Shingles / Herpes Zoster

 Herpes Zoster / Shingles

Painful Skin Rash

Your parents aged 50 years or older could be at risk of Shingles. Over 90% of adults over 50 already carry the virus that causes Shingles. One in three people will develop Shingles in their lifetime. The disease has been recognized since ancient times. Shingles has no relationship to season and does not occur in epidemics. There is, however, a strong relationship with increasing age.

The family name of all the herpes viruses  derives from the Greek word herpēs, from herpein ("to creep") referring to the latent, recurring infections typical of this group of viruses. Zoster comes from Greek zōstēr, meaning "belt" or "girdle", after the characteristic belt-like dermatomal rash. The common name for the disease, shingles, derives from the Latin cingulus, a variant of Latin cingulum, meaning "girdle". Because herpes zoster affects the nerve cells in the body, it is very common for the rash to appear in the formation of a band on one side of the body along the path of a nerve.

Varicella zoster virus (VZV) has a high level of infectivity  and has a worldwide. prevalence. Shingles is a re-activation of latent VZV infection: zoster can only occur in someone who has previously had chickenpox (varicella).

Herpes zoster usually clears in 2 to 3 weeks and rarely returns. If the virus affects the nerves that control movement (the motor nerves), one  may have temporary or permanent weakness or paralysis. Sometimes the pain in the area where the shingles occurred may last from months to years.  Although symptoms can be severe, risk of death is very low.

Shingles causes a rash that is contagious and painful. The disease can have serious complications. The best thing you can do to reduce your risk is to get the Shingles vaccine. And increase your immunity by exercise, healthy diet.

The incidence rate of shingles ranges from 1.2 to 3.4 per 1,000 person‐years among younger healthy individuals, increasing to 3.9–11.8 per 1,000 person‐years among those older than 65 years, and incidence rates worldwide are similar. This relationship with age has been demonstrated in many countries, and is attributed to the fact that cellular immunity declines as people grow older.

Introduction

Shingles Virus / or Varicella zoster virus

Varicella is less contagious than measles, but more contagious than mumps and rubella.

                                              

Different phases of varicella zoster viral infection

Shingles or Herpes zoster, is caused by varicella virus. Varicella-Zoster virus (VZV) is a DNA virus that belongs to the α-herpesvirus family. It causes chickenpox as a primary infection and herpes zoster (shingles) if reactivation occurs later in life. It usually occurs later in life when the virus gets re-activated under stress or with immune suppression. Chicken pox-like lesions occur in restricted areas (dermatome) that are innervated by a single ganglion; The vesicles appear in a dermatomal distribution, almost always unilaterally. Skin lesions: Usually in the thorax. Shingles of an intercostal nerve produces vesicular eruptions and burning pain in the affected dermatome. Chronic burning or itching pain called post-herpetic neuralgia. Maculopapular with an erythematous base, and usually heal in about two weeks. Reactivation can affect the eye via the trigeminal nerve and the brain via the cranial nerve VII and VIII. In immunocompromised life-threatening disseminated pneumonia may occur

Shingles is  caused by the reactivation of varicella virus. This is the same virus that causes chickenpox. After the body recovers from chickenpox, the virus can lie dormant and eventually reactivate as shingles.

 In adults, shingles typically cause a rash  to form on trunk, along one of the thoracic dermatomes. The rash may be preceded by pain, itching, or tingling in the area. A person with a weakened immune system may develop a more widespread shingles rash that covers three or more dermatomes. This is called disseminated zoster. 

It is characterized by a painful skin rash with blisters in a localized area. Typically the rash occurs in a single, wide mark either on the left or right side of the body or face. Two to four days before the rash occurs there may be tingling or local pain in the area.

Blisters on localized area

Rash appears on One side of the body

Rash that appears on one side of the body. The rash is accompanied by a pricking and sometimes stabbing pain. It erupts into clusters of small red patches that develop into blisters.Within 7 - 10 days the blisters break open and a fluid comes out. During this period, if anyone who never had chickenpox  before, accidentally touches the oozing blisters of the patient, he/she will develop chickenpox. Once the fluid comes out, the rash slowly begins to dry and crust. The rash disappears completely after two to four weeks. When the blisters scab and dry, the virus cannot spread anymore. 

