What are the symptoms and treatment options for shingles?

Symptoms and Treatment of Shingles

Shingles (herpes zoster) manifests as a painful cutaneous eruption in a dermatomal distribution, often preceded by prodromal pain, with skin changes progressing from erythematous maculopapular rash to clear vesicles, followed by pustulation and scabbing. 1

Symptoms of Shingles

Prodromal Phase

• Pain: Burning or radiating pain in the affected dermatome typically precedes the rash by several days 2
• Sensory changes: Tingling, itching, or numbness in the affected area
• Systemic symptoms: May include fever, headache, malaise, and anorexia

Acute Rash Phase

• Rash location: Follows a dermatomal distribution, most commonly:

  • Thoracic dermatomes (40-50% of cases)
  • Cranial nerve (20-25%)
  • Cervical (15-20%)
  • Lumbar (15%)
  • Sacral (5%) 1

• Rash progression:

  1. Erythematous maculopapular rash
  2. Clear vesicles appear (contain thousands of infectious viral particles)
  3. Vesicles continue forming for 3-5 days
  4. Pustulation and scabbing follow
  5. Crusts typically persist for 2-3 weeks 1

• Pain characteristics: Can be severe during the acute phase

Complications

• Postherpetic neuralgia (PHN): Persistent pain after rash resolution, occurring in approximately 10-15% of patients 1, 2
• Cutaneous dissemination: May occur in 25-50% of cases, especially in immunocompromised patients 1
• Ocular complications: When affecting the trigeminal nerve (keratitis, iridocyclitis, secondary glaucoma, vision loss) 3
• Neurological complications: Various motor neuropathies, encephalitis, Guillain-Barré syndrome 3
• Secondary bacterial infection of vesicles 3

Treatment Options

Antiviral Therapy

• Start within 72 hours of rash onset for maximum effectiveness 2
• First-line options:
  • Acyclovir 800 mg orally 5 times daily for 7-10 days
  • Valacyclovir 1000 mg orally 3 times daily for 7 days
  • Famciclovir 500 mg orally 3 times daily for 7 days 2

Pain Management

• Acute pain:

  • NSAIDs or acetaminophen for mild pain
  • Opioid analgesics may be necessary for moderate to severe pain 2

• For postherpetic neuralgia:

  • Tricyclic antidepressants (e.g., amitriptyline)
  • Anticonvulsants (e.g., gabapentin, pregabalin)
  • Topical agents: capsaicin cream, lidocaine patches 2, 4

Adjunctive Therapy

• Corticosteroids: May provide modest benefits in reducing acute pain and potentially reducing PHN incidence 2
  • Consider short course of oral prednisone in patients without contraindications
  • Not recommended as monotherapy (must be combined with antivirals)

Special Considerations

• Immunocompromised patients: Often develop more severe disease lasting up to two weeks with higher risk of complications 3
• Ocular involvement: Merits prompt referral to an ophthalmologist 2
• HIV-infected patients: May have multiple dermatomes involved and higher recurrence rates 3

Prevention

• Zoster vaccine: Reduces the incidence of both herpes zoster and postherpetic neuralgia by enhancing zoster-specific cell-mediated immunity 5
• No drug has been proven to prevent recurrence of shingles in HIV-infected persons 1

Clinical Pitfalls to Avoid

• Delayed treatment: Antiviral therapy is most effective when started within 72 hours of rash onset
• Inadequate pain control: PHN can be debilitating and requires aggressive management
• Missing atypical presentations: Some cases may present without pain (especially in elderly) 6
• Overlooking ocular involvement: Can lead to serious complications if not promptly addressed
• Failing to consider underlying immunosuppression: New-onset shingles may be a sign of immunocompromise, including undiagnosed HIV infection

Early recognition and prompt treatment of shingles are essential to reduce the risk of complications and improve outcomes, particularly in preventing the development of postherpetic neuralgia.