Herpes zoster

Last Updated: 2021-10-05

Author(s): Anzengruber, Navarini

Shingles.

Contagious, segmentally arranged skin disease, which is caused by reactivation of VZV in the spinal and cranial nerve ganglia

Lifetime prevalence: 20%.

  • Incubation period: 1-2 weeks
  • Predisposing factors:
    • Immune suppression
    • Stress
    • Older age

Herpetiform, grouped, segmentally arranged blisters on an erythematous base. In the course of the disease, the blisters burst and crusts form. If there are no more blisters, the patient is no longer classified as infectious. In some cases, there is pain, allodynia, itching, reduced general condition and, rarely, fever.

  • Clinical appearance
  • Tzanck test: swab with cotton swab from the base of the vesicle (press firmly)
    • Smear onto a microscope slide, stain with methylene blue
  • PCR
    • Swab with cotton swab from base of bubble (press firmly). Place cotton swab in virus medium, leave for 15 sec, then remove swab

Unilateral on the body. Mostly thoracic dermatome, second most common in trigeminal area.

Rarely also other localisations, e.g. genital.

  • Postzoster neuralgia
  • CNS involvement of the zoster
  • Pyogenic infections
  • Herpetic keratitis in V.1 infestation

Shingrix vaccination recommended, Zostavax is far less effective.

Vaccination also recommended after clinical course of herpes zoster. Recurrences occur in 6% after zoster, of which approx. 50% occur at the same site.

  • Light protection
  • Contact with pregnant women or young children should be avoided if possible
  • In young patients, exclusion of immunosuppression (especially HIV) is useful
  • Need-oriented analgesic therapy
  • Pain therapy, therapy of postzosteric neuralgia (step-by-step scheme)
    • 1st stage NSAIDs (e.g. ibuprofen, max. 2.4g/d) or paracetamol max. 4d/d
    • 2nd stage additionally weak opioid analgesics (e.g. tramadol 200-400mg/d)
    • 3rd stage (in addition to stage 1) strong opioid analgesics (e.g. oxycodone)
    • 4th stage (in addition to stage 1 or 2) anticonvulsants (e.g. gabapentin max. 3.6g/d), pregabalin max. 600mg/d or antidepressants (e.g. amitriptyline max. 150mg/d); presentation in the pain consultation

 

  • Therapy
    • 1st line: Valacyclovir, Brivudin, Acyclovir, Famciclovir
    • 2nd line: Pain therapy incl. topical lidocaine patch
    • 3rd line: Adult immunisation, steroids, capsaiscin

 

Systemic therapy

  • Absolute indications for systemic treatment, ideally within the first 72 hours after infection:
    • Age > 50 years.
    • Extratruncal infestation
    • Moderate or severe pain
    • Extensive local findings
    • Immune suppression
    • Involvement of internal organs
    • Early initiation
    • is essential for any antiviral therapy
    • Start therapy 72 h after the onset of skin symptoms or 72 h after the onset of skin symptoms when new vesicles are formed. In addition, there is an increased risk of secondary bacterial infection

 

Virostatics

 

  • Valaciclovir
    • Add.: 500 mg 2x/d for 7d
    • CI: hypersensitivity, lactation
    • ADVERSE REACTIONS (common): headache, nausea
    • CAVE:
      • Adjustment of dosage in impaired renal function
      • Hydration state

 

  • Brivudine (tbl.)
    • Administer: 125 mg 1x/d for 7 days
    • WW: 5-fluorouracil preparations (at least 4 weeks apart)
    • NWM (common): nausea
    • KI: 5-fluorouracil- therapy, pregnancy, lactation, hypersensitivity to ingredient, not tested in children and adolescents

 

  • Aciclovir
    • Administer: 3x 5mg/kg daily i.v. or 5x 200mg/d p.o., at immunosuppression 10mg/kg daily i.v.
    • CI: Hypersensitivity, lactation (since transfer to breast milk)
    • ADVERSE REACTIONS (very common): headache, nausea
    • CAVE:
      • In elderly patients, there is an increased risk for the occurrence of reversible neurological disorders
      • Adjust dosage if renal function is impaired
      • Enough fluid intake

 

  • Famciclovir
    • Application: 500 mg 2x/d
    • In pat. >50, 500mg 3x/d can/should be given
    • to prevent zoster neuralgia
    • Independent of meals
    • Interactions: Probenecid
    • CI: Pregnancy, lactation, hypersensitivity to famciclovir or penciclovir
    • CAVE:
      • In patients at risk of dehydration, especially elderly patients, adequate hydration should be ensured
      • Efficacy may be reduced in black patients

 

  • Foscarnet
    • In immunosuppression and aciclovir resistance
    • Administration: 3 x 40 mg/kg bw/d i.v.
    • KI: hypersensitivity, pregnancy, lactation
    • Side effects (very common): granulocytopenia, anorexia, hypokalaemia, hypomagnesaemia, hypocalcaemia, paraesthesias, headache, dizziness, nausea, vomiting, diarrhoea, rash, increased serum creatinine, fever, fatigue, chills, asthenia
    • CAVE:
      • Adjust dosage if renal function is impaired
      • Enough fluid intake

 

  • Systemic glucocorticoids
    Note: Although systemic glucocorticoids are sometimes used, the data supporting this strategy are rather weak. Although studies have been conducted that showed a positive effect of glucocorticoids with regard to quality of life and a reduction in cases with postzoster neuralgia, these data could not be confirmed in a meta-analysis.

 

  • Topical therapy
    • Tanning agents / Lsg. several times a day

 

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