Can shingles recur?

Shingles Recurrence

Yes, shingles can recur, though recurrence is relatively uncommon in immunocompetent individuals but occurs more frequently in immunocompromised patients, particularly those with HIV infection.

Recurrence Patterns

• In the general population of immunocompetent individuals, approximately 1.2-9.6% may experience shingles recurrence, with an incidence rate of 1.7-16.6 cases per 1000 person-years 1
• Immunocompromised individuals have a significantly higher risk, with recurrence reported in up to 18.2% of cases and incidence rates of 17.0-55 cases per 1000 person-years 1
• HIV-infected patients specifically may experience more frequent recurrences of shingles compared to the general population 2

Risk Factors for Recurrence

Several factors increase the risk of shingles recurrence:

• Immunocompromised status: HIV infection, chemotherapy, malignancies, and chronic corticosteroid use 3
• Advanced age: Older individuals have declining cellular immune responses to varicella-zoster virus 2
• Female sex 1
• Family history of herpes zoster 1
• Comorbidities such as diabetes 1
• Long-lasting pain after the initial shingles episode 1
• Herpes zoster ophthalmicus (involvement of the ophthalmic branch of the trigeminal nerve) 1

Clinical Presentation of Recurrent Shingles

Recurrent shingles typically presents similarly to the initial episode:

• Prodromal pain or discomfort in the affected dermatome
• Local edema and erythema preceding the rash
• Maculopapular and vesicular rash that evolves into crusts 2

In immunocompromised patients, particularly those with HIV:

• Pain and itching may occur several days before skin lesions appear
• Multiple dermatomes may be involved
• Lesions may be more numerous and severe 2

Prevention of Recurrence

According to current guidelines:

• No drug has been proven to prevent recurrence of shingles in HIV-infected persons 4, 5
• Vaccination is the most effective strategy for prevention of herpes zoster and its complications 5
• For immunocompetent adults aged 60 years and older, a live attenuated vaccine can significantly reduce the incidence of both herpes zoster and postherpetic neuralgia 6

Management of Acute Episodes

When shingles recurs, prompt treatment is essential:

• Antiviral therapy should be initiated within 72 hours of rash onset for optimal effectiveness 3
• Recommended options include:
  • Valacyclovir 1 gram three times daily for 7 days 5
  • Acyclovir or famciclovir as alternatives 3
• For immunocompromised patients with acyclovir-resistant HSV, intravenous foscarnet or cidofovir may be used 4

Complications and Their Management

• Postherpetic neuralgia: The most common complication, may require:
  • Various analgesics
  • Tricyclic antidepressants or anticonvulsants in low doses
  • Capsaicin, lidocaine patches, or nerve blocks in selected patients 3
• Ocular complications: Keratitis, iridocyclitis, secondary glaucoma, or vision loss may occur and generally require ophthalmology referral 3

Special Considerations

• HIV-infected patients may develop more severe disease with longer duration, more numerous lesions, and higher risk of cutaneous dissemination 2
• Pregnant women with shingles usually have a mild course, but there have been rare reports of congenital abnormalities 2

Remember that while recurrence is possible, it is not the norm for most immunocompetent individuals. However, patients should be educated about recognizing early symptoms to enable prompt treatment if recurrence does occur.