© copyright annals of internal medicine, 2011 ann int med. 154 (5): itc3-1. in the clinic herpes...

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

in the clinic

Herpes Zoster


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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


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


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


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


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


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


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


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


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


What symptoms are typical?


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


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

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

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


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)


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


What complications should the clinician anticipate?

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

Postherpetic neuralgia Pain >3 months after rash has resolved

Intensity varies from trivial to debilitating

More frequent with age, severe acute pain, larger rash


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


When should intravenous antivirals be given?

CNS involvement, especially myelitis

Manifestations where active viral replication less certain

For example, delayed contralateral hemiparesis

Dissemination of herpes zoster to liver, lungs, or other visceral organs


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


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


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


When should patients be hospitalized?

If patient has disseminated herpes zoster

If patient has ocular involvement

For observation, supportive care, and IV acyclovir


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


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


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


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. in the clinic herpes...

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