Development of the shingles Rash

Day 1

Day 2

Day 5. Shingles blisters. Pain disappearing.

Day 6. Characteristic purple colour.

In the case of chickenpox, also called varicella, the initial infection with the virus typically occurs during childhood or adolescence. Once the chickenpox has resolved, the virus can remain dormant  or (inactive) in human nerve cells (dorsal root ganglia or cranial nerves) nerve cells. (for years or decades, after which it may reactivate. Shingles results when the dormant varicella virus is reactivated. The virus then travels along nerve bodies to nerve endings in the skin, producing blisters. During an outbreak of shingles, exposure to the varicella virus found in shingles blisters can cause chickenpox in someone who has not yet had chickenpox, although that person will not suffer from shingles, at least on the first infection. How the virus remains dormant in the body or subsequently re-activates is not well understood. 

Dermatomes

Dermatomes are areas of skin that send signals to the brain through the spinal nerves. The dermatome system covers the entire body from the hands and fingers to the feet and toes. The part of a nerve that exits the spinal cord is called the nerve root. Damage to a nerve root can trigger symptoms in the nerve’s corresponding dermatome. 

Spinal nerves exit the spine in pairs. There are 31 pairs The spinal nerves are classified into five groups, according to the region of the spine from which they exit.The five groups and their points of exit from the spines are :  

1. Cervical nerves: These exit the neck region and are labeled C1–C8.
2. Thoracic nerves: These exit the torso region and are labeled T1–T12.
3. Lumbar nerves: These exit the lower back region and are labeled L1–L5.
4. Sacral nerves: These exit the base of the spine and are labeled S1–S5.
5. A coccygeal nerve pair: These exit the tailbone, or coccyx.

Location of Dermatomes

Cervical nerves and their dermatomes

• C2: the base of the skull, behind the ear
• C3: the back of the head and the upper neck
• C4: the lower neck and upper shoulders
• C5: the upper shoulders and the two collarbones
• C6: the upper forearms and the thumbs and index fingers
• C7: the upper back, backs of the arms, and middle fingers
• C8: the upper back, inner arms, and ring and pinky fingers

Thoracic nerves and their dermatomes

• T1: the upper chest and back and upper forearm
• T2, T3, and T4: the upper chest and back
• T5, T6, and T7: the mid-chest and back
• T8 and T9: the upper abdomen and mid-back
• T10: the midline of the abdomen and the mid-back
• T11 and T12: the lower abdomen and mid-back

Lumbar nerves and their dermatomes

• L1: the groin, upper hips, and lower back
• L2: the lower back, hips, and tops of the inner thighs
• L3: the lower back, inner thighs, and inner legs just below the knees
• L4: the backs of the knees, inner sections of the lower legs, and the heels
• L5: the tops of the feet and the fronts of the lower legs

Sacral nerves and their dermatomes

• S1: the lower back, buttocks, backs of the legs, and outer toes
• S2: the buttocks, genitals, backs of the legs, and heels
• S3: the buttocks and genitals
• S4 and S5: the buttocks

The coccygeal nerves and their dermatome

The dermatome corresponding with the coccygeal nerves is located on the buttocks, in the area directly around the tailbone, or coccyx.

                                      "Vaccination can help prevent Shingles."

Cause

• Weakening of the immune system: Yes Weekend immune system predisposes to reactivation. There are several causes for these weekend immune system like, stress, lack of sleep, during the time of periods in women, having unhealthy fast foods, hypothyroidism, smoking, drinking, lack of exercise, Fever due to any other cause, Excessive tiredness, fasting, dehydration, malnutrition,  etc. and all the above bad health habits to be avoided. 
• Stress.
• Have had chickenpox  as a child
• Are above 50 years of age. The risk increases with age, no matter how healthy you are.
• Are suffering from any illnesses such as diabetes, HIV, cancer
• Are taking any medications that affect the immune system such as steroids
• Are taking treatments for certain ailments such as cancer
• Are recuperating from any illness, be it even a cold, or  flu. 
• An erratic sleeping patterns  
• Mechanical trauma 
• to immunotoxins. 

