Shingles

Question 1

What is shingles?

Answer 1

herpes zoster infection: acute, unilateral, painful blistering rash caused by reactivation of the varicella-zoster virus

Question 2

What causes shingles?

Answer 2

following the primary infection with VZV i.e. chickenpox, the virus lies dormant in the dorsal root or cranial nerve ganglia

Question 3

What are 3 risk factors for shingles?

Answer 3

1. Increasing age
2. HIV: strong risk factor, 15x more common
3. Other immunosuppressive conditions e.g. steroids, chemotherapy

Question 4

What are the most commonly affected dermatomes in shingles?

Answer 4

T1-L2

Question 5

What are the 2 key aspects of the presentation of shingles?

Answer 5

1. Prodromal period - burning pain, fever, headache, lethargy
2. Rash - dermatomal + erythematous, macular → vesicular

Question 6

What are 4 aspects of the prodromal period of shingles?

Answer 6

1. Burning pain over affected dermatome for 2-3 days, may be severe, interfere with sleep
2. Around 20% of patients will experience fever,
3. headache,
4. lethargy

Question 7

What is the nature of the pain during the prodromal period of shingles?

Answer 7

burning pain, over affected dermatome

may be severe and interfere with sleep

2-3 days prior to rash

Question 8

What is the nature of the rash in shingles?

Answer 8

• initially erythematous, macular rash over affected dermatoma
• quickly becomes vesicular
• characteristically well-demarcated by the dermatome and doesn’t cross midline but some bleeding into adjacent areas may be seen

Question 9

What is the diagnosis of shingles usually based on?

Answer 9

usually a clinical diagnosis

Question 10

What are 3 key aspects of the management of shingles?

Answer 10

1. Remind patients they are potentially infectious - avoid pregnant women/immunosuppressed
2. Analgesia
3. Antivirals

Question 11

Who should patients with shingles be advised to avoid?

Answer 11

pregnant women and immunosuppressed

Question 12

When are patients with shingles typically infectious?

Answer 12

until vesicles have crusted over, usually 5-7 days following onset

Question 13

How can the risk of infectivity of shingles be reduced?

Answer 13

covering the lesions

Question 14

What is the first line analgesic to give in shingles?

Answer 14

paracetamol and NSAIDs are first line

Question 15

What are 3 groups of drugs that may be used as analgesia in shingles?

Answer 15

1. Paracetamol and NSAIDs
2. if not responding then neuropathic agents e.g. amitriptyline
3. oral corticosteroids may be considered in first 2 weeks in immunocompetent adults with localised shingles if pain not responding

Question 16

If a patient with shingles is not responding to paracetamol/NSAIDs as analgesia then what is the next line treatment?

Answer 16

neuropathic agents e.g. amitriptyline

Question 17

When can you consider giving oral corticosteroids for analgesia in shingles?

Answer 17

in the first 2 weeks in immunocompetent adults with localised shingles

only if pain severe and not responding to other analgesia

Question 18

When do NICE recommend antivirals are used to treat shingles?

Answer 18

use them within 72 hours for the majority of patients, unless patient <50y and has ‘mild’ truncal rash associated with mild pain and no underlying risk factors

Question 19

When do the NICE guidelines suggest you don’t need to use antivirals to treat shingles?

Answer 19

patient <50 years and has ‘mild’ truncal rash associated with mild pain, no underlying risk factors

Question 20

What is one of the key benefits of prescribing antivirals in shingles?

Answer 20

reduced incidence of post-herpetic neuralgia, particularly in older people

Question 21

What are 3 examples of antivirals that are recommended for use in shingles?

Answer 21

1. aciclovir
2. famciclovir
3. valaciclovir

Question 22

What are 3 complications of shingles?

Answer 22

1. Post-herpetic neuralgia
2. Herpes zostes ophthalmicus (ocular branch of trigeminal nerve)
3. Herpes zoster oticus (Ramsay-Hunt syndrome) - CNVIII

Question 23

What is the most common complication of shingles?

Answer 23

post-herpetic neuralgia

Question 24

In which group of patients is post-herpetic neuralgia most common?

Answer 24

older patients (affects between 5-30% of patients depending on age)

Question 25

How long does post-herpetic neuralgia usually last for?

Answer 25

most commonly resolves within 6 months (but may last longer)

Question 26

What can herpes zoster oticus lead to?

Answer 26

ear lesions and facial paralysis