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Herpes Zoster
Key Points
●

●

●

●

In the absence of the herpes zoster vaccine, persons who live to 85
years of age have a 50% risk of herpes zoster.
The persons most likely to benefit from antiviral therapy for herpes
zoster are those who have or are at risk for complications of herpes
zoster, including immunocompromised persons, those 50 years of age
or older, and those with severe pain or severe rash
Antiviral agents hasten the resolution of herpes zoster lesions and
decrease the severity of acute pain but have not been shown to reduce
the risk of postherpetic neuralgia
Valacyclovir or famciclovir is preferable to acyclovir because of ease
of dosing and higher levels of antiviral drug activity
Key Points
●

●

Patients with herpes zoster and new visual symptoms should be
evaluated by an ophthalmologist to determine whether eye-specific
therapy is needed
The herpes zoster vaccine is recommended by the Advisory
Committee on Immunization Practices for persons 60 years of age or
older and is used in those with or without a history of herpes zoster
Symptoms
●

●

●

●

●

The rash of herpes zoster is dermatomal and does not cross the
midline
The rash is often preceded by tingling, itching, or pain (or a
combination of these) for 2 to 3 days and these symptoms can be
continuous or episodic
The rash begins as macules and papules, which evolve into vesicles
and then pustules
The rash usually dries with crusting in 7 to 10 days
The characteristics of pain associated with herpes zoster vary:
paresthesias (e.g., burning and tingling), dysesthesia (altered or
painful sensitivity to touch), allodynia (pain associated with
nonpainful stimuli), or hyperesthesia (exaggerated or prolonged
response to pain), pruritus
Diagnosis
●

●

Most cases of herpes zoster can be diagnosed clinically
Atypical rashes may require a direct immunofluorescence assay for
VZV antigen or a polymerase-chain-reaction (PCR) assay for VZV
DNA in cells from the base of lesions after they are unroofed
Treatment and Prevention
●

●

●

Antiviral therapy is recommended for herpes zoster in certain
nonimmunocompromised patients and all immunocompromised
patients
The oral bioavailability and levels of antiviral drug activity in the
blood are higher and more consistent in patients receiving thrice-daily
valacyclovir or famciclovir than in those receiving acyclovir five
times daily
These antiviral agents hasten the resolution of lesions, reduce the
formation of new lesions, reduce viral shedding, and decrease the
severity of acute pain
Treatment and Prevention
●

●

●

Antiviral therapy is recommended for herpes zoster in certain
nonimmunocompromised patients and all immunocompromised
patients
The oral bioavailability and levels of antiviral drug activity in the
blood are higher and more consistent in patients receiving thrice-daily
valacyclovir or famciclovir than in those receiving acyclovir five
times daily
These antiviral agents hasten the resolution of lesions, reduce the
formation of new lesions, reduce viral shedding, and decrease the
severity of acute pain
Treatment and Prevention
●

●

●

●

Treatment has been initiated within 72 hours after the onset of the
rash, and it is recommended that treatment start as early as possible
within this interval
Many experts recommend that if new skin lesions are still appearing
or complications of herpes zoster are present, treatment should be
initiated even if the rash began more than 3 days earlier
Treatment is usually given for 7 days in the absence of complications
of herpes zoster
The use of glucocorticoids with antiviral therapy for uncomplicated
herpes zoster remains controversial
Acute Pain Associated with Herpes Zoster
●

●

●

●

Nonsteroidal antiinflammatory drugs or acetaminophen can be
administered in patients with mild pain
Opioids are used for more severe pain associated with herpes zoster
Opioids were more effective than gaba­pentin for herpes zoster–
related pain in a randomized, placebo­controlled trial
Tricyclic antidepressants have been used when opioids were
insufficient for pain
Post Herpetic Neuralgia
●

●

●

Pain associated with post herpetic neuralgia is challenging to treat
Combination therapy, such gabapentin+nortriptyline or opiate and
gabapentin, have been more effective for post herpetic neuralgia than
single­agent therapy, but also confer a greater risk of side effects
Many patients do not have adequate relief of pain, referral to a pain
specialist can be helpful
Prevention of Herpes Zoster
●

