Herpes zoster by dr bashir ahmed dar associate professor medicine sopore kashmir

HERPES ZOSTER

BY
Dr Bashir Ahmed Dar
Associate Professor Medicine
Chinkipora Sopore Kashmir
Email—drbashir123@gmail.com

HERPES ZOSTER (Shingles)
• Shingles is caused by the same virus that
causes chickenpox

• The chicken pox rash
begins as small discrete
red dots separated apart
on the face, scalp, torso
and upper arms and legs;
progressing over 10–12
hours to small
bumps, blisters and
pustules; followed by
umbilication and the
formation of scabs.

• Shingles, also known as herpes zoster, is not
related to the sexually transmitted herpes
virus disease called herpes genitalis, or the
oral herpes virus, herpes simplex.

• Shingles, also called
herpes zoster or
zona, gets its name
from both the Latin and
French words for belt or
girdle and refers to
girdle-like skin
eruptions that may
occur on the trunk of
the body.

• The chickenpox virus (varicella-zoster) may
remain in a dormant state in the body after an
individual has chickenpox, usually in the roots
of peripheral nerves that control sensation or
in cranial nerves.

• In about one out of five people previously
infected with chickenpox, the virus "wakes
up," or reactivates, often many years or
decades after a childhood chickenpox
infection. When the virus is reactivated it then
causes shingles (referred as herpes zoster)

• And results in nerve and skin inflammation

• This virus is called the varicella zoster virus
(VZV) and belongs to the herpes family of
viruses

• Under certain circumstances, such as
emotional stress, immune deficiency (from
AIDS or chemotherapy), or with cancer, the
virus reactivates and causes shingles

• Therefore anyone who ever had chickenpox is
at risk for the development of
shingles, although it occurs most commonly in
people over the age of 60. It has been
estimated that up to 1,000,000 cases of
shingles occur each year in the U.S.

Symptoms and signs
• Before a rash is visible, the patient may notice
several days to a week of burning pain and
sensitive skin. When the characteristic rash is
not yet apparent, it may be difficult to
determine the cause of the often severe pain.

Symptoms and signs
• Shingles rash starts as
small blisters on a red
base, with new blisters
continuing to form for
three to five days.

Symptoms and signs
• The blisters follow the path of individual
nerves that come out of the spinal cord in a
specific "ray-like" distribution (called a
dermatomal pattern) and appear in a band-
like pattern on an area of skin

Symptoms and signs
• Generally, only one
nerve level is involved.
In a rare case, more
than one nerve will be
involved.

Symptoms and signs
• The entire path of the
affected nerve may be
involved, or there may
be areas in the
distribution of the
nerve with blisters and
areas without blisters.

Symptoms and signs
• Eventually, the blisters
pop, and the area starts
to ooze

Symptoms and signs
• The affected areas will
then crust over and
heal.

Symptoms and signs
• The duration of the outbreak may take three
to four weeks from start to finish. On
occasion, the pain will be present but the
blisters may never appear. This can be a very
confusing cause of local pain.

Symptoms and signs
• Shingles is contagious and can be spread from
an affected person to babies, children, or
adults who have not had chickenpox. But
instead of developing shingles, these people
develop chickenpox.

Symptoms and signs
• Similar to chickenpox, the time prior to
healing or crusting of the blisters is the
contagious stage of shingles. Once all of the
blisters are crusted over, the virus can no
longer be spread and the contagious period is
over.

How is shingles diagnosed
• The clinical appearance of shingles, with
characteristic painful blisters localized to the
region of a specific nerve, is usually sufficient
to establish the diagnosis. No diagnostic tests
are usually required.

How is shingles diagnosed
• However, particularly in people with impaired
immune function, shingles may sometimes
not display the characteristic clinical pattern.
In these cases, samples from the affected area
may be tested in a laboratory, either by
culturing the tissue for growth of the virus or
by identifying the genetic material of the
virus.

Complications of shingles?
• Generally, shingles heals well and problems
are few. However, on occasion, the blisters can
become infected with bacteria, causing
cellulitis, a bacterial infection of the skin. If
this occurs, the area will become
reddened, warm, firm, and tender. You might
notice red streaks forming around the wound.
Antibiotics can be used to treat these
complications.

• A more worrisome complication occurs when
shingles affects the face, specifically the
forehead and nose. In this situation, it is
possible, although not likely, that shingles can
affect the eye (known as herpes zoster
ophthalmicus), leading to loss of vision.

• A rare complication of shingles is known as
Ramsay Hunt syndrome. In this case, the
cranial nerves (cranial nerves V, IX, and X) are
involved. Symptoms may include peripheral
facial nerve weakness and deafness. The
typical rash is often observed around the ear
and ear canal

Post herpetic neuralgia
• when the nerve pain associated with shingles
persists beyond one month, even after the rash is
gone.

