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Home , Chickenpox, Herpes simplex, Shingles

Herpes Zoster ()

Jessie McCary, MD

nfection with varicella-zoster (VZV) causes two distinct clinical syndromes: primary varicella () and herpes zoster (shingles). Herpes Izoster will be discussed in this chapter. Varicella infection is discussed in a separate chapter.

Once a person has had chickenpox, VZV lies a recurrence. dormant in the human body for decades before Immunocompromised individuals, including reactivating to cause a localized skin eruption in transplant recipients, HIV-infected patients, and the distribution of one or two dermatomes. The patients receiving long term steroids, are at higher Herpes Zoster typical of shingles are painful red (or risk of developing herpes zoster than the general (Shingles) of the T5 vesicles) that occur on one side of the body and do population, and these patients are more likely . not cross the midline. The zoster lesions erupt for to have disseminated and recurrence of The lesions are red, raised, fluid- several days and go through stages of healing over shingles. filled vesicles or the course of 2-4 weeks. blisters that contain The likelihood of occurrence and severity of this Mode of and Pathogenesis varicella-zoster virus. illness are related to each person’s underlying health of Disease Note that these lesions are confined status. Elderly and immunosuppressed (people During an episode of primary varicella infection to a very specific are at highest risk of VZV reactivation, and the (chickenpox), VZV is highly contagious and spread area on one side of resulting illness is often more severe. Antiretroviral both by respiratory droplets (sneezing and coughing) the chest. , if given early in the course of illness, and direct contact. Infection with VZV occurs Photo by can decrease the severity and duration of symptoms when the virus comes into contact with the mucosa Howard Koh MD and reduce the complications of herpes zoster. of the upper respiratory tract or the of the eye. The virus travels in the bloodstream and Distribution via mononuclear cells to the skin, resulting in the The cumulative lifetime of herpes generalized of chickenpox. The virus also zoster is estimated to be 10-20% of the population. infects human cells in the dorsal root ganglia of The majority of cases occur in the elderly, with both the spinal column and cranial nerve ganglia, where sexes affected equally. This infection seems to occur it becomes latent. Essentially protected from the less often in African-American people than white human , VZV typically remains populations, as evidenced by a study of elderly dormant in the ganglia for decades. people in North Carolina. Approximately 4% of Herpes zoster occurs when the virus subse- patients who develop herpes zoster will experience quently reactivates, initially causing and soon

The Health Care of Homeless Persons - Part I - Herpes Zoster (Shingles) 47 Dermatomes. A dermatome is a segmental area of the skin innervated by fibers from a single dorsal nerve root of the . Helpful hints: C6 (thumb), T10 (umbilicus), L5 (top of foot), S1 (bottom of foot). Courtesy of MGH

afterwards a vesicular rash in the distribution of one and not via airborne droplets. This fragile virus or two contiguous dermatomes. Herpes zoster is less can live for short periods of time on fomites such contagious than varicella. Zoster generally spreads as towels, linens, and clothes. These items must be only by direct contact with open, draining lesions viewed as potential sources of transmission. Once