●

●

●

A live attenuated herpes zoster vaccine is recommended for persons
60 years of age or older to prevent herpes zoster and its complications,
including postherpetic neuralgia
Reduction in the risk of herpes zoster remained significant for at least
5 years after vaccination
In vaccinated (as compared with unvaccinated) persons in whom
herpes zoster developed, pain was significantly shorter in duration and
less severe
Risk of recurrent herpes zoster after a recent episode of the disease is
relatively low and because the cellular immune response to VZV
during the first 3 years after vaccination is similar to that after an
episode of herpes zoster
Areas of Uncertainty
●

●

●

Improved therapies are needed for pain associated with herpes zoster
and postherpetic neuralgia and to prevent the development of
postherpetic neuralgia
To determine which patients are at highest risk for postherpetic
neuralgia so that more aggressive therapy can be given
Safety and effectiveness of the vaccine in persons with
immunocompromising conditions that are currently considered
contraindications to vaccination, the duration of immunity induced by
the vaccine, and the need for booster doses
Conclusion
●

●

●

●

●

Herpes zoster is often mild in healthy young persons, older persons
are at increased risk for pain and complications
Antiviral therapy is most beneficial for persons who have
complications of herpes zoster or who are at increased risk for
complications
Valacyclovir or famciclovir is preferred over acyclovir owing to the
reduced frequency of dosing and higher levels of antiviral drug
activity
Patient should also be advised to avoid contact with persons who have
not had varicella or have not received the varicella vaccine until his
lesions have completely crusted
Herpes zoster vaccination is recommended to reduce the risk ofn
recurrence
N Engl J Med 2013;369:255-63.DOI:
10.1056/NEJMcp1302674
The New England Journal of Medicine
Downloaded from nejm.org on October 10, 2013. For personal
use only. No other uses without permission.
Copyright © 2013 Massachusetts Medical Society. All rights
reserved.

