• pain followed by development of vesicular rash

    • unilateral

    • typically affects one dermatome

  • 1/3 lifetime

    • 1/2 who live to 80

  • reactivation of varicella zoster virus

    • cranial nerve and dorsal root ganglia

  • if reactivated travels from cell bodies of neurons to their nere terminals in skin

    • local inflammation

    • pain

    • rash

  • self limiting - post-herpetic neuralgia is a frequent complication

    • pain persists for months/years after rash has resolved

  • risk

    • people with chicken pox

    • 60% female

    • pregranncy not increase prevalence

      • not same risk as chicken pox

    • compromised immunity

clinical features

  1. prodrome - 1-4 days prior to rash appearing

    1. acute neuralgia

    2. localised tingling, itching, burning wiht intermittent stabbing

    3. malaise, fever, headahce may also be present

    4. lymph nodes may be enlarged

  2. infectious rash - 7-10d

    1. single dermatome in a unilateral band-like pattern

    2. sometimes extends past midline

    3. more rarely - multiple adjacent dermatomes

    4. rare cases - painless

    5. first stage brief erythematous and macular phase - often missed

    6. papules -> vesicle

    7. pustulate within 1 week, crusting 3-5d later

      1. pustules may appear black

    8. if vesicles burst - may be infectiou sto people who haven’t had VZV - to very yojng people and only occ. adults

  3. resolution 2-4 wks

    1. after crust over

      1. no longer infectious

    2. may persist for further 2-4 wks

  4. dermatomal pain but no rash

    • zoster sine herpete

      • rare form of shingles that occurs wihtout the rash

      • diagnosis more challengeing

Management

  • don’t scratch

    • reduce risk of transmission and avoid scarring

    • keep lesions clean and dry

  • avoid phsycial contact with other people

    • especially immunocompromised and infants \<1yr

  • simple absorbant dressings

    • avoid adhesive dressing

  • risk of secondary bacterial infection

    • not treat with topical antibiotics

  • calamine lotion

    • ?usefulness

Antiviral

  • much debate

  • modest effect on reducing severity in acute phase

  • ?reduce incidence of post-herpetic neuralgia

  • reduce duration of virla shedding and new lesion formation

  • accelerate rash healing time when givne to patients in early stages of shingles

  • consider:

    • >50yo

    • opthalmic involvement

    • immunocompromised status

    • atypical presentation

      • neck, limbs, pernium

    • moderate/severe pain

    • moderatte/severe rash

  • oral aciclovir = first line

    • aciclovir 800g five times daily for 7d

      • eFGR 10-25 = reduce to tds

  • valaciclovir = greater overall effectiveness than aciclovir

    • risk of vision impairment (opthalmic zoster) or

    • immunocompromised

Corticosteroids

  • role less clear than antiviral

  • unlikley to benefit majority

  • do not reduce post herpetic neuralgia

pain management

  • step wise

  • paracetamol

  • nsaid

  • codeine

  • tramadol

  • morphine

  • tca

  • gabapentin

post herpetic neuralgia

  • pain persisting for at least 120d after onset of rash

  • 1/3 of cases

  • most cases resolve spontaneously

    • pain can persist for several months/years

  • rarely appear months after acute epsidoe

  • usually same dermatome as rash

  • treated in same manner

  • trial capsaicin

    • 0.075%

    • pea sized amount

    • healed lesions

    • fully subsidised with endorsement for post-herpetic neuralgia

herpes zoster opthalmicus

  • opthalmic branch of tigeminal nerve

    • 5th cranial nerve

  • 5-25% of all zoster

  • referred urgently

    • especially if visual symptoms

      • corneal epithelium defect - seen on fluroscein

      • Hutchinson sign

        • presence of vesicular lesions on nose

Ramsay Hunt syndrome type II

  • rare complication

  • geniculate ganglion of facial nerve

  • presents with lesions in ear and side of tongue and facial paralysis

  • loss of tast

  • vertigo/tinnitus

  • may be initially difficult to diffenetiate from Bell’s palsy

    • usually painless

    • doesn’t affect ear or tongue

Zostavax

  • vaccine

  • unsubsidised

  • older adults had 50% reduced incidence than placebo

  • 60-69yo = most effective

  • single dose may be considered for >50yo

    • irrespective of exposure to chicken pox or previous occurrence of shingles

  • contraindicated for

    • women who are pregnant

    • people with active untreated tb

    • people with known anaphylactic reactions

  • live attenuated