in the clinic

Herpes Zoster

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
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© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
Who should receive the vaccine against
varicella zoster?
 Immunocompetent ≥60 years (regardless prior HZ)
 Zostavax (concentrated version of chickenpox vaccine)

 Single, subcutaneous dose in the deltoid of arm

 Don’t use antivirals 24h before until 14d after vaccination

 Can be given at same time as flu vaccine

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What are risk factors for herpes zoster?

 Occurs at any age in persons with previous varicella

 Risk factors
 Being older than age 60
 Being immunocompromised from disease or medical Rx
 Having varicella before 1 yr of age

 Proximate cause rarely established

 Recurrence uncommon

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
Who should not receive the vaccine against
varicella zoster (a live-virus vaccine)?
 Those with a life-threatening or severe allergic reaction
to gelatin, neomycin, or another component of vaccine

 Those with leukemia, lymphoma, or another blood or

bone cancer

 Those with HIV/AIDS who have T-cell counts <200

 Those treated with drugs that affect the immune system,

including high-dose steroids

 Women who are or might be pregnant

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What is the evidence that the vaccine works?
Shingles Prevention Study
 Double-blind RCT: 38,546 people ≥60y with Hx of varicella

 315 HZ cases among vaccine recipients vs. 642 with placebo

 27 cases of postherpetic neuralgia among vaccine recipients

vs. 80 among placebo recipients

 Vaccine more effective preventing HZ in those <70 but more

effective preventing postherpetic neuralgia in those ≥70

 Effective for at least 6 years

Observational study
 75,761 vaccinated and 227,283 unvaccinated people ≥60y

 Vaccine reduced frequency of HZ and involvement of the

eye and hospitalizations for HZ

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What are the barriers to vaccination?

 Fewer than 10% eligible people in U.S. receive vaccine

 Costs $100 to $300

 Most expensive vaccine for older adults

 Many physicians unaware Medicare pays for it

through Part D instead of Part B

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
When should clinicians consider low-
dose acyclovir to prevent herpes zoster?
 Low-dose acyclovir recommended for:

 Immunocompromised patients who can’t receive the VZV

vaccine because it contains a live virus

 Including patients receiving bortezomib and recipients of

allogenic transplants of peripheral blood stem cells

 Comparable dose of valacyclovir / famciclovir can be used

 Note: For patients receiving anti-TNF-α therapy, low-dose

acyclovir not yet recommended

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
CLINICAL BOTTOM LINE: Prevention…
 Herpes zoster (shingles) occurs most commonly in…
 People >60y with age-related immune system weakening
 People who are immunocompromised

 Live-virus vaccine recommended to prevent varicella in

children and adults w/o antibodies against VZV

 Concentrated formulation of the vaccine against varicella

recommened to prevent herpes zoster in adults ≥60y

 Vaccine contraindicated if immune system weakened

 Use low-dose acyclovir instead

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
Can serologic tests help guide decisions
about vaccination for herpes zoster?

 To establish whether immunity present

 Obtain titers of serologic antibodies against VZV

 However, screening before vaccination unneeded

 Safe to vaccinate immune persons

 Postvaccination serologic testing not recommended

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
CLINICAL BOTTOM LINE: Screening…
 Screening for serologic antibodies to VZV before vaccination
 Generally not required
 Safe to vaccinate people already immune to the disease

 However, screening provides information on immunity status

 Might be useful to some people

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What symptoms are typical?

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What symptoms are typical?
 Erythematous, maculopapular rash
 Band-like distribution corresponds to affected nerve

 Does not cross the midline

 Isolated lesions outside primary dermatome not unusual

 Rash is followed by clear vesicles for 3 to 5 days,

pustulation, and scabbing

 Other possible symptoms

 Generally feeling unwell, malaise

 Photophobia, headache

 Significant fever is rare

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What conditions can be confused with
herpes zoster?
 Contact dermatitis cutaneous reaction to topical Rx
 Especially from exposure to toxic plants
 Localized HZ-like rash doesn’t usually conform to
dermatomal distribution

 Zosteriform herpes simplex, especially in sacral area

 Painful skin vesicles with distribution that may mimic HZ
 Patients with >2 episodes HZ should have virologic testing
to distinguish between HSV and varicella zoster virus

 Consider an alternative diagnosis if

 The patient has a rash without pain
 Rash doesn’t conform to a dermatomal distribution
 Neuralgic pain persists without typical skin eruption

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
When should clinicians consult a specialist
to help diagnose herpes zoster?
 Infectious disease specialist or dermatologist
 For assistance recognizing atypical presentations
 For assistance with procedures such as skin biopsy

 Ophthalmologist
 Eye involvement (herpes zoster ophthalmicus)

 Otolaryngologist
 Facial nerve involvement (Ramsay-Hunt syndrome)

