A case series published in the journal Pediatric Dermatology describes the occurrence of herpes zoster at the site of varicella-zoster vaccination in 7 healthy children without a history of primary varicella.

Each of the 7 children received varicella-zoster vaccination between 12 and 14 months of age; the children were between the ages of 1.5 and 6 years old when they presented with symptoms. Viral exanthem, eczema herpeticum, atopic dermatitis, contact dermatitis, microcystic lymphatic malformation, herpes simplex infection, and herpes zoster infection were all considered in the differential diagnosis.

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In their discussion of the case, the authors acknowledged that herpes zoster can occur in patients without a history of varicella and that it can also occur in patients after varicella vaccination, as previously reported in the literature. “It is likely that the vaccine strain infects cutaneous sensory nerves around the injection site and travels to the dorsal ganglion through retrograde transport,” they write.

As the children in these cases did not present with typical herpes zoster rash, but rather with small pink to erythematous papules, pseudovesicles, and plaques, the authors state that a “high index of clinical suspicion is necessary for timely diagnosis.” Direct fluorescent antibody (DFA) testing was conducted in 4 of the 7 patients.

All of the patients in this case series recovered without complications; 5 were treated with acyclovir and 2 received no treatment. “This series supports and expands upon the existing literature regarding herpes zoster in vaccinated healthy children and highlights the close correlation between the vaccination site and cutaneous eruption,” the authors conclude.

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