From the Guidelines
Diagnosis and Treatment of Herpes Zoster (Shingles)
The appropriate workup for Herpes Zoster (Shingles) includes a physical examination to confirm the diagnosis, and in some cases, a viral culture or PCR test to rule out other conditions 1.
Treatment
Treatment typically involves antiviral medications such as:
- Acyclovir 800mg five times a day for 7-10 days
- Valacyclovir 1g three times a day for 7-10 days
- Famciclovir 500mg three times a day for 7-10 days These medications can help reduce the severity and duration of symptoms when started within 72 hours of rash onset 1.
Pain Management
Pain management is also crucial, and over-the-counter pain medications such as acetaminophen or ibuprofen can be used. In some cases, prescription pain medications like gabapentin or pregabalin may be necessary to manage postherpetic neuralgia, a potential complication of shingles.
Prevention of Infection and Hospitalization
It is also recommended to keep the rash clean and dry, and to avoid scratching to prevent infection. In severe cases or in individuals with weakened immune systems, hospitalization may be necessary.
Vaccination
Vaccination against shingles, such as with the recombinant zoster vaccine, is also recommended for adults 50 years and older to prevent the condition 1. The recombinant zoster vaccine is preferred over the live zoster vaccine due to its higher efficacy and longer duration of protection 1.
Key points to consider:
- The recombinant zoster vaccine has a higher efficacy (97.2%) compared to the live zoster vaccine (51.3%) 1.
- The recombinant zoster vaccine provides longer protection against shingles and postherpetic neuralgia, with a duration of protection of up to 10 years 1.
- Vaccination is recommended for all adults 50 years and older, regardless of their history of shingles or varicella infection 1.
From the Research
Diagnosis of Herpes Zoster
- Herpes zoster (shingles) is diagnosed clinically by recognition of the distinctive, painful vesicular rash appearing in a unilateral, dermatomal distribution 2
- Laboratory testing, including polymerase chain reaction, can confirm atypical cases 2
- The diagnosis of HZ is usually made by history and physical examination, with virus isolation and serological tests used in exceptional cases 3
Treatment of Herpes Zoster
- Treatment with acyclovir, famciclovir, or valacyclovir decreases the duration of the rash 2
- Adjunct medications, including opioid analgesics, tricyclic antidepressants, or corticosteroids, may relieve the pain associated with acute herpes zoster 2
- Antiviral treatment should be started as early as possible, with various factors determining the indication to initiate an antiviral medication 4
- Early and sufficient analgesic treatment according to the WHO pain ladder and, if required, with anticonvulsant adjuvants is necessary to treat acute pain and to reduce the risk for postherpetic neuralgia (PHN) 4
Prevention of Herpes Zoster
- Immunization to prevent herpes zoster and postherpetic neuralgia is recommended for most adults 60 years and older 2
- The recombinant VZV subunit zoster vaccine is recommended for all adults of 60+ years and for immunocompromised persons of 50+ years 4
- A live, attenuated vaccine aimed at boosting immunity to VZV and reducing the risk of HZ is now available and is recommended for adults older than 60 years 5
Management of Postherpetic Neuralgia
- Postherpetic neuralgia in the cutaneous nerve distribution may last from 30 days to more than six months after the lesions have healed 2
- Evidence supports treating postherpetic neuralgia with tricyclic antidepressants, gabapentin, pregabalin, long-acting opioids, or tramadol; moderate evidence supports the use of capsaicin cream or a lidocaine patch as a second-line agent 2
- Early recognition and treatment of HZ can reduce acute symptoms and may also reduce PHN 5