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Herpes Zoster (Shingles)
Robert J. Hyde, MD, MA, NRP, FACEP
image BASICS
  • Results from reactivation of latent varicella-zoster virus (human herpesvirus type 3) infection
  • Postherpetic neuralgia (PHN) is defined as pain persisting at least 1 month after rash has healed. The term zoster-associated pain is more clinically useful.
  • Usually presents as a painful unilateral vesicular eruption with a dermatomal distribution
  • System(s) affected: nervous; integumentary; exocrine
  • Synonym(s): shingles
Predominant sex: male = female
  • Incidence increases with age. 2/3 of cases occur in adults age ≥50 years. Incidence is increasing overall as the U.S. population ages.
  • Herpes zoster: 4/1,000 person-years (1)
  • PHN: 18% in adult patients with herpes zoster; 33% in patients ≥79 years of age
Nearly 1 million new cases of herpes zoster annually
Pregnancy Considerations
May occur during pregnancy
Geriatric Considerations
  • Increased incidence of zoster outbreaks
  • Increased incidence of PHN
Pediatric Considerations
  • Occurs less frequently in children
  • Has been reported in newborns infected in utero
Reactivation of varicella-zoster virus from dorsal root/cranial nerve ganglia. Upon reactivation, the virus replicates within neuronal cell bodies, and virions are carried along axons to dermatomal skin zones, causing local inflammation and vesicle formation.
  • Increasing age
  • Immunosuppression (malignancy or chemotherapy)
  • HIV infection
  • Use of immunosuppressant drugs (e.g., following organ transplant surgery)
  • Spinal surgery
  • Herpes zoster vaccination (Zostavax) is recommended by Advisory Committee on Immunization Practices (ACIP) for patients ≥60 years (FDA-approved for patients >50 years) (2,3,4):
    • Vaccine reduces cases of zoster and the incidence of PHN (5,6).
  • Patients with active zoster may transmit disease-causing varicella virus (chickenpox) to susceptible persons.
Immunocompromised individuals, HIV infection, posttransplantation, immunosuppressive drugs, and malignancy
  • Acute phase
    • Rash: initially erythematous and maculopapular; evolves rapidly to grouped vesicles
    • Vesicles become pustular and/or hemorrhagic in 3 to 4 days.
    • Weakness (1% have weakness in distribution of rash)
    • Resolution of rash, with crusts separating by 14 to 21 days
  • Possible sine herpete (zoster without rash) and other chronic disorders associated with varicellazoster virus without the typical rash
    • Herpes zoster ophthalmicus (HZO). Vesicles on tip of the nose (Hutchinson sign) indicate involvement of the external branch of cranial nerve V; associated with increased incidence of ocular zoster.
  • Chronic phase
    • PHN (15% overall; increases with age)
    • A small percentage (1-5%) may affect the motor nerves, causing weakness (zoster motorius); facial nerve (e.g., Ramsay Hunt syndrome); spinal motor radiculopathies.
  • Rash
    • Herpes simplex virus
    • Coxsackievirus
    • Contact dermatitis
    • Superficial pyoderma
  • Pain
    • Cholecystitis
    • Appendicitis
    • Nephrolithiasis
    • Pleuritis
    • Myocardial infarction
    • Diabetic neuropathy
Initial Tests (lab, imaging)
Rarely necessary because clinical appearance is sufficiently distinctive
Follow-Up Tests & Special Considerations
  • Viral culture
  • Tzanck smear (does not distinguish from herpes simplex, and false-negative results occur)
  • Polymerase chain reaction
  • Immunofluorescent antigen staining
  • Varicella-zoster-specific IgM
Test Interpretation
  • Multinucleated giant cells with intralesional inclusion
  • Lymphatic infiltration of sensory ganglia with focal hemorrhage and nerve cell destruction
  • Treatment is directed to control symptoms and prevent complications.
  • Antiviral therapy decreases viral replication, lessens inflammation and nerve damage, and reduces the severity and duration of long-term pain.
  • Prompt analgesic control may shorten the duration of zoster-associated pain.
  • Lotions, such as calamine and colloidal oatmeal, may help reduce itching and burning sensation.
First Line
  • Acute treatment
    • Antiviral agents initiated within 72 hours of skin lesions help relieve symptoms, speed resolution, and prevent or mitigate PHN (7)[A].
    • Valacyclovir: 1,000 mg PO TID for 7 days
    • Famciclovir: 500 mg PO TID for 7 days
    • Acyclovir: 800 mg q4h (5 doses daily) for 7 days
  • Analgesics (acetaminophen, NSAIDs)
  • Corticosteroids given acutely during zoster infection do not prevent PHN (8).
