Herpes Zoster / Shingles



by: Karen Vines, MD
Board Certified Family Medicine Physician Grandview Medical Group –Hoover/Trace Crossings

Shingles are caused by the varicella-zoster virus (VZV). This virus causes two clinically distinct forms of the disease. The primary infection of this virus results in varicella (chickenpox), which is characterized by skin blisters on the face, trunk, and extremities. The other clinical form that this virus can cause is herpes zoster, also known as shingles. This results from reactivation of VZV infection. This clinical form of the disease is characterized by a painful, unilateral vesicular (blistering) eruption, which usually occurs in a restricted skin region. The mid and lower backs are the most commonly involved sites of shingles.

Approximately 32 percent of people in the United States will experience shingles. This equates to one million individuals annually. Incidence rates progressively increase with age, presumably due to the decline in VZV-specific cell-mediated immunity.

Shingles is usually characterized by rash and acute pain. The rash starts as red skin lesions that evolve into grouped skin blisters. Within three to four days, these blisters can bust open. In most people, the lesions crust by 7 to 10 days and are no longer considered infectious. Pain is the most common symptom of shingles. The pain may be constant or intermittent and can precede the rash by days to weeks. Most patients describe a deep "burning", "throbbing", or "stabbing" sensation. Some individuals describe the pain only when the involved area is touched, whereas others complain primarily of itching sensation.

While the shingles vaccination is licensed to be used in immunocompetent individuals ages > 50 years of age, the CDC recommends the vaccine for immunocompetent adults over the age of 60. The reason being that the duration of protection may not last until the later decades when the vaccine is needed the most.

The management of shingles includes antiviral therapy, which speeds up the healing process of the skin lesions. The antiviral therapy also decreases the duration and severity of pain. The most clinical benefits are seen in patients who receive the antiviral within 48-72 hours of rash onset. So it is Pain control is very important in the treatment management of shingles. Pain control options include NSAIDs, acetaminophen, and tramadol in the acute phase. Patients may develop post-herpetic neuralgia, which is nerve pain. This nerve pain is due to nerve damage caused by the varicella zoster virus. Post-herpetic neuralgia can last 3 months or longer. First line treatment for post-herpetic neuralgia includes tricyclic antidepressants, gabapentin, and pregabalin.


References:

1. Dworkin RH, Johnson RW. Breuer J. et al. Recommendations for the management of herpes zoster. Clin Infect Dis 2007: 44 Supple 1:S1.
2. Straus SE. Ostrove JM. Inchauspe G. et al. NIH conference. Varicella-zoster virus infections. Biology, natural history, treatment and prevention. Ann Intern Med 1988: 108:221.
3. Oxman MN. Immunization to reduce the frequency and severity of herpes zoster and its complications. Neurology 1995: 45: S41.