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Primary Care

Herpes Zoster: Clinical Presentation and Treatment

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SUMMARY:

Herpes zoster, more commonly known as shingles, is caused by a virus that establishes latency on dorsal root and cranial nerve ganglia after a varicella-zoster (chickenpox) infection. Eventual reactivation of the virus causes it to spread from a nerve root to a cutaneous dermatome and produce a characteristic painful rash. The incidence of herpes zoster increases with age, which is why the rash usually presents in elderly populations, with a median age of 64.

  • Clinical presentation
  • Differential diagnosis
  • Complications
  • Treatment

Clinical Presentation

  • Painful prodrome typically precedes rash by 2 to 3 days
  • Pain can be constant or intermittent—usually described as a “burning” or “throbbing”
  • Rash manifests as erythema and macules, followed by papules
    • Papules develop into vesicles in 1 to 2 days
    • Vesicle formation continues for 3 to 4 days
    • All types of lesions (erythema, macules, papules, vesicles) may be present at 1 week
  • Lesions tend to cluster at cutaneous nerve branches
  • Only a single dermatome is typically affected in immunocompetent patients
Classic Presentation Along Dermatome
Zoster can Also Present on Back

Differential Diagnosis

  • Can be confused with zosteriform herpes simplex and contact dermatitis
  • Diagnostic tests such as PCR and immunohistochemical analysis of a skin scraping can be used to confirm diagnosis

Complications of Herpes Zoster

  • Mostly limited to immunocompromised populations (e.g. AIDS, chemotherapy)
    • Encephalitis
    • Herpes zoster ophthalmicus with delayed contralateral hemiparesis
    • VZV retinitis
    • Myelitis
    • Persistent pain (postherpetic neuralgia)

Treatment

Antiviral Therapy Shortens Duration of Rash and Viral Shedding

  • Acyclovir: 800 mg 5 times daily for 7 to 10 days
  • Famciclovir: 500 mg 3 times daily for 7 days
  • Valacyclovir: 1000 mg 3 times daily for days

Acute Pain

  • Treat acute pain with OCT analgesics: Acetaminophen or NSAIDs
    • Keep lesions clean and dry
  • If OCTs fails, consider longer term pain management
    • Gabapentin: Start with 100 mg capsule twice a day and titrate up 300 mg 3 times a day
    • Pregabalin: 75 mg daily titrated up to 300 mg in 3 divided doses
    • Nortriptyline: 10 mg and titrate up to 40 mg nightly
  • There is no indication for systemic glucocorticoids
  • Therapy during the acute phase does not prevent postherpetic neuralgia
  • Lesions may take 2 to 4 weeks to heal

Secondary Bacterial Infections

  • Treat with systemic antibiotics to cover staph and strep (such as cephalosporin)

Additional Considerations

  • Transmission Risk
    • Patients with active lesions can transmit VZV to persons who have not had varicella infection, varicella-zoster vaccination or immunocompromise patients
    • Pregnant women who do not have adequate varicella titers are also at higher risk
    • Patients are considered contagious until all lesions have crusted over
  • Varicella Vaccination
    • Adults who do not have antibodies to varicella should receive 2 doses of varicella vaccine 1 to 2 months apart
    • Exceptions: Pregnant woman or women planning pregnancy

Learn More – Primary Sources:

IDSA: Recommendations for the treatment of herpes zoster, Clinical Infectious Diseases 2007

AAFP: Herpes Zoster and Postherpetic Neuralgia: Prevention and Management

CDC: Shingles (Herpes Zoster)

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Related ObG Topics:

Shingles Vaccine: CDC/ACIP Recommendations 
Vaccination in Pregnancy: CDC Recommendations and ACOG Update
CDC Adult Vaccination Schedule

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