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
CLINICAL BOTTOM LINE: Diagnosis…
 Characteristic rash in the involved dermatome
 Erythematous maculopapular rash followed by clear
vesicles for 3 to 5 days, pustulation, and scabbing
 Sensations may range from mild itching or tingling to
severe pain preceding the development of skin lesions
 Clinical appearance of fully developed HZ is quite distinct
 When diagnosis isn’t obvious, order confirmatory lab tests
 Differential Dx: contact dermatitis; HSV infection
 Consult specialists when presentation is atypical or complex

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What complications should the clinician
anticipate?
 Postherpetic neuralgia
 Pain >3 months after rash has resolved
 Intensity varies from trivial to debilitating
 More frequent with age, severe acute pain, larger rash
 Vision and hearing impairments
 Neurologic complications
 Vasculopathy, myelitis, cranial and peripheral nerve
palsies, and polyradiculitis

 Bacterial infection of cutaneous lesions

 Varicella zoster infection of lungs and CNS
 In immunocompromised persons

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What antiviral drugs are available to
treat herpes zoster?
 For those presenting within 72h of lesion onset:
 Start antiviral drug: famciclovir; valacyclovir; or acyclovir
 Reduces pain duration
 Shortens new lesion formation duration
 Accelerates healing + reduce duration of viral shedding
 Role in postherpetic neuralgia less clear

 For those presenting >72h after lesion onset:

 Use antivirals if new vesicle formation continuing or patient
has complications (cutaneous, motor, neurologic, ocular)
 Despite lack of evidence on effectiveness

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
When should intravenous antivirals be given?
 CNS involvement, especially myelitis

 Dissemination of herpes zoster to liver, lungs, or other

visceral organs

 Manifestations where active viral replication less certain

 For example, delayed contralateral hemiparesis

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What drugs can be used for control of
acute pain?
 Even with limited skin involvement, pain can be severe
 Early pain relief may reduce risk of postherpetic neuralgia

 Start with OTC pain relief (acetaminophen, ibuprofen)

 Have low threshold for adding a short-acting narcotic
 Prescribe on a regular schedule, not “as-needed”
 Consider adding gabapentin or tricyclic antidepressant
 Be aware some tricyclic antidepressants (amitriptyline)
can cause serious problems in older adults

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
 What is the role of corticosteroids in
treating herpes zoster?

 Corticosteroids don’t reduce frequency or severity of

postherpetic neuralgia
 But provide other benefits: early healing and less acute pain

 Prescribe 10 to 14 days of tapering oral prednisone for

patients >50y with moderate-to-severe pain
 Prescribe only if you also prescribe antiviral drugs

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What nondrug therapies should be
considered when managing herpes zoster?

 Keep cutaneous lesions clean and dry

 Wash rash with soap and water and pat dry
 Warm or cool astringent soaks may be soothing
 Consider using sterile, occlusive, nonadherent dressing
to protect lesions and promote healing
 Wear loose-fitting clothing
 Topical creams and ointments provide no benefit

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
When should patients be hospitalized?

 If patient has disseminated herpes zoster

 If patient has ocular involvement

 For observation, supportive care, and IV acyclovir

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
When should a specialist be consulted?
 Pain specialist
 When treating postherpetic neuralgia

 Neurologist
 When patient develops vasculopathy or myelitis

 Ophthalmologist
 All patients with herpes zoster ophthalmicus

 Infectious disease specialist

 For managing antiviral drugs

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What should patients know about their
herpes zoster?
 How to soothe and protect involved skin

 What to expect regarding potential for chronic

 Dosing regimen for pain medicines

 Risk of transmitting virus to others and causing

chickenpox (varicella)
 Avoid contact with susceptible infants, small children,
pregnant women, and immunocompromised individuals

 Virus transmits primarily through direct contact, but also

through the air

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
What other complications should a clinician
look for after an episode of herpes zoster?
 Contralateral hemiparesis
 VZV can induce CNS angiitis and result in stroke-like
symptoms
 Hemiparesis contralateral to antecedent trigeminal zoster

 Multifocal vasculopathy
 Consider if altered mental status or focal neurologic
findings during / after episode

 Acute retinal necrosis

 Consider in patients w/ acute visual changes and Hx of HZ
 Most cases occur in patients w/ AIDS

 Herpes zoster not associated with increased cancer risk

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.
CLINICAL BOTTOM LINE: Treatment…
 Use antiviral drugs: famciclovir, valacyclovir, acyclovir
 Add oral corticosteroids for beneficial anti-inflammatory effects
 Treat pain early and aggressively
 To reduce acute and postherpetic neuralgia
 Start with OTC pain relievers and add short-acting narcotic
analgesics if needed
 Use on scheduled rather than an as-needed basis
 Use conservative measures to soothe and protect involved skin
 Hospitalize for disseminated HZ infection or ocular involvement
 Consult a specialist if Dx or management unclear or complicated

© Copyright Annals of Internal Medicine, 2011

Ann Int Med. 154 (5): ITC3-1.