1][3][6]

Other neurological manifestations



(Images shown below courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

Genitourinary System

(Images shown below courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)



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  2. Cohen JI, Brunell PA, Straus SE, Krause PR (1999). "Recent advances in varicella-zoster virus infection". Ann. Intern. Med. 130 (11): 922–32. PMID 10375341. 
  3. 3.0 3.1 3.2 3.3 3.4 Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA (2008). "Varicella zoster virus infection: clinical features, molecular pathogenesis of disease, and latency". Neurol Clin. 26 (3): 675–97, viii. PMC 2754837Freely accessible. PMID 18657721. doi:10.1016/j.ncl.2008.03.011. 
  4. 4.0 4.1 Karmon Y, Gadoth N (2005). "Delayed oculomotor nerve palsy after bilateral cervical zoster in an immunocompetent patient". Neurology. 65 (1): 170. PMID 16009918. doi:10.1212/01.wnl.0000167287.02490.76. 
  5. Shaikh S, Ta CN (2002). "Evaluation and management of herpes zoster ophthalmicus". Am Fam Physician. 66 (9): 1723–30. PMID 12449270. 
  6. Sweeney CJ, Gilden DH (2001). "Ramsay Hunt syndrome". J. Neurol. Neurosurg. Psychiatr. 71 (2): 149–54. PMC 1737523Freely accessible. PMID 11459884. 
  7. Merchut MP, Gruener G (1996). "Segmental zoster paresis of limbs". Electromyogr Clin Neurophysiol. 36 (6): 369–75. PMID 8891477. 
  8. 8.0 8.1 "Public Health Image Library (PHIL)".