48 The Health Care of Homeless Persons - Part I - Herpes Zoster (Shingles) The Health Care of Homeless Persons - Part I - Herpes Zoster (Shingles) 49 (left) Multinucleated . This Tzanck smear is from a scraping from the base of an unroofed . This microscopic finding of a multinucleated the lesions of shingles have crusted over and are no on the basis of these characteristic giant cell indicates longer draining, the patient is no longer infectious. the presence of a symptoms and findings. confirmation virus of the herpes Remember that a person with shingles cannot is necessary only in cases in which an atypical rash family. transmit zoster or shingles to others. However, renders the diagnosis uncertain. Vesicular fluid can contact with drainage from zoster lesions can cause be examined by Tzanck smear, culture, polymerase (right) chickenpox in individuals who have no history Herpes Zoster chain reaction, or fluorescence microscopy. (Shingles) of the of prior varicella infection and have never had T11-T12 chickenpox. Treatment Dermatomes. Immunocompromised patients with zoster are The goal of treatment of herpes zoster Several of the at risk of developing widespread infection with VZV, is to accelerate the healing of painful lesions and blisters have become called disseminated herpes zoster. This potentially crusted. Severe to prevent complications such as those mentioned pain commonly serious illness may result in skin lesions over the in the next section. Many studies have examined accompanies this entire body and infection of internal organs. This the effects of antiviral with acyclovir (Zovi- infection. Note that infection is thought to be more contagious than raxTM), valacyclovir (ValtrexTM), and these lesions do not cross the mid-line. typical herpes zoster and may be spread by airborne TM (Famvir ), all three of which are FDA-approved Photos by droplets, as in primary varicella infection. For this for the treatment of herpes zoster infection. The Howard Koh MD reason, any patient with disseminated zoster, as well use of oral steroids in combination with antiviral as those at risk for this infection, should be hospital- therapy has also been studied. The evidence that ized with strict respiratory isolation. any of these is effective in preventing complications is limited, and no formal consensus Symptoms and Diagnosis for the use of these agents exists. A of , , and An acceptable approach is to withhold antiviral often precedes the vesicular eruption. Many patients therapy from healthy adults under the age of 50 experience pain and dysesthesias in the distribution unless there is ophthalmic involvement or severe of a sensory dermatome several days or weeks before pain. Patients over the age of 50 should be treated the rash appears. with an antiviral agent. Antiviral agents are more In immunocompetent individuals, the typical effective if begun within 72 hours of the onset of rash begins with groups of fluid-filled vesicles on a symptoms. Some clinicians consider initiating red or erythematous base. These are on one side of therapy after this 72 hour window if new skin the body and limited to one or two dermatomes. lesions continue to emerge. The mainstay of The most commonly involved dermatomes are antiviral therapy for normal adults has been a 7-10 those innervated by the thoracic and lumbar nerves, day course of acyclovir (ZoviraxTM) 800 mg PO and the ophthalmic branch of the . five times per day. Valacyclovir (Valtrex TM) 1000 Crusting of the lesions usually occurs within ten mg PO TID and famciclovir (Famvir TM) 500 mg days but may take as long as one month. PO TID have simpler dosing regimens and may be The diagnosis of herpes zoster is made clinically preferred for this reason. by the history of the prodrome, often with localized Oral antiretrovirals are also effective in HIV pain, and followed by the typical rash. Shingles positive patients with localized zoster infection. can usually be differentiated from chickenpox and Because of the increased risk of relapse, treatment

48 The Health Care of Homeless Persons - Part I - Herpes Zoster (Shingles) The Health Care of Homeless Persons - Part I - Herpes Zoster (Shingles) 49 should continue until all lesions have completely and are not at risk of developing shingles or chick- resolved. If dissemination occurs, intravenous enpox if exposed to a patient with shingles. therapy is indicated. Persons who have never had primary varicella The addition of steroids to an antiviral regimen infection are at risk of developing chickenpox if they has not been proven to prevent post herpetic are exposed directly to the draining vesicles of shin- , but should be considered in patients with gles. For this reason, several precautions should be severe pain in order to reduce the duration of acute taken to decrease the risk to non-immune persons. symptoms. Steroids should not be used in patients Caregivers should wear gloves when examining the with relative contraindications such as diabetes patient. Draining vesicles should be covered with mellitus, gastritis, osteoporosis, or glaucoma. a dressing until they have crusted over. Fomites, Amitriptyline (Elavil TM), a tricyclic antidepres- such as linens and clothes, may harbor the virus and sant that has also been used to treat neuropathic should be handled with gloves. Once crusting of the pain, may decrease the risk of post herpetic vesicles occurs, there is no longer a risk of infectivity. neuralgia. A dose of 25 mg nightly, started within a If these precautions are taken, the risk to others in a couple days of the onset of the rash and continued shelter is minimal. for 90 days, has not been widely studied. Pregnant women who are susceptible to VZV Pain control is a very important aspect in the (have never had chickenpox) and are exposed to a treatment of this illness as well as zoster’s most patient with shingles should be referred for adminis- common , post herpetic neuralgia. tration of varicella zoster immune globulin (VZIG) Potential treatments to control pain include to decrease potential risk to the . ointment (ZostrixTM), tricyclic antidepres- Immunocompromised patients with herpes sants, (NeurontinTM), topical , zoster are at high risk of developing disseminated narcotics, and even regional nerve blocks. disease, in which airborne spread is possible in addi- tion to direct contact. Therefore, hospitalization Complications and respiratory isolation should be considered in Post herpetic neuralgia is the most common immunocompromised patients with localized or complication of herpes zoster, occurring in 10-15 disseminated zoster. percent of all patients. The risk of this complication Varicella is a live, attenuated vaccine increases with age. Post herpetic neuralgia is defined against VZV that was licensed in 1995. It is as sensory symptoms (usually pain or numbness) contraindicated during and is currently that exist in the distribution of the previously not recommended in HIV-infected individuals, involved dermatome more than 30 days after the although its safety in this population is under initial rash. evaluation. Vaccination against VZV is currently Herpes zoster ophthalmicus is another recommended for the following susceptible adults common complication. Caregivers should be aware (without a reliable history of chickenpox or a sero- that involvement of the ophthalmic branch of the logic test indicating immunity): health care workers, trigeminal nerve is potentially sight-threatening. those with close contact to immunocompromised Evidence of this complication may include individuals or young children, and women who unilateral eye pain, vesicular eruption around the could become pregnant. eye, , , iritis, or lid droop. Referral to an ophthalmologist must be made Special Consideratons for Homeless Populations immediately. While not proven by research studies at this Health care providers should monitor patients time, psychological may be a for for signs of bacterial superinfection of skin lesions, the development of herpes zoster. Although the which may require antibiotic therapy. Change in prevalence of herpes zoster in homeless populations mental status, spread of skin lesions beyond two has not been specifically determined, the profound dermatomes, or involvement of the eyes should psychological stresses of homelessness may be prompt immediate referral to specialists. associated with an increased risk of this condition in homeless persons, especially the elderly. Prevention and Control Herpes zoster is not as contagious as primary Summary varicella infection (chickenpox). People who have Herpes zoster results from reactivation of VZV, had chickenpox in the past are considered immune the same virus that causes chickenpox. The illness