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Herpes Zoster

  • 2. Key Points ● ● ● ● In the absence of the herpes zoster vaccine, persons who live to 85 years of age have a 50% risk of herpes zoster. The persons most likely to benefit from antiviral therapy for herpes zoster are those who have or are at risk for complications of herpes zoster, including immunocompromised persons, those 50 years of age or older, and those with severe pain or severe rash Antiviral agents hasten the resolution of herpes zoster lesions and decrease the severity of acute pain but have not been shown to reduce the risk of postherpetic neuralgia Valacyclovir or famciclovir is preferable to acyclovir because of ease of dosing and higher levels of antiviral drug activity
  • 3. Key Points ● ● Patients with herpes zoster and new visual symptoms should be evaluated by an ophthalmologist to determine whether eye-specific therapy is needed The herpes zoster vaccine is recommended by the Advisory Committee on Immunization Practices for persons 60 years of age or older and is used in those with or without a history of herpes zoster
  • 4. Symptoms ● ● ● ● ● The rash of herpes zoster is dermatomal and does not cross the midline The rash is often preceded by tingling, itching, or pain (or a combination of these) for 2 to 3 days and these symptoms can be continuous or episodic The rash begins as macules and papules, which evolve into vesicles and then pustules The rash usually dries with crusting in 7 to 10 days The characteristics of pain associated with herpes zoster vary: paresthesias (e.g., burning and tingling), dysesthesia (altered or painful sensitivity to touch), allodynia (pain associated with nonpainful stimuli), or hyperesthesia (exaggerated or prolonged response to pain), pruritus
  • 5.
  • 6.
  • 7. Diagnosis ● ● Most cases of herpes zoster can be diagnosed clinically Atypical rashes may require a direct immunofluorescence assay for VZV antigen or a polymerase-chain-reaction (PCR) assay for VZV DNA in cells from the base of lesions after they are unroofed
  • 8. Treatment and Prevention ● ● ● Antiviral therapy is recommended for herpes zoster in certain nonimmunocompromised patients and all immunocompromised patients The oral bioavailability and levels of antiviral drug activity in the blood are higher and more consistent in patients receiving thrice-daily valacyclovir or famciclovir than in those receiving acyclovir five times daily These antiviral agents hasten the resolution of lesions, reduce the formation of new lesions, reduce viral shedding, and decrease the severity of acute pain
  • 9. Treatment and Prevention ● ● ● Antiviral therapy is recommended for herpes zoster in certain nonimmunocompromised patients and all immunocompromised patients The oral bioavailability and levels of antiviral drug activity in the blood are higher and more consistent in patients receiving thrice-daily valacyclovir or famciclovir than in those receiving acyclovir five times daily These antiviral agents hasten the resolution of lesions, reduce the formation of new lesions, reduce viral shedding, and decrease the severity of acute pain
  • 10. Treatment and Prevention ● ● ● ● Treatment has been initiated within 72 hours after the onset of the rash, and it is recommended that treatment start as early as possible within this interval Many experts recommend that if new skin lesions are still appearing or complications of herpes zoster are present, treatment should be initiated even if the rash began more than 3 days earlier Treatment is usually given for 7 days in the absence of complications of herpes zoster The use of glucocorticoids with antiviral therapy for uncomplicated herpes zoster remains controversial
  • 11.
  • 12. Acute Pain Associated with Herpes Zoster ● ● ● ● Nonsteroidal antiinflammatory drugs or acetaminophen can be administered in patients with mild pain Opioids are used for more severe pain associated with herpes zoster Opioids were more effective than gaba­pentin for herpes zoster– related pain in a randomized, placebo­controlled trial Tricyclic antidepressants have been used when opioids were insufficient for pain
  • 13.
  • 14. Post Herpetic Neuralgia ● ● ● Pain associated with post herpetic neuralgia is challenging to treat Combination therapy, such gabapentin+nortriptyline or opiate and gabapentin, have been more effective for post herpetic neuralgia than single­agent therapy, but also confer a greater risk of side effects Many patients do not have adequate relief of pain, referral to a pain specialist can be helpful
  • 15. Prevention of Herpes Zoster ● ● ● ● A live attenuated herpes zoster vaccine is recommended for persons 60 years of age or older to prevent herpes zoster and its complications, including postherpetic neuralgia Reduction in the risk of herpes zoster remained significant for at least 5 years after vaccination In vaccinated (as compared with unvaccinated) persons in whom herpes zoster developed, pain was significantly shorter in duration and less severe Risk of recurrent herpes zoster after a recent episode of the disease is relatively low and because the cellular immune response to VZV during the first 3 years after vaccination is similar to that after an episode of herpes zoster
  • 16. Areas of Uncertainty ● ● ● Improved therapies are needed for pain associated with herpes zoster and postherpetic neuralgia and to prevent the development of postherpetic neuralgia To determine which patients are at highest risk for postherpetic neuralgia so that more aggressive therapy can be given Safety and effectiveness of the vaccine in persons with immunocompromising conditions that are currently considered contraindications to vaccination, the duration of immunity induced by the vaccine, and the need for booster doses
  • 17. Conclusion ● ● ● ● ● Herpes zoster is often mild in healthy young persons, older persons are at increased risk for pain and complications Antiviral therapy is most beneficial for persons who have complications of herpes zoster or who are at increased risk for complications Valacyclovir or famciclovir is preferred over acyclovir owing to the reduced frequency of dosing and higher levels of antiviral drug activity Patient should also be advised to avoid contact with persons who have not had varicella or have not received the varicella vaccine until his lesions have completely crusted Herpes zoster vaccination is recommended to reduce the risk ofn recurrence
  • 18. N Engl J Med 2013;369:255-63.DOI: 10.1056/NEJMcp1302674 The New England Journal of Medicine Downloaded from nejm.org on October 10, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.

Editor's Notes

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