    • Tricyclic antidepressants (TCAs; amitriptyline 25 mg at bedtime and other low-dose TCAs) relieve pain acutely and may reduce pain duration; dose may be titrated up to 75 to 150 mg/day as tolerated.
    • Lidocaine patch 5% (Lidoderm) applied over painful areas (limit 3 patches simultaneously or trim a single patch) for up to 12 hours may be effective.
    • Gabapentin: 100 to 600 mg TID for pain and other quality-of-life indicators; limited by adverse effects
    • P.479

    • Capsaicin cream and other analgesics may be useful adjuncts. Use opioids sparingly.
    • Pregabalin: 50 to 100 mg TID reduces pain, but usefulness is limited by side effects.
  • Prevention of PHN and zoster-associated pain: No treatment has been shown to prevent PHN completely, but treatment may shorten duration and/or reduce severity of symptoms (9)[A].
    • Antiviral therapy with valacyclovir, famciclovir, or acyclovir given during acute skin eruption may decrease the duration of pain.
    • Low-dose amitriptyline (25 mg at bedtime) started within 72 hours of rash onset and continued for 90 days may reduce PHN incidence/duration.
    • Insufficient evidence to suggest that corticosteroids reduce incidence, severity, or duration of PHN (8)
  • Precautions
    • Assess renal function prior to using valacyclovir, famciclovir, or acyclovir.
    • Valacyclovir, famciclovir, and acyclovir are pregnancy Category B.
Second Line
Numerous therapies have been advocated, but supporting evidence to routinely recommend is lacking.
Studies on cupping therapy (traditional Chinese medicine) show potential benefit, but evidence is conflicting (10)[A].
Admission Criteria/Initial Stabilization
Outpatient treatment, unless disseminated or occurring as complication of serious underlying disease requiring hospitalization
Referral to ophthalmology if concern for involvement of ophthalmic branch of the trigeminal nerve
Patient Monitoring
Follow duration of symptoms—particularly PHN. Consider hospitalization if symptoms are severe; patients are immunocompromised; >2 dermatomes are involved; serious bacterial superinfection, disseminated zoster, or meningoencephalitis develops.
No special diet
  • The duration of rash is typically 2 to 3 weeks.
  • Encourage good hygiene and proper skin care.
  • Warn of potential for dissemination (dissemination must be suspected with constitutional illness signs and/or spreading rash).
  • Warn of potential PHN.
  • Warn of potential risk of transmitting illness (chickenpox) to susceptible persons.
  • Seek medical attention if any eye involvement.
  • Immunocompetent individuals should experience spontaneous and complete recovery within a few weeks.
  • Acute rash typically resolves within 14 to 21 days.
  • PHN may occur in patients despite antiviral treatment.
1. Yawn BP, Saddier P, Wollan PC, et al. A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc. 2007;82(11):1341-1349.
2. Hales CM, Harpaz R, Ortega-Sanchez I, et al. Update on recommendations for use of herpes zoster vaccine. MMWR Morb Mortal Wkly Rep. 2014;63(33):729-731.
3. Schmader KE, Levin MJ, Gnann JW Jr, et al. Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years. Clin Infect Dis. 2012;54(7):922-928.
4. Harpaz R, Ortega-Sanchez IR, Seward JF, et al. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;57(RR-5):1-30.
5. Chen N, Li Q, Zhang Y, et al. Vaccination for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2011;(3):CD007795.
6. Langan SM, Smeeth L, Margolis DJ, et al. Herpes zoster vaccine effectiveness against incident herpes zoster and post-herpetic neuralgia in an older US population: a cohort study. PLoS Med. 2013;10(4):e1001420.
7. McDonald EM, de Kock J, Ram FS. Antivirals for management of herpes zoster including ophthalmicus: a systematic review of highquality randomized controlled trials. Antivir Ther. 2012;17(2):255-264.
8. Chen N, Yang M, He L, et al. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2010;(12):CD005582.
9. Li Q, Chen N, Yang J, et al. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2009;(2):CD006866.
10. Cao H, Li X, Liu J. An updated review of the efficacy of cupping therapy. PLoS One. 2012;7(2):e31793.
See Also
  • Bell Palsy; Chickenpox (Varicella Zoster); Herpes Eye Infections; Herpes Simplex
  • Algorithm: Genital Ulcers
  • B02.9 Zoster without complications
  • B02.29 Other postherpetic nervous system involvement
Clinical Pearls
  • Zoster vaccine is recommended for patients ≥60 years of age and is approved for patients >50 years.
  • Patients with herpes zoster should begin antiviral therapy within 72 hours of the onset of rash to be most effective.
  • Patients with active herpes zoster can transmit clinically active disease (chickenpox) to susceptible individuals.