Herpes zoster (shingles) is the clinical manifestation of the reactivation of latent varicella-zoster virus from the dorsal root and cranial nerve ganglia. Approximately one-third of the population will develop herpes zoster, which most commonly results in a self-limited, painful, vesicular, dermatomal rash that resolves within 2 to 4 weeks. Complications of herpes zoster can result in chronic debility. Postherpetic neuralgia, a persistent dermatomal pain syndrome lasting longer than 90 days after symptom onset, is the most common complication, occurring in 10% to 18% of people who have herpes zoster. Older adults and immunocompromised individuals are at higher risk of developing herpes zoster and its associated complications. Treatment for herpes zoster involves antiviral medications (eg, acyclovir, valacyclovir, famciclovir) with or without adjunctive pain management. First-line treatment of postherpetic neuralgia includes gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants. Topical drugs are an adjunctive treatment. Herpes zoster and its complications are largely preventable with vaccination (recombinant zoster vaccine), which is covered by Medicare and commercial insurances. Two doses of recombinant zoster vaccine are recommended for adults 50 years and older and those 19 years and older with immunocompromise. Obstacles to receiving vaccination include low awareness, administration errors, necessity of receiving multiple doses, and vaccine adverse effects.
Varicella-zoster virus is a herpesvirus that causes chicken-pox; it subsequently resides dormant in the dorsal root and cranial nerve ganglia. Reactivation of latent varicella-zoster virus leads to herpes zoster (shingles).
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comment |
|---|---|---|
| Antivirals (acyclovir, valacyclovir, and famciclovir) should be used within 72 hours of symptom onset to reduce acute pain, shorten the duration of symptoms, and reduce risk of long-term complications, with valacyclovir and famciclovir achieving superior pain control and reducing the risk of postherpetic neuralgia.25,26,31 | A | Systematic review and meta-analysis |
| Gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are first-line treatment options for postherpetic neuralgia.34–37 | B | Systematic reviews and meta-analyses |
| Topical treatments for postherpetic neuralgia (eg, capsaicin patches 8% [Qutenza], capsaicin cream 0.075%, lidocaine 5% formulations) should be considered as adjunctive therapy for postherpetic neuralgia.34,35 | B | Systematic review and meta-analysis |
| Recombinant zoster vaccine is recommended for patients 19 years and older with immunocompromise and all adults 50 years and older to reduce the risk of primary and recurrent herpes zoster and postherpetic neuralgia.45–47 | A | Clinical trials, systematic review, and meta-analysis |
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
Herpes zoster most commonly presents as dysesthesia (pain, tingling, or itching) in one or two adjacent dermatomes on the face or trunk. A maculopapular rash erupts within 2 to 4 days and progresses to vesicles that crust within 7 to 10 days (Figure 1). Herpes zoster may be accompanied by a prodrome of malaise, headache, and low-grade fever. Symptoms resolve within 2 to 4 weeks. Although rare, herpes zoster can cross the body's midline with adjacent dermatomal activation.1,2 Symptoms of herpes zoster are less severe in children and young adults, and immunocompromised persons are at highest risk of developing herpes zoster and its complications.1–3 Incidence of zoster sine herpete (herpes zoster without rash) is unknown and requires a high index of suspicion for diagnosis.4
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