TOC | ID | DERM
Shingles (Herpes Zoster)
RX | Prevention See vaccine_herpeszoster
A disease usually presenting as a painful unilateral dermatomal rash eruption. It results from reactivation of varicella-zoster (chickenpox) virus that has been dormant in the dorsal root ganglia.
SIGNS AND SYMPTOMS
Herpes Zoster patients often have prodromal symptoms (prior to rash) of burning, aching, and/or lancing pain, numbness, tingling, and/or itching prior to the appearance of classic vesicles with an erythematous base that typically follows a unilateral dermatomal distribution. The outbreak is bilateral in 4% of patients, and recurrences in immunocompetent patients occur in 1 to 5% of cases, with 50% of these recurring in the same dermatome. Occasionally, cutaneous dissemination, defined as involvement of 20 or more vesicles outside primary or adjacent dermatomes, may occur. Other complications of Herpes zoster include postherpetic neuralgia (PHN), ophthalmic zoster, motor paralysis, secondary bacterial infection, pneumonitis, encephalitis, and hepatitis.
Acute Phase Constitutional symptoms
Antiviral agents, if initiated early (within 48-72 hours of rash) are of benefit in relieving symptoms and speeding resolution of rash. Postherpetic neuralgia is probably reduced when antiviral agents prescribed in acute phase of zoster. Clearly indicated for zoster associated with serious underlying condition and in ophthalmic zoster.
For Herpes Zoster (Shingles):
Varicella virus vaccine (Varivax) was approved in the United States in March of 1995 and is recommended by the American Academy of Pediatrics for all children 12 months of age or older. One dose is recommended for children 12 months to 13 years of age, and two doses, with a 4- to 8-week interval, for those older than 13. In children, seroconversion after one dose of the Varivax vaccine occurs in 97% of cases, and it gives 95% protection against severe disease. Use of this live attenuated vaccine is contraindicated in immunocompromised persons, those with a family history of immunodeficiency, those with anaphylaxis to neomycin, and pregnant women. Side effects include injection site tenderness in 20 to 30% of patients, a transient rash in 5 to 10%, and, rarely, fever with a temperature of 102°F or greater. Studies are in progress to determine if a "booster" immunization 4 to 6 years after the primary vaccine is necessary. Also, the vaccine is being tested in older persons to boost their natural immunity to VZV and to prevent zoster.
Varicella-zoster immune globulin (VZIG) is recommended for passive immune prophylaxis of the immunocompromised patient if exposure to the virus occurs without previous varicella infection or vaccination. VZIG should also be considered in neonates whose mothers develop varicella 5 days before delivery until 2 days after delivery and in susceptible pregnant women exposed to VZV.
of varicella: recommendations of the Advisory Committee on Immunization
MMWR Morb Mortal Wkly Rep 1996 Jul 12;45(RR-11):1-36 [118 references]
Corticosteroid efficacy to prevent postherpetic neuralgia remains controversial. Some sources advocate symptomatic ganglionic block to prevent postherpetic neuralgia. Capsaicin, transcutaneous electrical nerve stimulation (TENS) and low dose amitriptyline are the current treatment(s) of choice for postherpetic neuralgia.