Herpes Zoster (Shingles)

BASICS

DESCRIPTION

  • Results from reactivation of latent varicella-zoster virus (VZV) (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.
  • Herpes zoster ophthalmicus (HZO) is an important complication involving branch of the trigeminal nerve
  • Zoster usually presents as a painful unilateral vesicular eruption with a dermatomal distribution
  • System(s) affected: nervous; integumentary; exocrine
  • Synonym(s): shingles

EPIDEMIOLOGY

Incidence

  • 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 with higher rates in older adults and women
  • PHN: 18% in adult patients with herpes zoster; 33% in patients ≥79 years of age
  • Individual lifetime risk of 30% in the United States

Prevalence

~1 million new cases of herpes zoster annually in the United StatesPregnancy Considerations
May occur during pregnancyGeriatric 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

ETIOLOGY AND PATHOPHYSIOLOGY

Reactivation of VZV 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.

RISK FACTORS

  • Increasing age
  • Immunosuppression (malignancy or chemotherapy)
  • Physical trauma
  • Female
  • HIV infection
  • Spinal surgery

GENERAL PREVENTION

  • Recombinant herpes zoster vaccine (Shingrix) is the preferred vaccine. It is also recommended for adults who previously received zoster vaccine live (Zostavax).
  • Consider 2 doses of Shingrix for adults aged ≥19 years who are or will be immunodeficient or immunosuppressed.
    • Two doses separated by 2 to 6 months
    • Those who would benefit from completing the series in a shorter period, the second dose can be administered 1 to 2 months after the first.
  • No specific amount of time to wait before giving Shingrix to patients who have had herpes zoster. Do not give Shingrix to patients with acute episode of herpes zoster.
  • Patients with active zoster may transmit disease-causing varicella virus—typically through direct contact.

COMMONLY ASSOCIATED CONDITIONS

Immunocompromised states, HIV infection, posttransplantation, immunosuppressive drugs, and malignancy

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