Herpes zoster

Question 1

What is shingles (Herpes Zoster)?

Answer 1

• It is a painful rash caused by reactivation of varicella
• Athe virus is seeded to the nerves of the spinal cord after a primary chicken pox in childhood and reactivates later on in life
• Shingles patients are infectious resulting in chicken pox both from virus in the lesions and in some instances the nose and throat

Question 2

Who gest shingles?

Answer 2

• Anyone who has previously had chicken pox can develop it
• It is more common and more severe in the older group
• It is more severe in patients with poor immunity
• Chicken pox or shingles in the early months of pregnancy can harm the foetus

Question 3

What are the clinical features of shingles?

Answer 3

• The first sign is very severe pain in the areas of the sensory nerves
• The patient feels unwell and draining lymph nodes are enlarged
• 1-3 days after the onset of pain, a blistering rash appears
• In uncomplicated patients, recovery is usually in 3-4 weeks
• Chest, neck, forehead (ophthalmic) and lumbar sacral nerves are most commonly affected
• It is rare to affect both sides of the body
• Facial nerve is most commonly affected; 50% chance of complete recovery
• 15% of all cases can affect the trigeminal nerve(ophthalmic branch) with lesions on the tip of the nose and eyes (conjunctiva and cornea)

Question 4

What is post-herpetic neuralgia?

Answer 4

• Persistence or recurrence of pain more than a month after the onset of shingles
• More likely in the older age group and facial nerve involvement
• The affected area may be painful or itchy

Question 5

What is the treatment of shingles?

Answer 5

• Oral antiviral medication (famciclovir, acyclovir, valaciclovir) is recommended if seen withn 72hrs of rash, elderly, poor immunity and facial shingles
• Rest, pain relief and protective dressing over the rash
• In severe cases, IV aciclovir may be used
• ORal ABx may be used for secondary infection
• Mildly contagious, hence avoid contact with children and new borns who have never had chicken pox, immunocompromised and those undergoing chemo
• Consider immunoglobulins to immunocompromised contacts

Question 6

What is the treatment of post-herpetic neuralgia?

Answer 6

• DIfficult to treat successfully
• Topical capsaicin, tricyclics, SSRI, SNRI, anti-epileptic medications such as carbamazepine and gabapentin, TENS and botilinum toxin have been used
• NSAIDs are unhelpful

Question 7

How to prevent shingles?

Answer 7

• Those aged over 60 can consider zoster vaccine
• The vaccine (Zostavax) is estimated to be 14 times more potent than chicken pox and can be given to people >50 years.
• Immunocompromise is a contraindication for the vaccine
• It reduces the shingles by half and symptoms are less severe if it develops