What is the True Etiology of “Recurrent Shingles”?

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Ramya Vangipuram
Harrison Nguyen
Stephen Tyring


herpes zoster, herpes simplex, shingles, zosteriform


Purpose:  To determine the true etiology of cases of putative recurrent shingles referred to a dermatology clinic.

Methods: A prospective cohort study of patients aged 15-87 years with reported recurrent herpes zoster was conducted. Vesicular fluid and serology for herpes simplex 1, 2, and varicella zoster virus immunoglobulins were obtained from patients presenting with vesicles. Biopsies were obtained from patients with ambiguous presentations.

Results:  44 patients (56%) had evidence of herpes simplex virus infection. 32% of patients had positive herpes simplex virus cultures or polymerase chain reaction sequencing, and 24% additional patients were diagnosed with presumptive simplex infection based on elevated antibody titers. 44% of patients had a diagnosis other than zoster or simplex. One individual had a positive viral culture for varicella zoster virus. 99% of patients who presented with suspected recurrent herpes zoster had no definitive evidence of varicella zoster virus reactivation.

Conclusions:  The most common diagnosis was herpes simplex infection. Our results suggest that true recurrent shingles in immunocompetent patients is rare.


1. Gnann JW Jr, Whitley RJ. Herpes zoster. N Engl J Med 2002;347:340-346

2. Yawn BP, Wollan PC, Kurland MG et al. Herpes Zoster Recurrences more frequent than previously reported. Mayo Clin Proc. 2011;86(2):88-93.

3. Nakamura Y, Miyagawa F, Okazaki A, et al. Clinical and immunologic features of recurrent herpes zoster (HZ). J Am Acad Dermatol. 2016 Nov;75(5):950-956.e1

4. Chien AJ. Why do so many clinicians believe that recurrent zoster is common? Derm Online J. 2007; 13 (2):2.

5. Volpo A, Gatti A, Pica F. Frequency of Herpes Zoster Recurrence. Mayo Clin Proc. 2011;86(2):584-587.

6. Pierson JC. Reluctance regarding recurrent herpes zoster J Am Acad Derm. 2017 Apr;76(4):e143.

7. Sax P. Common Curbsides: The Patient with “Recurrent Zoster”. December 30, 2014. N Engl J Med Journal Watch. Accessed 12 January 2019. https://blogs.jwatch.org/hiv-id-observations/index.php/common-curbsides-the-patient-with-recurrent-zoster/2014/12/30/

8. Heskel NS, Hanifin JM. "Recurrent herpes zoster": an unproved entity? J Am Acad Dermatol. 1984 Mar;10(3):486-90.

9. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med, 352 (2005), pp. 2271-2284

10. Hope-Simpson R. The nature of herpes zoster: a long-term study and a new hypothesis. Proc R Soc Med. 1965;58:9-20.

11. Ragozzino MW, Melton LJ III, Kurland LT, Chu CP, Perry HO. Population-based study of herpes zoster and its sequelae. Medicine (Baltimore, Md). 1982;61:310-316.

12. Hernandez, P.O., S. Javed, N. Mendoza, W. LaPolla, L.D. Hicks and S.K. Tyring. Family history and herpes zoster risk in the era of shingles vaccination. J Clin Virol. 52:344-348; 2011.

13. Hicks, L.D., R.H. Cook-Norris, N. Mendoza, V. Madkan, A. Arora, S.K. Tyring. Family history as a risk factor for herpes zoster: a case-control study. Arch Dermatol. 144: 603-608; 2008.

14. Lafferty WE, Coombs RW, Benedetti J, et al. Recurrences after Oral and Genital Herpes Simplex Virus Infection. N Engl J Med 1987; 316:1444–9.

15. Forrest WM, Kaufman HE (1976) Zosteriform herpes simplex. Am J Ophthalmol 81: 86-88.

16. Kalman CM, Laskin OL (1986) Herpes zoster and zosteriform herpes simplex virus infections in immunocompetent adults. Am J Med 81: 775-778. [Crossref]

17. Rübben A, Baron JM, Grussendorf-Conen EI (1997) Routine detection of herpes simplex virus and varicella zoster virus by polymerase chain reaction reveals that initial herpes zoster is frequently misdiagnosed as herpes simplex. Br J Dermatol 137: 259-261.

18. Koh MJ, Seah PP, Teo RY (2008) Zosteriform herpes simplex. Singapore Med J 49: e59-60.

19. Aithal S, Kuruvila S, Ganguly S (2013) Zosteriform herpes simplex and herpes zoster: A clinical clue. Indian Dermatol Online J 4: 369.

20. Freeman ML, Sheridan BS, Bonneau RH, Hendricks RL: Psychological Stress Compromises CD8+ T Cell Control of Latent Herpes Simplex Virus Type 1 Infections. J Immunol. 2007, 179: 322-32

21. Schepp ED, Cohen PR. Zosteriform Staphylococcus aureus cutaneous infection: report of two patients with dermatomal bacterial infection. Skinmed. 2015;13:275–281.

22. Cohen PR. Zosteriform impetigo: Wolf's isotopic response in a cutaneous immunocompromised district. Dermatol Pract Concept. 2015 Jul 31;5(3):35-9.

23. Shetty S, Rao R, Pai S. Impetigo contagiosa in a zosteriform pattern. J Paediatr Child Health. 2016 Jun;52(6):684-5.

24. Chen SX, Cohen PR. Edema Bullae Mimicking Disseminated Herpes Zoster. Cureus. 2017 Oct; 9(10): e1780.

25. Braun RP, Barua D, Masouyé I (1998) Zosteriform lichen planus after herpes zoster. Dermatology 197: 87-88.

26. McQuillan G, Kruszon-Moran D, Flagg EW, and Paulose-Ram R. Prevalence of Herpes Simplex Virus Type 1 and Type 2 in Persons Aged 14–49: United States, 2015–2016. NCHS Data Brief. 2018 Feb. No. 304.

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