Duration 

• 2 to 4 Weeks.

"Children with chickenpox boosts adult cell-mediated immunity to help postpone or suppress shingles," 

"Adults with latent VZV infection who are exposed intermittently to children with chickenpox receive an immune boost. This periodic boost to the immune system helps to prevent shingles in older adults." 

Signs & Symptoms

The three phases of the infection include:

• Pre Eruptive stage presents with abnormal skin sensations or pain within the dermatome affected. this phase appears at least 48 hours prior to any obvious lesions. At the same time, the individual may experience headaches, general malaise, and photophobia, fever, and excruciating burning pain followed by the outbreak of vesicles that appear in one to three crops over three to five days. 
• The Acute eruptive phase is marked by the vesicles and the symptoms seen in the pre-eruptive phase. The lesions initially start as macules and quickly transform into painful vesicles. The vesicles often rupture, ulcerate and eventually crust over. Patients are most infectious in this stage until the lesion dry out. Pain is severe during this phase and often unresponsive to traditional pain medications. The phase may last 2-4 weeks but the pain may continue.
• Chronic infection is characterized by recurrent pain that lasts more than 4 weeks. Besides the pain, patients experience paresthesias, shock-like sensations, and dysesthesias. The pain is disabling and may last 12 months or longer
• Lesions are distributed unilaterally within a single dermatome. 
• Clinically, lesions start as closely grouped erythematous papules which, rapidly become vesicles on an erythematous and edematous base and may occur in continuous or interrupted bands in one, two, or more contiguous dermatomes unilaterally. 
• Dermatomes commonly involved are thoracic (53%), cervical (20%), and trigeminal (15%) including ophthalmic and lumbosacral (11%).A Shingles infection usually starts with a skin rash that affects a small part of the body. The affected person may also experience pain that feels like electric shocks# or piercing nails# or burns caused by boiling water#, itching, tingling, and numbness localised to the affected areas 48-72 hours before the rash appears.
• People can also experience upset stomach. 
• Itching, hyperesthesia  (oversensitivity), or paresthesia ("pins and needles": tingling, pricking, or numbness).
• In most cases, after one to two days – but sometimes as long as three weeks – the initial phase is followed by the appearance of the characteristic skin rash. The pain and rash most commonly occur on the torso but can appear on the face, eyes, or other parts of the body. At first, the rash appears similar to the first appearance of hives; however, unlike hives, shingles causes skin changes limited to a dermatome, normally resulting in a stripe or belt-like pattern that is limited to one side of the body and does not cross the midline. 
• Shingles in children is often painless, but people are more likely to get shingles as they age, and the disease tends to be more severe.
• Zoster sine herpete ("zoster without herpes") describes a person who has all of the symptoms of shingles except this characteristic rash.

A case of shingles that demonstrates a typical dermatomal distribution, here C8/T1

Face

Eye

• Herpes zoster ophthalmicus:

Herpes Zoster ophthalmicus.  exudative erythema, scabs, blister, eyelid swelling

Herpes zoster ophthalmicus: Throbbing pain in the eye with burning sensation and irritation. Soreness and redness in and around the eye. Constant eye watering, blurred vision.Shingles may have additional symptoms, depending on the dermatome involved. The trigeminal nerve is the most commonly involved nerve, of which the ophthalmic division is the most commonly involved branch. When the virus is reactivated in this nerve branch it is termed zoster ophthalmicus . The skin of the forehead, upper eyelid and orbit of the eye may be involved. Zoster ophthalmicus occurs in approximately 10% to 25% of cases. In some people, symptoms may include conjunctivitis, keratitis, uveitis, and optic nerve palsies that can sometimes cause chronic ocular inflammation, loss of vision, and debilitating pain.

.The symptoms in the eyes usually vanish within three to five weeks. 

A person with shingles cannot transmit shingles to another person. Though, he can transmit chickenpox to a person, who has never had chickenpox  before.

Ramsay hunt innervation /Trigeminal Nerve

                                               

                                                     "Vaccination can help prevent Shingles."

