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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

• Fatigue, malaise, headache, low-grade fever, dermatomal rash, weakness (1% may have weakness in distribution of rash; herpes zoster motoricus)
• Rash (typically follows a unilateral dermatomal distribution): Initially erythematous and maculopapular rash that evolves rapidly to grouped vesicles. Vesicles become pustular and/or hemorrhagic in 3 to 4 days; Resolution of rash with crusts separating by 14 to 21 days.
• Possible sine herpete (zoster without rash)

Chronic phase

• Postherpetic neuralgia (15% overall; increases dramatically with age)
• A small percentage (1-5%) may affect the motor nerves causing weakness (herpes zoster motoricus), e.g., facial nerve (Ramsay Hunt syndrome), spinal motor radiculopathies

Treatment       

Supportive Rx:

• Wet dressings with tap water or 5% aluminum acetate (Burow's) applied 30-60 min. 4-6 x/d
• Lotions such as calamine or Caladryl lotion
• Analgesics for pain
• Atarax for itching
• Silver sulfadiazine (Silvadene) topically or PO antibiotics for secondarily infected rash

Anti-Viral Rx:
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):

• Famvir/Famciclovir  500 mg tid x1week for Shingles
• Zovirax/Acyclovir  800 mg 5x/day x1 week for Shingles
• Valtrex/Valacyclovir 500 mg 2 caplets tid x1 week for Shingles.
• IV acyclovir  10 mg/kg IV q 8 h for 7-10 days  or IV foscarnet for 14 days (until healing) for disseminated Herpes Zostrer disease.

Prevention        

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.

Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices
MMWR Morb Mortal Wkly Rep 1996 Jul 12;45(RR-11):1-36 [118 references]

Postherpetic Neuralgia                                                                                                

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.                   

• Neurontin (Gabapentin )  Start 100 mg tid, may increase up to 600 mg tid usual dose (Max  up to 3,600 mg/day)
• Lyrica (Pregabalin) 50 mg PO tid, may increase after 1 week to max 100 mg tid  
  - for painful neuropathy    
• Pain Med  
• Lidoderm/ Lidocaine 5% patch for postherpetic neuralgia for 12 hours/day  
• A medicated skin patch containing capsaicin (Qutenza 8%) was approved last week to treat pain from post-herpetic neuralgia in patients with shingles

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2006