At what age does the risk of herpes zoster (shingles) increase in patients?

Age-Related Increase in Herpes Zoster Risk

The risk of herpes zoster increases significantly starting at age 50, with a marked escalation after age 60, and reaches its peak in patients over 85 years old, where lifetime risk approaches 50%. 1

Critical Age Thresholds

Age 50: Initial Risk Elevation

• Age 50 marks the beginning of substantially increased herpes zoster risk, which is why vaccination recommendations typically begin at this age 1
• Approximately 68% of all herpes zoster cases occur in patients aged 50 years and older 2
• The incidence rate in the general adult population ranges from 1.2 to 4.8 cases per 1000 person-years, but this increases progressively with advancing age 1

Age 60: Major Risk Acceleration

• Patients aged 60 and older face approximately double the attack rate compared to those under 50 years 3
• The 2014 IDSA guidelines specifically recommend zoster vaccination for all patients aged ≥60 years, reflecting the substantial risk increase at this threshold 1
• This age group experiences both higher incidence and more severe complications 1

Age 75-85+: Peak Risk Period

• The proportion of postherpetic neuralgia (PHN) among herpes zoster cases aged >75 years reaches 4%, representing the most debilitating complication 1
• In patients aged 79 years and older, PHN occurs in 33% of herpes zoster cases 2
• Among those aged >85 years, the lifetime risk of herpes zoster may increase to 50%, compared to 20-30% in the general population 1
• In the very aged population, the attack rate nearly doubles again compared to those aged 50-60 years 3

Age-Specific Incidence Data

The evidence demonstrates a clear age-gradient in risk:

• Patients aged 55-74 years have an adjusted odds ratio of 4.2 (95% CI 1.8-9.7) for developing PHN compared to younger patients 4
• Patients aged >75 years have an adjusted odds ratio of 10.7 (95% CI 4.6-25.1) for PHN 4
• The overall lifetime risk of herpes zoster occurrence is estimated at 32.2% in Taiwan, with significantly higher rates in older age groups 1

Clinical Implications

The age-related increase in herpes zoster risk is driven by progressive loss of cell-mediated immunity to varicella-zoster virus, which appears to be the primary factor disrupting the containment of latent virus within sensory ganglia 3. This immunosenescence explains why:

• Severe forms of the disease and complications like postherpetic neuralgia are more likely among the elderly 3
• The frail elderly experience greater disease burden and are less able to recover their pre-illness functional status 5
• Vaccination strategies appropriately target adults aged ≥50 years, with stronger recommendations for those ≥60 years 1

Important Caveats

While age is the dominant risk factor, immunocompromised patients of any age face elevated risk:

• In immunocompromised populations, herpes zoster incidence increases with age within each disease category (except for people living with HIV) 1
• For immunocompromised patients aged 18-49 years versus 60-64 years, incidence rates increase from 40 to 51 per 1000 person-years in hematopoietic stem cell transplant recipients 1

The most recent 2024 guidelines from the Infectious Diseases Society of Taiwan confirm that vaccination should be considered for all adults aged ≥50 years, with universal recommendation for those ≥60 years, reflecting the substantial morbidity burden in these age groups 1.