50 The Health Care of Homeless Persons - Part I - Herpes Zoster (Shingles) The Health Care of Homeless Persons - Part I - Herpes Zoster (Shingles) 51 is generally less severe than chickenpox, with painful to infectious disease specialists is indicated in these skin lesions that are typically limited to one or two situations. dermatomes. Patients with herpes zoster can transmit VZV to Early treatment of localized zoster infection others via direct contact with draining skin lesions. with antiretroviral is indicated in Only people who have never had chickenpox are at patients over the age of 50 or any patient with risk, and the resulting illness is primary varicella either ophthalmologic involvement or severe pain. infection (chickenpox). This risk becomes minimal Steroids, in addition to anti-retrovirals, may decrease in shelters if skin lesions are covered with dressings the severity and duration of pain. Analgesia is an and gloves are worn when clothes and linens are important aspect in the treatment of this painful handled. E infection. Serious complications may arise from herpes zoster, including disseminated disease, ophthal- The author of this chapter gratefully acknowledges mologic involvement, and infection of various the invaluable contribution of Janet Groth, RN, MS, organs. Immunocompromised individuals are at who authored this chapter in the original Manual. particular risk of complications. Immediate referral

Herpes Zoster Medication List

Generic Brand Name Cost

acyclovir Zovirax $

amitryptyline Elavil $

capsaicin Zostrix $

famciclovir Famvir $$$

gabapentin Neurontin $$$$$

valacyclovir Valtrex $$$$

References Albrecht MA. Clinical features of varicella-zoster infection: herpes zoster. UpToDate; 2002. http://uptodate.com

Abrecht MA. Treatment and prevention of herpes zoster. UpToDate; 2002. http://www.uptodate.com

Alper BS, Lewis PR. Does treatment of acute herpes zoster prevent or shorten ? Journal of Family Practice 2000;49(3):255-264.

Buchbinder SP, Katz MH, Hessol NA, et al. Herpes zoster and human virus infection. Journal of Infectious 1992;166(5):1153-1156.

Cohen JI, Brunell PA, Straus SE, et al. Recent advances in varicella-zoster virus infection. Annals of Internal Medicine 1999;130(11):922-932.

Glesby M, Moore RD, Chaisson RE. Clinical spectrum of herpes zoster in adults infected with human immunodefi- ciency virus. Clinical Infectious Diseases 1995;21(2):370-375.

Gnann JW, Whitley RJ. Clinical practice. Herpes zoster. New England Journal of Medicine 2002;347(5):340-346.

Straus SE, Ostrove JM, Inchauspe G, et al. Varicella-zoster virus . Biology, natural history, treatment, and prevention. Annals of Internal Medicine 1988;108(2):221-237.

50 The Health Care of Homeless Persons - Part I - Herpes Zoster (Shingles) The Health Care of Homeless Persons - Part I - Herpes Zoster (Shingles) 51