Ear

Herpes Zoster Oticus

Shingles oticus, also known as Ramsay Hunt, syndrome type  II, involves the ear. It is thought to result from the virus spreading from the facial nerve  to the vestibulocochlear nerve. Symptoms include hearing loss and vertigo (rotational dizziness). Involving cranial nerve VIII

The vestibulocochlear nerve consists of the vestibular and cochlear nerves, also known as cranial nerve eight (CN VIII). Each nerve has distinct nuclei within the brainstem. The vestibular nerve is primarily responsible for maintaining body balance and eye movements, while the cochlear nerve is responsible for hearing

Herpes Zoster Oticus

^Mouth
Shingles may occur in the mouth if the maxillary or mandibular division of the trigeminal nerve is affected, in which the rash may appear on the mucous membrane  of the upper jaw (usually the palate, sometimes the gums of the upper teeth) or the lower jaw (tongue or gums of the lower teeth) respectively. Oral involvement may occur alone or in combination with a rash on the skin over the cutaneous distribution of the same trigeminal branch. As with shingles of the skin, the lesions tend to only involve one side, distinguishing it from other oral blistering conditions. In the mouth, shingles appears initially as 1–4 mm opaque blisters (vesicles), which break down quickly to leave ulcers  that heal within 10–14 days. The prodromal pain (before the rash) may be confused with toothache. Sometimes this leads to unnecessary dental treatment. Post-herpetic neuralgia uncommonly is associated with shingles in the mouth. 

 Varicella zoster virus is not the same as herpes simplex virus, although they belong to the same family of herpes viruses.

Disseminated Shingles

In those with deficits in immune function, disseminated shingles may occur (wide rash). It is defined as more than 20 skin leisions appearing outside either the primarily affected dermatome or dermatomes directly adjacent to it. Besides the skin, other organs, such as the liver or brain, may also be affected (causing hepatitis or encephalitis, respectively), making the condition potentially lethal.

Pathogenesis

Varicella-zoster virus enters through the upper respiratory mucosa or the conjunctiva. VZV infects macrophages and pneumocytes in the respiratory mucosa. Virus spreads to the reticuloendothelial system, replicates in the regional lymph nodes, and enters the bloodstream (primary viremia). From the hematogenous route, it reaches the liver, and spleen and multiplies there. Secondary viremia occurs, and the VZV present in the infected mononuclear cells are transported to skin, respiratory tract, and neurons.

1. Skin: Virus replication in the epithelial cells leads to the development of typical rashes. Swelling of epithelial cells, ballooning degeneration, and accumulation of tissue fluids result in the formation of vesicles.
2. Respiratory tract: VZV is shed in the respiratory secretions of the infected individuals leading to the transmission of infection to other individuals.
3. Neurons: VZV gains access to neurons and undergoes latency in dorsal root ganglia.

Three types of lesions are most often seen in varicella-zoster infections;

maculopapular lesions (lesions with a raised red bump), vesicular lesions (blister-like or fluid-filled lesions), and scabbed or crusted lesions.

Pathophysiology

Electron micrograph of Varicella Zoster Virus.

Progression of shingles. A cluster of small bumps (1) turns into blisters (2). The blisters fill with lymph , break open (3), crust over (4), and finally disappear. Postherpetic neuralgia  can sometimes occur due to nerve damage .

