Management of Herpes Zoster Reactivation in Individuals with Varicella Antibodies
High-dose intravenous acyclovir is the treatment of choice for herpes zoster reactivation in immunocompromised individuals with varicella antibodies, while oral antiviral therapy is appropriate for mild cases in patients with transient immune suppression. 1, 2
Understanding Herpes Zoster Reactivation
- Herpes zoster (shingles) occurs when varicella zoster virus (VZV) reactivates from its latent state in ganglionic neurons, typically in individuals who previously had varicella (chickenpox) and thus have varicella antibodies 3, 4
- The presence of varicella antibodies indicates prior exposure to VZV and identifies patients at risk for future reactivation infection 1
- Reactivation risk increases with advancing age and immunosuppression, with herpes zoster occurring most frequently during the first year following chemotherapy treatment or following receipt of blood, bone marrow, or solid organ transplants 1
Clinical Presentation of Herpes Zoster
- Typical presentation includes prodromal pain that often precedes skin findings by 24-72 hours, followed by a unilateral vesicular eruption with dermatomal distribution 2
- Lesions progress from erythematous macules to papules and then to vesicles, which may coalesce, form bullae, and scab before healing 1
- In immunocompetent hosts, lesions continue to erupt for 4-6 days with total disease duration of approximately 2 weeks 2
- In immunocompromised patients, skin lesions may develop over a longer period (7-14 days) and generally heal more slowly without effective antiviral therapy 1
Treatment Recommendations
For Immunocompetent Patients:
- Oral antiviral therapy with acyclovir (800 mg 5 times daily for 7-10 days), valacyclovir, or famciclovir should be initiated within 72 hours of rash onset 5, 6
- Treatment is most effective if started within the first 48 hours 1
- Adults greater than 50 years of age show greater benefit from antiviral treatment 6
For Immunocompromised Patients:
- High-dose intravenous acyclovir remains the treatment of choice for VZV infections in compromised hosts 1, 2
- Oral acyclovir, famciclovir, and valacyclovir should be reserved for mild cases of VZV disease in patients with transient immune suppression 1
- Consider oral therapy to complete treatment once the patient has shown a clinical response to IV acyclovir 1
- A temporary reduction in immunosuppressive medication should be considered in patients with disseminated or invasive herpes zoster 5
Prevention Strategies
- Recipients of allogeneic blood and bone marrow transplants routinely take acyclovir (800 mg twice daily) or valacyclovir (500 mg twice daily) during the first year following transplant for prevention of VZV and HSV reactivation 1
- The adjuvanted recombinant zoster vaccine (RZV) is recommended as a preventive strategy for immunocompromised patients to reduce the incidence and severity of VZV reactivations 1
- Varicella zoster immunoglobulin within 96 hours of exposure is recommended for varicella-susceptible patients exposed to individuals with active VZV infection 5
Special Considerations and Complications
- Without adequate treatment, some immunocompromised patients develop chronic ulcerations with persistent viral replication, complicated by secondary bacterial and fungal superinfections 1, 2
- If skin lesions suspicious of VZV develop in patients already taking antivirals, antiviral resistance should be investigated 1
- Herpes zoster can lead to postherpetic neuralgia, cranial nerve palsies, zoster paresis, meningoencephalitis, and other neurological complications 7
- Ocular involvement in herpes zoster can lead to rare but serious complications and generally merits referral to an ophthalmologist 3