What to check if a patient experiences recurrent herpes zoster (shingles)?

From the Guidelines

If a patient experiences recurrent herpes zoster (shingles), they should be evaluated for underlying immunodeficiency or immunosuppression, and their healthcare provider should check their immune system function through blood tests, including complete blood count, HIV testing, and possibly immunoglobulin levels. This is crucial because recurrent shingles can indicate a weakened immune system from conditions like HIV, cancer, or autoimmune disorders [ 1 ].

Evaluation and Management

When evaluating a patient with recurrent herpes zoster, the following steps should be taken:

• Review medication history for immunosuppressive drugs
• Check for underlying medical conditions that may be contributing to immunosuppression, such as cancer or autoimmune disorders
• Consider referral to an infectious disease specialist or immunologist for further evaluation and management

Treatment Options

For patients with frequent recurrences (more than 3 episodes per year), suppressive therapy with antiviral medications like valacyclovir 500-1000mg daily or acyclovir 400-800mg twice daily may be recommended [ 1 ]. The zoster vaccine (Shingrix) should also be considered, even for those with previous shingles, as it can reduce recurrence risk.

Key Considerations

• Identifying and addressing any underlying cause of immunosuppression is essential for proper management
• Patients with multiple recurrences may require ongoing monitoring and adjustment of their treatment plan
• The zoster vaccine (Shingrix) is a valuable tool in reducing recurrence risk and should be considered for all patients with a history of shingles, regardless of age or underlying medical conditions [ 1 ].

From the FDA Drug Label

Herpes Zoster (Shingles) There are no data on treatment initiated more than 72 hours after onset of zoster rash Patients should be advised to initiate treatment as soon as possible after a diagnosis of herpes zoster.

The patient should be checked for:

• Immune system status: to determine if the patient has a normal immune system or if they are immunocompromised
• Time of onset of zoster rash: to determine if treatment can be initiated within 72 hours
• Presence of postherpetic neuralgia: to assess the risk of long-term pain after the rash has resolved
• Underlying medical conditions: to assess the risk of complications from herpes zoster 2 2

From the Research

Recurrent Herpes Zoster (Shingles) Checks

If a patient experiences recurrent herpes zoster (shingles), the following should be checked:

• The patient's age, as herpes zoster is more prevalent and usually more severe in older patients (i.e., persons over 50 years of age) 3
• The patient's medical history, including any previous episodes of herpes zoster or chickenpox 4
• The patient's immune status, as immunocompromised persons are at higher risk for complications from herpes zoster 4
• The presence of postherpetic neuralgia (PHN), a common complication of herpes zoster that can cause chronic, often debilitating pain 3, 5, 4
• The patient's current medications, including any antiviral agents or corticosteroids that may be used to treat herpes zoster 3, 6, 4

Treatment Options

Treatment options for recurrent herpes zoster (shingles) may include:

• Antiviral agents such as acyclovir, valacyclovir, and famciclovir, which can help shorten the duration of the illness and reduce the risk of PHN 3, 5, 6, 7
• Corticosteroids, which may be used in combination with antiviral agents to reduce inflammation and pain 3, 4
• Pain management medications, such as analgesics and tricyclic antidepressants, which may be used to treat PHN 4

Prevention

Prevention of herpes zoster (shingles) may include:

• Vaccination with the live attenuated zoster vaccine, which is recommended for all persons aged 60 years and older who have no contraindications 4
• Antiviral therapy, which may be used to suppress the virus and prevent future outbreaks of genital herpes 5