The causative agent for shingles is the varicella zoster virus (VZV) – a double-stranded DNA virus  related to the herpes simplex virus . Most individuals are infected with this virus as children which causes an episode of chickenpox. The immune system eventually eliminates the virus from most locations, but it remains dormant (or latent) in the ganglia adjacent to the spinal cord (called the dorsal root ganglion ) or the trigeminal ganglion in the base of the skull.
Shingles occurs only in people who have been previously infected with VZV; although it can occur at any age, approximately half of the cases occur in those aged 50 years or older. Shingles can recur. In contrast to the frequent recurrence of herpes simplex symptoms, repeated attacks of shingles are unusual. It is extremely rare for a person to have more than three recurrences.
The disease results from virus particles in a single sensory ganglion switching from their latent phase to their active phase. Due to difficulties in studying VZV reactivation directly in humans (leading to reliance on small-animal models), its latency is less well understood than that of the herpes simplex virus. Virus-specific proteins continue to be made by the infected cells during the latent period, so true latency, as opposed to chronic, low-level, active infection, has not been proven to occur in VZV infections. Although VZV has been detected in autopsies of nervous tissue, there are no methods to find dormant virus in the ganglia of living people.
Unless the immune system is compromised, it suppresses reactivation of the virus and prevents shingles outbreaks. Why this suppression sometimes fails is poorly understood, but shingles is more likely to occur in people whose immune systems are impaired due to aging, immunosuppressive therapy, psychological stress, or other factors. Upon reactivation, the virus replicates in neuronal cell bodies, and virions are shed from the cells and carried down the axons  to the area of skin innervated by that ganglion. In the skin, the virus causes local inflammation and blistering. The short- and long-term pain caused by shingles outbreaks originates from inflammation of affected nerves due to the widespread growth of the virus in those areas.
As with chickenpox and other forms of alpha-herpesvirus infection, direct contact with an active rash can spread the virus to a person who lacks immunity to it. This newly infected individual may then develop chickenpox, but will not immediately develop shingles.

Herpes zoster-associated lower limb paresis may be an uncommon complication of a common disorder. The diagnosis can be challenging as sciatica or weakness may occur before the typical herpes zoster skin lesions develop.

"Cases of shingles were often followed by chickenpox in younger people who lived with the person with shingles." 

Diagnosis

Diagnosis is typically based on the signs and symptoms presented.

Clinically based on symptoms :

• Shingles almost always occurs on just one side of the body. Usually follows the path of the nerves where the inactive virus had been  lying dormant. Virus will reactivate in patients with weakened immune system, such as elderly, people with AIDS or people who have been stressed.
• Common sites of Shingles

Shingles on Chest.

• Lab tests, which usually involves scraping a part of your blisters formed from the rash, and testing it in the lab.

• Based on symptoms. : If the rash has appeared, identifying this disease (making a differential diagnosis) requires only a visual examination, since very few diseases produce a rash in a dermatomal Pattern 
• When the rash is absent (early or late in the disease, or in the case of zoster sine herpete), shingles can be difficult to diagnose. Apart from the rash, most symptoms can occur also in other conditions.
• Laboratory tests are available to diagnose shingles. The most popular test detects VZV-specific IgM antibody  in blood; this appears only during chickenpox or shingles and not while the virus is dormant. 
• PCR Test ; In larger laboratories, lymph collected from a blister is tested by polymerase chain reaction (PCR) for VZV DNA, Or examined with an electron microscope for virus particles. Molecular biology tests based on in vitro nucleic acid amplification (PCR tests) are currently considered the most reliable. Nested PCR test has high sensitivity, but is susceptible to contamination leading to false positive results. . The latest real- time PCR tests are rapid, easy to perform, and as sensitive as nested PCR, and have a lower risk of contamination. They also have more sensitivity than viral cultures. screening for VZV by PCR is recommended.

The presence of rash, as well as specific neurological symptoms, were required to diagnose a CNS infection caused by VZV. Since 2000, PCR testing has become more widely used, and the number of diagnosed cases of CNS infection has increased.

Differential Diagnosis

• Herpes Simplex
• Chest Pain.
• Insect bites.
• Cutaneous Leishmaniasis

"Shingles was a more serious disease in adults than in children and that it increased in frequency with advancing age."

Complications

                                

While most people recover from Shingles infection fully, some might face health complications.

Shingles is a self-limiting condition which disappears within three weeks. However, in people with very low immunity, it may take a serious turn. Delaying, or not undertaking medical treatment can cause serious complications which include:

• Post-Herpetic Neuralgia (PHN): which is nerve pain caused by the damage to nerves by the varicella-zoster virus. The stabbing pain can remain for months and even for years in patients. Around 20% of the people who suffer from shingles may develop a condition known as post-herpetic neuralgia. It is commonly believed that shingles causes scar tissue to develop around the nerve, which when inadvertently pressed, causes pain signals to go to the brain.  Some people go on to develop PHN. The person suffering from PHN will experience a sudden throbbing, burning, shooting, or even a stabbing pain along the damaged nerve for months, or even years, after the rash has healed. In some cases, the pain may be continuous for a few months after the rash has healed, however, if the condition runs into years, the person will experience paroxysms of pain along the nerve.

