Zoster (Shingles)

- Recommend HIV testing, especially in young adults.

- Herpes zoster ophthalmicus - involvement of cranial nerve V1 occurs in 10-25% of herpes zoster (HZ) cases. Blisters on tip of nose may be seen. Consult ophthalmology.

- Ramsay-Hunt syndrome - severe ear pain, facial muscle weakness, and rash indicates infection of facial nerve.

- Oral corticosteroid therapy may provide some benefit in acute herpes zoster (HZ) symptoms, but they have significant adverse effects and have not been shown to lower incidence or duration of postherpetic neuralgia (PHN). Therefore, the overall risk/benefit profile does not support the routine use of corticosteroids in herpes zoster.

- Immunity is boosted once a person has herpes zoster, so recurrence is uncommon (≤ 5%) in immunocompetent persons.

- Direct contact with the skin lesions of a person with regional/limited herpes zoster, or via airborne route in disseminated zoster, can lead to varicella (chicken pox) in persons who have not had varicella or been immunized.

Immunocompetent

Prevention:

• Zoster (live) vaccine is approved for prevention of herpes zoster and its complications in immunocompetent adults ≥ 50 years of age.

• Post-exposure immunization with varicella vaccine recommended in non-pregnant, non-immune close contacts ideally within 72 hours (no longer than 5 days) following exposure.

NB: Antiviral medications should not be used within 24h before or 14 days after vaccination.

Treatment:

-Topical therapy not recommended as ineffective.

- Early attention to pain management during acute zoster may reduce the probability and severity of PHN.

Varicella zoster

Immunocompromised

Prevention:

• Antiviral prophylaxis is recommended to prevent herpes zoster (HZ) in immunocompromised persons who cannot receive the live HZ vaccine:

• Agents:

  • Duration: Continue until end of immunosuppressive therapy and/or for at least 1 year after transplant or leukemia induction therapy

    • Acyclovir 400-800mg PO daily or

    • Famciclovir 500mg PO daily or

    • Valacyclovir 250-500mg PO daily

Treatment:

• Therapy ideally should be started within 72 hours of rash onset, or at any time if new vesicles forming or cutaneous/ motor/neurologic/ocular complications.

Varicella zoster

Mild-moderate

Severe/Disseminated