• The pain can be severe and debilitating.
Postherpetic neuralgia occurs primarily in people
over the age of 50 and affects 10%-15% of people
with shingles. There is evidence that treating
shingles with antiviral agents can reduce the
duration and occurrence of Postherpetic
neuralgia.

• The pain of Postherpetic neuralgia can be
reduced by a number of medications.
• Tricyclic antidepressant
• antiseizure medications (gabapentin
[Neurontin],
• carbamazepine [Tegretol],
• pregabalin [Lyrica])

• In 2012, the FDA approved the use of gabapentin
enacarbil (Horizant), previously used for the
management of restless legs syndrome, for the
treatment of postherpetic neuralgia.

• Lidocaine pain patches (Lidoderm) applied
directly to the skin can also be helpful in relieving
nerve pains by numbing the nerves with local
lidocaine anesthetic. These options should be
discussed with your health care professional.

Can shingles be prevented with a
vaccine?
• In May 2006, the U.S. Food and Drug
Administration (FDA) approved the first
vaccine for adult shingles. The vaccine known
as Zostavax, is approved for use in adults ages
50 and over who have had chickenpox.

• It is a onetime injection (shot) that does not
need to be repeated. The shingles vaccine
contains a booster dose of the chickenpox
vaccine usually given to children.

• There are certain contraindications to
receiving the shingles vaccine. People with
weakened immune systems due to immune-
suppressing medications, cancer
treatment, HIV disease, or organ transplants
should not receive the shingles vaccine
because it contains live, weakened viral
particles.

• Since the chickenpox vaccine is now
recommended for children, the incidence of
chickenpox has been reduced. This is also
expected to reduce the incidence of shingles
in adults in the future as these vaccinated
children age

Is shingles dangerous in pregnant
women?
• fortunately, shingles in pregnancy is very rare.
The antiviral medications described above are
considered safe to use in pregnant women, as
are most pain-relieving drugs.

women?
• The shingles vaccine should not be
administered to pregnant women. It is
recommended that a woman wait three
months before trying to become pregnant
after she has received the shingles vaccine.

women?
• Having chickenpox during pregnancy has the
potential to cause birth defects

Management of herpes
Zoster(options)
• Acyclovir
• 800 mg orally five times daily for 7 to 10 days 10 mg
per kg IV every 8 hours for 7 to 10 days‡
•
• Famciclovir
• 500 mg orally three times daily for 7 days

•
• Valacyclovir
• 1,000 mg orally three times daily for 7 days
•

Zoster(options)
• Prednisone
• 30 mg orally twice daily on days 1 through 7;
then 15 mg twice daily on days 8 through 14;
then 7.5 mg twice daily on days 15 through 21

Zoster(options)
• ANALGESICS
• Patients with more severe pain may require
the addition of a narcotic medication.

Zoster(options)
• Lotions containing calamine (e.g., Caladryl)
may be used on open lesions to reduce pain
and pruritus.

Zoster(options)
• Topically administered lidocaine (Xylocaine)
and nerve blocks have also been reported to
be effective in reducing pain.

Treatment of Postherpetic Neuralgia
• Lidocaine (Xylocaine) patch
• Apply to affected area every 4 to 12 hours as
needed.

• Tricyclic antidepressants
•
• Amitriptyline
• 10 to 25 mg orally at bedtime; increase
dosage by 25 mg every 2 to 4 weeks until
response is adequate, or to maximum dosage
of 150 mg per day.

• Nortriptyline
• 10 to 25 mg orally at bedtime; increase dosage
by 25 mg every 2 to 4 weeks until response is
adequate, or to maximum dosage of 125 mg per
day.
• Imipramine
• 25 mg orally at bedtime; increase dosage by 25
mg every 2 to 4 weeks until response is
adequate, or to maximum dosage of 150 mg per
day.

• Anticonvulsants
• Carbamazepine (Tegretol)
• 100 mg orally at bedtime; increase dosage by 100 mg
every 3 days until dosage is 200 mg three times
daily, response is adequate or blood drug level is 6 to12
μg per mL (25.4 to 50.8 μmol per L).
•
• Gabapentin (Neurontin)
• 100 to 300 mg orally at bedtime; increase dosage by
100 to 300 mg every 3 days until dosage is 300 to 900
mg three times daily or response is adequate. (Drug
levels for clinical use are not available.)

• THANK YOU & BEST OF LUCK

Herpes zoster by dr bashir ahmed dar associate professor medicine sopore kashmir

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