Is herpes zoster unilateral?
QUESTION: The Varicella zoster virus (VZV) follQws a dermatomal distribution
and unless disseminated, the reactivation of this virus is thought to be unilateral.
Why do the lesions in Figures 1 and 2 appear to cross the midline?
Richard P Usatine
Carmine Clemente
University of California
Los Angeles, CA
Correspondence to:
Dr R Usatine
rusatine@uda.edu
Figure
Figure 2
ANSWER: The answer lies in the anatomy of the spinal
nerves (Figure 3). The posterior primary ramus of each
spinal nerve has a small medial branch and a larger lat-
eral branch. Therefore, the cutaneous innervation to the
back is crossed with the medial branch, only reaching a
few centimeters across the midline.
These clinical photographs of two different cases of
zoster demonstrate the anatomy of the spinal nerves.
These cases are not disseminated zoster, but each case
represents a single dermatome innervated by a single
spinal nerve showing cross-innervation. Both cases were
in otherwise healthy young adults. Neither patient
developed disseminated zoster nor was found subse-
quently to have any underlying illness.
Most zoster cases are acutely painful, uncomplicated,
and resolve spontaneously in 1 to 2 weeks. Disseminated
zoster can occur in immunosuppressed individuals. The
VZV remains latent in the dorsal root ganglia and be-
comes reactivated in zoster. Because we do not have any
curative antiviral agents for VZV, the goals of therapy are
to diminish pain, viral shedding, and duration of symp-
q- " ,, 1: " "j "
z,
Figure 3
toms, and to prevent postherpetic neuralgia. There are data
that suggest that treating zoster with an antiviral agent in
older individuals may prevent post-herpetic neuralgia.13
Acyclovir (Zovirax) was the first antiviral agent with
proven efficacy against VZV. Two newer agents now
available are famciclovir (Famvir) and valacyclovir (Val-
trex). Preliminary data on these new agents indicate that
they are at least as effective as acyclovir for the treatment
of zoster.4 Both newer agents have the advantage of
requiring fewer doses per day and currently valacyclovir
is priced less expensively than acyclovir and famciclovir.
References
1. Jackson JL, Gibbons R, Meyer G, Inouye L. The effect of treating her-
pes zoster with oral acydovir in preventing postherpetic neuralgia. A
meta-analysis. Arch Intern Med 1997; 157:909-912.
2. Wood MJ, Shukla S, Fiddian AP, Crooks RJ. Treatment of acute herpes
zoster: effect of early (< 48h) versus late (48-72 h) therapy with acydovir
and valaciclovir on prolonged pain. JInfectDis 1998; 178:S81-S84.
3. Dworkin RH, Boon RJ, Griffin DR, Phung D. Postherpetic neuralgia:
impact of famciclovir, age, rash severity, and acute pain in herpes zoster
patients. J Infect Dis 1998; 178:S76-S80.
4. Calza AM, Schmied E, Harms M. Systemic corticosteroids do not pre-
vent postherpetic neuralgia. Dermatology 1992; 184:314-316.
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