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Subject: Herpes Zoster (Shingles)
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Results from reactivation of latent varicella-zoster virus (human herpesvirus type 3) infection
Postherpetic neuralgia (PHN) is defined as pain persisting at least 1 month after rash has healed. The term zoster-associated pain is more clinically useful.
Usually presents as a painful unilateral vesicular eruption with a dermatomal distribution
System(s) affected: nervous; integumentary; exocrine
Incidence increases with age. ⅔; of cases occur in adults age ≥50 years. Incidence is increasing overall as the U.S. population ages.
Herpes zoster: 4/1,000 person-years (1)
PHN: 18% in adult patients with herpes zoster; 33% in patients ≥79 years of age
May occur during pregnancy
Increased incidence of zoster outbreaks
Increased incidence of PHN
Occurs less frequently in children
Has been reported in newborns infected in utero
Immunosuppression (malignancy or chemotherapy)
Use of immunosuppressant drugs (e.g., following organ transplant surgery)
Herpes zoster vaccination (Zostavax) is recommended by Advisory Committee on Immunization Practices (ACIP) for patients ≥60 years (FDA-approved for patients >50 years) (2,3 and 4):
Vaccine reduces cases of zoster and the incidence of PHN (5,6).
Patients with active zoster may transmit disease-causing varicella virus (chickenpox) to susceptible persons.
Prodromal phase (sensations over involved dermatome prior to rash)
Boring “knifelike” pain
Constitutional symptoms (e.g., fatigue, malaise, headache, low-grade fever) are variable.
Rash: initially erythematous and maculopapular; evolves rapidly to grouped vesicles
Vesicles become pustular and/or hemorrhagic in 3 to 4 days.
Weakness (1% have weakness in distribution of rash)
Resolution of rash, with crusts separating by 14 to 21 days
Possible sine herpete (zoster without rash) and other chronic disorders associated with varicella-zoster virus without the typical rash
Herpes zoster ophthalmicus (HZO). Vesicles on tip of the nose (Hutchinson sign) indicate involvement of the external branch of cranial nerve V; associated with increased incidence of ocular zoster.
PHN (15% overall; increases with age)
A small percentage (1–5%) may affect the motor nerves, causing weakness (zoster motorius); facial nerve (e.g., Ramsay Hunt syndrome); spinal motor radiculopathies.
Herpes simplex virus
Tzanck smear (does not distinguish from herpes simplex, and false-negative results occur)
Polymerase chain reaction
Immunofluorescent antigen staining
Multinucleated giant cells with intralesional inclusion
Lymphatic infiltration of sensory ganglia with focal hemorrhage and nerve cell destruction
Treatment is directed to control symptoms and prevent complications.
Antiviral therapy decreases viral replication, lessens inflammation and nerve damage, and reduces the severity and duration of long-term pain.
Prompt analgesic control may shorten the duration of zoster-associated pain.
Lotions, such as calamine and colloidal oatmeal, may help reduce itching and burning sensation.
Antiviral agents initiated within 72 hours of skin lesions help relieve symptoms, speed resolution, and prevent or mitigate PHN (7)[A].
Valacyclovir: 1,000 mg PO TID for 7 days
Famciclovir: 500 mg PO TID for 7 days
Acyclovir: 800 mg q4h (5 doses daily) for 7 days
Analgesics (acetaminophen, NSAIDs)
Corticosteroids given acutely during zoster infection do not prevent PHN (8).
Tricyclic antidepressants (TCAs; amitriptyline 25 mg at bedtime and other low-dose TCAs) relieve pain acutely and may reduce pain duration; dose may be titrated up to 75 to 150 mg/day as tolerated.
Lidocaine patch 5% (Lidoderm) applied over painful areas (limit 3 patches simultaneously or trim a single patch) for up to 12 hours may be effective.
Gabapentin: 100 to 600 mg TID for pain and other quality-of-life indicators; limited by adverse effects
Capsaicin cream and other analgesics may be useful adjuncts. Use opioids sparingly.
Pregabalin: 50 to 100 mg TID reduces pain, but usefulness is limited by side effects.
Prevention of PHN and zoster-associated pain: No treatment has been shown to prevent PHN completely, but treatment may shorten duration and/or reduce severity of symptoms (9)[A].
Antiviral therapy with valacyclovir, famciclovir, or acyclovir given during acute skin eruption may decrease the duration of pain.
Low-dose amitriptyline (25 mg at bedtime) started within 72 hours of rash onset and continued for 90 days may reduce PHN incidence/duration.
Insufficient evidence to suggest that corticosteroids reduce incidence, severity, or duration of PHN (8)
Assess renal function prior to using valacyclovir, famciclovir, or acyclovir.
Valacyclovir, famciclovir, and acyclovir are pregnancy Category B.
The duration of rash is typically 2 to 3 weeks.
Encourage good hygiene and proper skin care.
Warn of potential for dissemination (dissemination must be suspected with constitutional illness signs and/or spreading rash).
Warn of potential PHN.
Warn of potential risk of transmitting illness (chickenpox) to susceptible persons.
Seek medical attention if any eye involvement.
Immunocompetent individuals should experience spontaneous and complete recovery within a few weeks.
Acute rash typically resolves within 14 to 21 days.
PHN may occur in patients despite antiviral treatment.
Herpes zoster ophthalmicus: 10–20%
Superinfection of skin lesions
Hepatitis; pneumonitis; myelitis
Cranial and peripheral nerve palsies
Acute retinal necrosis
Bell Palsy; Chickenpox (Varicella Zoster); Herpes Eye Infections; Herpes Simplex
Algorithm: Genital Ulcers
B02.9 Zoster without complications
B02.29 Other postherpetic nervous system involvement
053.9 Herpes zoster without mention of complication
053.10 Herpes zoster with unspecified nervous system complication
4740000 Herpes zoster (disorder)
2177002 Postherpetic neuralgia (disorder)
Zoster vaccine is recommended for patients ≥60 years of age and is approved for patients >50 years.
Patients with herpes zoster should begin antiviral therapy within 72 hours of the onset of rash to be most effective.
Patients with active herpes zoster can transmit clinically active disease (chickenpox) to susceptible individuals.