What is the diagnosis and treatment for Herpes zoster (Shingles)?

From the Guidelines

Herpes Zoster (Shingles) Diagnosis and Treatment: Herpes zoster, also known as shingles, is a painful, vesicular, cutaneous eruption caused by the reactivation of varicella-zoster virus (VZV) and can lead to potentially debilitating complications.

Diagnosis

• The diagnosis of herpes zoster is typically based on the clinical presentation of a unilateral, vesicular eruption with dermatomal pain that often precedes the skin findings by 24-72 hours 1.
• The rash usually starts as erythematous macules that rapidly evolve to papules and then to vesicles, which can coalesce and form bullae before scabbing and healing.

Treatment

• Antiviral Therapy: High-dose intravenous acyclovir is the treatment of choice for VZV infections in compromised hosts, while oral acyclovir, famciclovir, and valacyclovir are beneficial for VZV infections in otherwise healthy hosts 1.
• Vaccination: Two types of herpes zoster vaccines, zoster vaccine live (ZVL) and recombinant zoster vaccine (RZV), have been approved for use, with RZV being more effective in preventing herpes zoster and postherpetic neuralgia (PHN) 1.
• Prevention: Recipients of allogeneic blood and bone marrow transplants may take acyclovir (800 mg twice daily) or valacyclovir (500 mg twice daily) during the first year after transplantation to prevent VZV reactivation 1.

Key Considerations

• Immunocompromised Hosts: Herpes zoster occurs more frequently in immunocompromised hosts, and the risk of dissemination and complications is higher in this population 1.
• Vaccine Efficacy: The efficacy of ZVL decreases with increasing age and wanes over time, while RZV maintains its efficacy for up to 8 years and decreases to 73% at 10 years 1.
• Safety: Both ZVL and RZV are generally safe, but RZV is associated with a higher rate of injection-site and systemic reactions compared to ZVL 1.

From the Research

Diagnosis of Herpes Zoster (Shingles)

• Herpes zoster, also known as shingles, is an acute, cutaneous viral infection caused by reactivation of the varicella zoster virus 2
• The incidence of herpes zoster increases with age and immunosuppression 3
• Patients may present with malaise, headache, low-grade fever, and abnormal skin sensations for two to three days before the classic maculopapular rash appears 4
• The rash is usually unilateral, confined to a single dermatome, and typically progresses to clear vesicles that become cloudy and crust over in seven to 10 days 4

Treatment of Herpes Zoster (Shingles)

• Herpes zoster can be treated with antiviral drugs such as acyclovir, valacyclovir, or famciclovir, ideally within 72 hours of the development of the rash 4
• Treatment is focused on symptom control and includes topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic antidepressants for postherpetic neuralgia 4
• The varicella zoster virus vaccine decreases the incidence of herpes zoster and is approved for adults 50 years and older 5, 4
• The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends this vaccine for adults 60 years and older, except for certain immunosuppressed patients 4

Prevention of Herpes Zoster (Shingles)

• The most effective management strategy for herpes zoster is prevention of the disease through vaccination in those who are most vulnerable 2
• The recombinant adjuvanted vaccine is remarkably effective in restoring the protective T cell-mediated immunity required to prevent HZ 5
• The vaccine has been recommended in the USA and Canada for people who are 50 years of age and older 5