• Life-threatening disseminated pneumonia may occur in immunocompromised.
  
  
• Eye Complications - Trigeminal nerve  involvement (as seen in herpes ophthalmicus). which can occur if the rash spreads to the eyes. Swelling of the cornea (Keratitis) may occur which can leave permanent scars. Shingles in the eye can also cause the retina to swell, or increase pressure in the eye which can lead to (glaucoma) and eventually loss of vision. Involvement of the tip of the nose in the zoster rash is a strong predictor of herpes ophthalmicus.
  
  
• Skin Infections - may occur if the area affected by the rash is not kept clean, which can lead to scarring.
  
  
• Neurological Complications - can ensue if the shingles affects the nerves in the brain. The neurological complications include Guillain-Barre Syndrome, Ramsay Hunt Syndrome, Facial Nerve Palsy or Bell’s palsy, encephalitis, meningitis, and even stroke anytime in the year following the illness.

• Disseminated Herpes Zoster- is when the virus spreads to other organs. People with compromised immune systems (those suffering from cancer, HIV/AIDS), are at a risk of Disseminated Herpes Zoster. This can be life-threatening especially if it affects the lungs.

• Rash may occur widely : In those with poor immune function.

• Unusual complications may occur with intra-oral shingles that are not seen elsewhere. Due to the close relationship of blood vessels to nerves, the virus can spread to involve the blood vessels and compromise the blood supply, sometimes causing ischemic necrosis ischemic. Therefore, oral involvement rarely causes complications, such as osteonecrosis, tooth loss, tooth loss, periodontitis (gum disease), pulp calcification, pulp necrosis, periapical lesions  and tooth developmental anomalies.

• In some people, shingles can reactivate presenting as zoster sine herpete: pain radiating along the path of a single spinal nerve (a dermatomal distribution), but without an accompanying rash. This condition may involve complications that affect several levels of the nervous system  and cause many cranial neuropathies, Guillain Barre syndrome, and myelitis, polyneuritis, myelitis, or aseptic meningitis. Other serious effects that may occur in some cases include partial facial paralysis (usually temporary), ear damage, or encephalitis. 

• There is a slightly increased risk of developing cancer after a shingles episode. However, the mechanism is unclear and mortality from cancer did not appear to increase as a direct result of the presence of the virus. Instead, the increased risk may result from the immune suppression that allows the reactivation of the virus.

• Although initial infections with VZV during pregnancy, causing chickenpox, may lead to infection of the fetus and complications in the newborn, chronic infection or reactivation in shingles are not associated with fetal infection.
• 
  

                                                               "Consult a Dermatologist."

Prevention

• Shingles Vaccine : Shingles vaccines reduce the risk of shingles by 50% to 90%, depending on the vaccine used. Vaccination also decreases rates of postherpetic neuralgia, and, if shingles occurs, its severity.
• Shingles is caused by the reactivation of the virus that remains in the body after chickenpox. So, if a person hasn’t had chickenpox, ask them to avoid contact with people who have chickenpox or Shingles. Also, ensure that they follow all hand and cough hygiene to reduce the risk of developing chickenpox.
• Shingles risk can be reduced in children by the chickenpox vaccine if the vaccine is administered before the individual gets chickenpox. 
• If primary infection has already occurred, there are Shingles vaccines that reduce the risk of developing shingles or developing severe shingles if the disease occurs. They include a live attenuated virus  vaccine, Zostavax, and an adjuvanted subunit vaccine, Shingrix.

Zostavax : 

Zostavax was useful for preventing shingles for at least three years. This equates to about 50% relative risk reduction. The vaccine reduced rates of persistent, severe pain after shingles by 66% in people who contracted shingles despite vaccination. Vaccine efficacy was maintained through four years of follow up. 

