Herpes Zoster on the Rise

Herpes zoster¹, otherwise known as shingles, is a viral disease characterized by a painful skin rash. Selecting this medical condition as the topic of this Top Paper should come as no surprise. Incidence of herpes zoster is on the rise and as primary care physicians, we are on the receiving end of an increased marketing push for the agents used to treat our patients. This paper offers advice for clinicians.

Magnitude

There are more than 1 million cases of shingles in the United States per year.¹ The incidence is increasing and rises after 50 years of age. A sobering statistic brings this home: Unvaccinated persons who live to age 85 have a 50% risk of the disease. Keep in mind, up to 3% of those afflicted require hospitalization.¹

Neurological Complications

Neurologic complications can be serious: Bell’s palsy, Ramsay Hunt Syndrome, transverse myelitis, as well as transient ischemic attacks and strokes (from a viral vasculitis) can worsen the disease. Ophthalmologic complications can be a disaster. Watch out for keratitis, scleritis, uveitis, and retinal necrosis. Deafness has been reported. The skin lesions may open a portal for Streptococcus and Staphylococcus. 

Indications

There are several indications for antiviral treatment in persons with herpes zoster. They include: age older than 50 years, moderate or severe pain, severe rash, involvement of the face or eye, other zoster-related complications, and/or immunocompromise. The earlier the start the better; treatment should definitely begin within the first 72 hours. Thrice daily valacyclovir or famciclovir are preferred over acyclovir (better and more consistent levels).

Glucocorticoids

Glucocorticoids are still controversial. They have not been shown to decrease post-herpetic neuralgia. They should not been given without antiviral therapy. Caution is urged in their use when zoster patients are diabetic, hypertensive, or elderly. 

Eye Complications

The presence of eye disease equals an ophthalmology consult. Combination treatment is recommended for postherpetic neuralgia (eg, gabapentin and nortriptyline).

Vaccinations

Persons 60 years of age or older who have had singles should also be vaccinated. The vaccine should be given to those individuals who already have a history of herpes zoster/shingles, although the optimal timing is not known. The vaccine is contraindicated in persons with hematologic cancers not in remission or in chemotherapy within the last three months, HIV persons with a CD4 count 200 cells or less/mm3, or administered high dose immunosuppressive therapy (20 mg or more of prednisone or anti-tumor necrosis factor therapy). 

Infectious

Remember that herpes zoster patients are infectious until their lesions crust. 

As primary care physicians, you have two roles: vaccinate when appropriate and treat effectively. Unfortunately, herpes zoster will not go away anytime soon but these helpful hints can help you deliver the best care for your patients.  

References  

1.Cohen JI. Herpes zoster. N Engl J Med. 2013;369:255-263. 

Gregory W. Rutecki, MD, is a professor of medicine in the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.