Recurrence of Herpes Zoster (Shingles)
Yes, shingles can occur more than once in the same person, with approximately 1.2-9.6% of individuals experiencing herpes zoster recurrence after an initial episode. 1
Understanding Herpes Zoster Recurrence
Herpes zoster (shingles) is caused by the reactivation of varicella-zoster virus (VZV), which remains latent in the dorsal root ganglia or sensory nerve ganglia after primary chickenpox infection 2. While most people are familiar with the first occurrence of shingles, it's important to understand that:
- After an initial episode of herpes zoster, the virus remains in the body and can reactivate again
- Recurrence typically occurs in different dermatomes than the initial outbreak 3
- The time between first and second episodes can range from 12 to 28 months 3
- Genomic studies show that recurrent episodes are caused by the same VZV strain that caused the initial episode 3
Risk Factors for Herpes Zoster Recurrence
Several factors increase the likelihood of experiencing shingles more than once:
- Immunocompromised status: Patients with conditions that decrease cell-mediated immunity are 20-100 times more likely to develop herpes zoster 4 and have higher recurrence rates (0.0-18.2% with incidence rates of 17.0-55 cases per 1000 person-years) 1
- HIV infection: Patients with HIV have a more than 15-fold increased risk of developing herpes zoster compared to age-matched controls 2
- Other risk factors 1:
- Female sex
- Family history of herpes zoster
- Comorbidities such as diabetes
- Long-lasting pain after initial episode
- Previous herpes zoster ophthalmicus
Prevention of Herpes Zoster and Its Recurrence
Vaccination is the most effective strategy for preventing both initial and recurrent herpes zoster episodes:
- Two vaccines are currently licensed for prevention of herpes zoster 5:
- Live-attenuated varicella-zoster virus vaccine (ZVL; ZOSTAVAX)
- Adjuvanted VZV glycoprotein E subunit vaccine (RZV; SHINGRIX)
- RZV is more effective than ZVL for prevention of herpes zoster 5
- RZV is non-replicating and safe for use in immunocompromised individuals 5
- The CDC's Advisory Committee on Immunization Practices recommends vaccination for adults 60 years and older, with certain exceptions for immunosuppressed patients 4
Management of Herpes Zoster Episodes
When herpes zoster does occur (whether first episode or recurrence), prompt treatment is essential:
- Antiviral therapy should be initiated within 72 hours of rash development 4
- Treatment options include:
- Acyclovir
- Valacyclovir
- Famciclovir
- For postherpetic neuralgia (the most common complication, occurring in about 20% of patients), treatment focuses on symptom control 4:
- Topical lidocaine or capsaicin
- Oral gabapentin, pregabalin, or tricyclic antidepressants
Clinical Presentation of Recurrent Herpes Zoster
Recurrent episodes of herpes zoster present similarly to initial episodes:
- Prodromal symptoms (malaise, headache, low-grade fever, abnormal skin sensations) for 2-3 days 4
- Classic maculopapular rash that progresses to vesicles and crusts over in 7-10 days 4
- Unilateral distribution confined to a single dermatome 4
- Pain in the affected area, which may persist as postherpetic neuralgia
Important Caveats
- Recurrent episodes typically occur in different dermatomes than the initial outbreak 3
- Individuals remain at risk for recurrence even after an initial episode, highlighting the importance of vaccination 1
- Immunocompromised individuals should be monitored closely due to their significantly higher risk of recurrence 1
- Vaccination should be considered even for those who have already experienced an episode of herpes zoster, as it may help prevent recurrence
Understanding that shingles can indeed recur is important for both patients and healthcare providers in developing appropriate prevention strategies and prompt treatment approaches.