What is Herpes Zoster (Shingles)?

From the Guidelines

Shingles vaccination is the most effective strategy to prevent the disease and its complications, and I strongly recommend the recombinant zoster vaccine for adults, as stated in the recent guidance published in the Journal of Microbiology, Immunology and Infection 1. The lifetime risk of herpes zoster (HZ) is estimated to be 20%–30% in the general population, with an increased risk in the elderly and immunocompromised populations.

• The guidance offers recommendations and suggestions for HZ vaccination in adults, aiming to reduce the disease burden of HZ and its complications.
• Two types of HZ vaccines, zoster vaccine live and recombinant zoster vaccine, have been approved for use.
• The recombinant zoster vaccine is preferred due to its higher efficacy and safety profile, especially in immunocompromised individuals.
• The vaccine should be administered in two doses, 2-6 months apart, and is recommended for adults over 50 years old, even if they have already had shingles.
• It is essential to note that the vaccine not only prevents the disease but also reduces the risk of postherpetic neuralgia, a condition where pain persists for months or years after the rash heals, as mentioned in the study 1.
• Pain management is crucial for patients with shingles, and may include acetaminophen, NSAIDs, or in severe cases, prescription medications like gabapentin or pregabalin.
• Keeping the rash clean and covered is also important to prevent spreading the virus to others who haven't had chickenpox.
• Early treatment and vaccination can significantly reduce the risk of complications and improve quality of life for patients with shingles, as supported by the recent study 1.

From the FDA Drug Label

Two randomized, double-blind trials, 1 placebo-controlled and 1 active-controlled, were conducted in 964 immunocompetent adults with uncomplicated herpes zoster. Treatment was initiated within 72 hours of first lesion appearance and was continued for 7 days In the placebo-controlled trial, 419 patients were treated with either famciclovir 500 mg three times daily (n=138), famciclovir 750 mg three times daily (n=135) or placebo (n=146). The median time to full crusting was 5 days among famciclovir 500 mg-treated patients as compared to 7 days in placebo-treated patients The times to full crusting, loss of vesicles, loss of ulcers, and loss of crusts were shorter for famciclovir 500 mg-treated patients than for placebo-treated patients in the overall study population. The effects of famciclovir were greater when therapy was initiated within 48 hours of rash onset; it was also more profound in patients 50 years of age or older. Among the 65. 2% of patients with at least 1 positive viral culture, famciclovir treated patients had a shorter median duration of viral shedding than placebo-treated patients (1 day and 2 days, respectively). There were no overall differences in the duration of pain before rash healing between famciclovir - and placebo-treated groups In addition, there was no difference in the incidence of pain after rash healing (postherpetic neuralgia) between the treatment groups. In the 186 patients (44. 4% of total study population) who developed postherpetic neuralgia, the median duration of postherpetic neuralgia was shorter in patients treated with famciclovir 500 mg than in those treated with placebo (63 days and 119 days, respectively).

Famciclovir is effective in the treatment of Herpes Zoster (Shingles). The median time to full crusting was shorter in patients treated with famciclovir 500 mg compared to placebo. Additionally, famciclovir reduced the duration of viral shedding and postherpetic neuralgia in some patients. Key points include:

• Treatment initiation: Within 72 hours of first lesion appearance
• Dosage: 500 mg three times daily
• Duration of treatment: 7 days
• Benefits: Shorter time to full crusting, reduced viral shedding, and shorter duration of postherpetic neuralgia in some patients 2

From the Research

Definition and Symptoms of Shingles

• Shingles, also known as herpes zoster, is a viral infection caused by the reactivation of the varicella-zoster virus 3.
• Common symptoms of shingles include fever, pain, and itch before the onset of a rash, as well as post-herpetic neuralgia, which is the most common complication associated with the infection 3.

Treatment of Shingles

• Antiviral therapy is the primary treatment for shingles, with oral valaciclovir, famciclovir, or aciclovir being the most commonly used medications 4, 5.
• Intravenous aciclovir therapy is reserved for severe cases, such as disseminated varicella zoster virus infection, ophthalmic involvement, or very severe immunosuppression 4.
• Foscarnet is used to treat aciclovir-resistant herpes zoster 4.
• Analgesic therapy should be combined with early antiviral treatment to reduce the incidence and severity of acute zoster pain and post-herpetic neuralgia 4, 5.

Prevention of Shingles

• Routine vaccination for individuals over 60 years has been shown to reduce the incidence of shingles and post-herpetic neuralgia 3.
• Treatment with antiviral drugs and analgesics within 72 hours of rash onset can reduce the severity and complications associated with shingles and post-herpetic neuralgia 3.

Management of Shingles

• Practical, evidence-based recommendations for the management of acute shingles have been published, including guidelines for antiviral therapy, pain management, and prevention of complications 6.
• The management of shingles should be individualized based on the patient's age, immune status, and the severity of the infection 4, 5, 3.