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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. 2/3 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
PHN: 18% in adult patients with herpes zoster; 33% in patients ≥79 years of age
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)
Herpes zoster vaccination (Zostavax) is recommended by Advisory Committee on Immunization Practices (ACIP) for patients ≥60 years (FDA approved for patients >50 years) 1,2:
Patients with active zoster may transmit diseasecausing varicella virus (chickenpox) to susceptible persons.
Prodromal phase (sensory changes over involved dermatome prior to rash)
Possible sine herpete (zoster without rash) and other chronic disorders associated with varicellazoster virus without the typical rash
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
Direct treatment 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 analgesia may shorten the duration of zoster-associated pain.
Lotions, such as calamine and colloidal oatmeal, may help reduce itching and burning.
Analgesics (acetaminophen, NSAIDs)
Corticosteroids given acutely during zoster infection do not prevent PHN.
Prevention of PHN and zoster-associated pain: Nothing has been shown to prevent PHN completely, but treatment may shorten duration and/or reduce severity of symptoms.
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)
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.
Zoster vaccine is recommended for patients ≥60 years of age and is approved for patients >50 years.