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Subject: Herpes Zoster (Shingles)
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Results from reactivation of latent varicella-zoster virus (VZV) (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
Individual lifetime risk of 30% in the United States
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)
Herpes zoster vaccination (Shingrix) is approved and recommended by the CDC for adults 50 years and older (1).
Shingrix is recommended for adults who previously received Zostavax and is the preferred vaccine.
Live VZV vaccine (Zostavax) (recommended for >60 years) is contraindicated in immunosuppressed persons, patients with HIV and CD4 counts <200, patients undergoing cancer treatment, and patients with hematologic or lymphatic (1),(2).
Patients with active zoster may transmit disease-causing varicella virus—typically through direct contact.
Prodromal phase (sensory changes over involved dermatome prior to rash)
Boring “knife-like” pain
Allodynia and hyperalgesia
Constitutional symptoms (e.g., fatigue, malaise, headache, low-grade fever) are variable.
Rash: initially erythematous and maculopapular; evolves to characteristic grouped vesicles usually in one dermatome but may affect two to three adjacent dermatomes
Thoracic and lumbar dermatomes are most commonly involved sites (2).
Vesicles become pustular and/or hemorrhagic in 3 to 4 days.
Weakness in distribution of rash (1%)
Rash crusts and resolves by 14 to 21 days.
Possible sine herpete (zoster without rash) and other chronic disorders associated with VZV 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 HZO
PHN is the most common complication (15% overall; increases with age).
1–5% of cases may affect the motor nerves, causing weakness (zoster motorius), facial nerve (e.g., Ramsay Hunt syndrome), spinal motor radiculopathies.
Lesions usually heal 2 to 4 weeks after onset, but scarring and pigmentation changes are common (2).
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
Treat to control symptoms and prevent complications.
Antiviral therapy decreases viral replication; lessens inflammation, nerve damage; and reduces the severity and duration of long-term pain.
Prompt analgesia may shorten the duration of zoster-associated pain.
Calamine and colloidal oatmeal may help reduce itching and burning.
Antiviral agents initiated within 72 hours of skin lesions help relieve symptoms, speed resolution, and prevent or mitigate PHN (3)[A].
Antivirals do not significantly reduce the incidence of PHN (4)[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
In children, oral acyclovir is the drug of choice.
Analgesics (acetaminophen, NSAIDs)
Corticosteroids do not prevent PHN but may accelerate resolution of acute neuritis.
Tricyclic antidepressants (TCAs); amitriptyline 10 to 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 three patches simultaneously or trim a single patch) for up to 12 hours may be effective.
Gabapentin: 300 to 600 mg TID for pain; limited by adverse effects
Capsaicin cream and other analgesics may be useful adjuncts. Use opioids sparingly.
Capsaicin 8% patch or plaster provides pain relief for patients with PHN (5)[C]; better tolerated when initially applied with topical anesthetic
Pregabalin: 150 to 300 mg/day divided BID or TID reduces pain; use is limited by side effects.
Prevention of PHN and zoster-associated pain: Nothing prevents PHN entirely, but treatment may shorten duration and/or reduce severity.
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.
Paravertebral blockade: Nerve blocks during the acute phase shorten the duration of pain; somatic blocks, paravertebral blocks, and repeated/continuous epidural blocks can be used to prevent PHN (6)[A].
Insufficient evidence to suggest that corticosteroids reduce incidence, severity, or duration of PHN
Assess renal function prior to using valacyclovir, famciclovir, acyclovir, gabapentin, and pregabalin.
Valacyclovir, famciclovir, and acyclovir are pregnancy Category B.
Outpatient treatment, unless disseminated or occurring as complication of serious underlying disease requiring hospitalization
Consultation with ophthalmology for ophthalmic involvement (VZO).
The rash typically lasts 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.
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)
Antiviral therapy within 72 hours of the onset of rash is most effective.
Patients with active herpes zoster can transmit clinically active disease (chickenpox) to susceptible individuals.
Shingrix is the recommended vaccine for healthy adults 50 years and older, including those who previously received Zostavax, to prevent shingles and related complications.