HERPES ZOSTER

BY Dr Bashir Ahmed Dar

Associate Professor MedicineChinkipora Sopore Kashmir

Email—drbashir123@gmail.com

HERPES ZOSTER (Shingles)

• Shingles is caused by the same virus that causes chickenpox

HERPES ZOSTER (Shingles)

• 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.

HERPES ZOSTER (Shingles)

• 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.

Herpes simplex

HERPES ZOSTER (Shingles)

• 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.

HERPES ZOSTER (Shingles)

• 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.

HERPES ZOSTER (Shingles)

• 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)

HERPES ZOSTER (Shingles)

• And results in nerve and skin inflammation

HERPES ZOSTER (Shingles)

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

HERPES ZOSTER (Shingles)

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

HERPES ZOSTER (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

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

Symptoms and signs

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.

Complications of shingles?

• 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.

Herpes zoster ophthalmicus

Herpes zoster ophthalmicus

Herpes zoster ophthalmicus

Complications of shingles?

• 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

Ramsay Hunt syndrome

Ramsay Hunt syndrome

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.

Post herpetic neuralgia

• The pain of Postherpetic neuralgia can be reduced by a number of medications.

• Tricyclic antidepressant • antiseizure medications (gabapentin

[Neurontin], • carbamazepine [Tegretol], • pregabalin [Lyrica])

Post herpetic neuralgia

• 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.

Post herpetic neuralgia

• 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.

Post herpetic neuralgia

• 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.

Post herpetic neuralgia

• 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.

Is shingles dangerous in pregnant 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.

Is shingles dangerous in pregnant 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•

Management of herpes 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

Management of herpes Zoster(options)

• ANALGESICS• Patients with more severe pain may require

the addition of a narcotic medication.

Management of herpes Zoster(options)

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

Management of herpes 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.

Treatment of Postherpetic Neuralgia

• 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.

Treatment of Postherpetic Neuralgia

• 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.

Treatment of Postherpetic Neuralgia

• 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