^{Shingrix :} 
healthy adults 50 years and older receive two doses of Shingrix, two to six months apart.. Two doses of Shingrix are recommended, which provide about 90% protection at 3.5 years. As of 2016, it had been studied only in people with an intact immune system. It appears to also be effective in the very old.
In the UK, shingles vaccination is offered by the National Health Service   (NHS) to all people in their 70s. As of 2021 Zostavax is the usual vaccine, but Shingrix vaccine is recommended if Zostavax is unsuitable, for example for those with immune system issues. 

There had been 1,104 adverse reaction reports by April 2018.

"Cases of shingles were often followed by chickenpox in younger people who lived with the person with shingles." 

Who should not get the Shingles vaccination?

• Who Should Not Get Shingrix. People with a history of severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine or after a previous dose of Shingrix. 
• People who currently have shingles, 
• Women who are pregnant or breastfeeding, should wait to get Shingrix.
•  It has been recommended that people with primary or acquired immunodeficiency (AIDS)  should not receive the live vaccine.
• Vaccination is not available to people over 80 as "it seems to be less effective in this age group"
• Conditions that suppress their immune system, and should not receive Zostavax.

                                      "Chickenpox and shingles were caused by the same virus." 

Treatment

Allopathy

Antiviral therapy hastens the resolution of lesions, decreases acute pain and helps to prevent post-herpetic neuralgia especially in elderly patients.

• mupirocin or soframycin help to prevent secondary bacterial infection.
• Analgesics help to relieve the pain.
• Occasionally, severe pain may require an opioid medication.
• Topical lidocaine and nerve blocks may also reduce pain.

Uncomplicated

Rx 

Tab Acyclovir 800 mg 5 times a day for 7 days. Effective only if started within 2 days. Use only for severe infection or high risk patients (eg old, immunocompromised, ophthalmic zoster).

or

Valacyclovir 1 gm Three times a day for 5 days.

or

Tab Famciclovir 500mg tds x 7 days.

Ideally the drug should be given 48-72 hours after appearance of rash.

Treatment duration longer in immunocompromised patients.

Rx 

Tab Ibuprofen 400 mg + Tab Paracetamol 1-1-1+ x 4-7 days.

Rx 

Tab Accetoflenac+Paracetamol

For local application

Rx

Silver sulfadiazine or

Rx

Acyclovir / Herpex Cream

Complicated by secondary infection

Same as above

Rx

Bactrim DS or Sepmax 1-0-1x8 days.

Rx

Amoxicillin 500 mg 1-1-1x8 days

Rx

Cephalosporin if severe infection

Rx

Neosporin or Fucidin ointment

For severe cases

Rx

Oral steroids to reduce postherpetic neuralgia.

Prednisolone 60 mg bd for 6 days, reducing to zero over 2-3 weeks.

For post herpetic Neuralgia

Rx

Gabapentin 300 mg/d in 3 divided doses for 3 weeks increased to 6oo mg/d for 4 weeks. Post-herpetic neuralgia commonly occurs in elderly patients, and once the lesions have crusted, they can use topical capsaicin and Emla cream.

Zoster Ophthalmicus

Treatment for zoster ophthalmicus  is similar to standard treatment for shingles at other sites. 

 

Physical Therapy Management 

TENS 

May be used to treat acute pain and reduce the healing time of the rash associated with herpes zoster. It can be used safely with antiretroviral treatment or as the only treatment.

• A recent study in 2012 found that TENS may be at least as effective as traditional pharmacological therapies, and it may help reduce or prevent the risk of developing postherpetic neuralgia.
• TENS therapy generally involves placing two electrodes on the dermatome affected by herpes zoster for 30 minutes five times per weeks for a period of time up to three weeks. Suggested electrical output was 1-5 mA with frequencies ranging from 20 to 40 Hz.
• If the facial nerve is affected by herpes zoster and peripheral Facial palsy results, facial exercises have been found to be effective. These exercises include exercises to stimulate functional movement in the face, achieve symmetry, to improve motor control, reduce synkinesis, improve perception of movement, and promote emotional expression. Mirror therapy, mime  therapy, facial muscular re-education, and Kabat's exercises were found to be effective means of facial rehabilitation techniques.

                                 "Chickenpox and shingles were caused by the same virus." 

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