Clinical Overview of Herpes Zoster (Shingles)

Cause

Herpes zoster, also known as shingles, is caused by reactivation of varicella-zoster virus (VZV), the same virus that causes varicella (chickenpox).

Primary infection with VZV causes varicella. After a person has varicella, the virus remains latent in the dorsal root ganglia. VZV can reactivate later in a person’s life and cause herpes zoster, a painful maculopapular and then vesicular rash.

Clinical Features

People with herpes zoster most commonly have a rash in one or two adjacent dermatomes. The rash most commonly appears on the trunk along a thoracic dermatome or on the face and it usually does not cross the body’s midline.

The rash is usually painful, itchy, or tingly. A person can experience the following symptoms several days before the rash appears:

• Headache
• Photophobia (sensitivity to bright light)
• Malaise

The rash develops into clusters of vesicles. New vesicles continue to form over 3 to 5 days, and the rash progressively dries and scabs over. The rash usually heals in 2 to 4 weeks. Permanent skin discoloration and scarring can occur.

Complications

Postherpetic neuralgia (PHN)

PHN is the most common complication of herpes zoster. PHN is pain that persists in the area where the rash once was located and continues more than 90 days after rash onset. PHN can last for months or even years.

A person’s risk of having PHN after herpes zoster increases with age. Older adults are more likely to have longer lasting, more severe pain. Approximately 10% to 18% of people with herpes zoster will have PHN. PHN is rare in people younger than 40 years old. The likelihood of PHN is also higher in people who experience more pain with the rash or have a large rash.

Herpes zoster ophthalmicus

Herpes zoster that affects the ophthalmic division of the trigeminal nerve is called herpes zoster ophthalmicus. This can result in acute or chronic ocular sequelae, including vision loss.

Disseminated zoster

Disseminated zoster can include generalized skin eruptions where the lesions occur outside of the primary or adjacent dermatomes. It can be difficult to distinguish from varicella. Visceral involvement of the central nervous system (meningoencephalitis), lungs (pneumonitis), and liver (hepatitis) can also occur. Disseminated zoster generally occurs in people with compromised or suppressed immune systems.

People with compromised or suppressed immune systems are more likely to have a severe, long-lasting rash and experience more severe complications from herpes zoster.

Vaccination

Recombinant zoster vaccine (RZV, Shingrix) is the recommended vaccine to prevent shingles and related complications. For information about vaccination recommendations see Shingles Vaccination.

Transmission

People with active herpes zoster lesions can spread VZV , which causes varicella in people who never had varicella or never received varicella vaccine. Once varicella resolves, these people would be at risk for herpes zoster.

Active herpes zoster lesions are infectious through direct contact with vesicular fluid or through breathing in virus particles from the blisters until they dry and scab over. People with active herpes zoster lesions should cover their lesions and avoid contact with susceptible people in their household and in occupational settings until their lesions are dry and scabbed.

Also see Managing People at High Risk for Severe Varicella and Preventing VZV Transmission from Herpes Zoster in Healthcare Settings

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Epidemiology

Risk Factors

Anyone who had varicella can develop herpes zoster. Approximately 99.5% of people born before 1980 in the United States were infected with wild-type VZV. Children who receive varicella vaccine have a lower risk of herpes zoster compared with children who were infected with wild-type VZV.

Approximately 1 in 3 people in the United States will develop herpes zoster during their lifetime. Most people have only one episode; however, herpes zoster can recur.

A person’s risk for herpes zoster and related complications sharply increases after 50 years of age. The reasons why VZV reactivates and causes herpes zoster are not well understood. However, a person’s risk for herpes zoster increases as their VZV-specific cell-mediated immunity declines. This decline in immunity can result from increasing age and medical conditions or medications that suppress a person’s immune system. People with the following conditions that compromise or suppress their immune system have an increased risk for herpes zoster:

• Bone marrow or solid organ (renal, cardiac, liver, and lung) transplant recipients
• Cancer, especially leukemia and lymphoma
• Human immunodeficiency virus (HIV)
• Taking immunosuppressive medications, including steroids, such as for treatment of autoimmune diseases and other immune system deficiencies

Other potential risk factors for herpes zoster have been identified, but the findings are either inconsistent or unexplained. For example:

• More women than men develop herpes zoster.
• Herpes zoster is less common in Blacks than in Whites.

Disease Rates

An estimated one million cases of herpes zoster occur annually in the United States.

• The incidence of herpes zoster varies by age and is approximately 2–9 cases per 1,000 US population annually.

The precise incidence of recurrence is not known.

Complications

• Approximately 10% to 18% of people with herpes zoster will have PHN.
• Approximately 1% to 4% of people with herpes zoster are hospitalized for complications.
• Older adults and people with compromised or suppressed immune systems are more likely to be hospitalized. About 30% of people hospitalized with herpes zoster have compromised or suppressed immune systems.

Deaths

One study estimated 96 deaths occur each year where herpes zoster was the underlying cause (0.28 to 0.69 per 1 million population). Almost all the deaths occurred in older adults or those with compromised or suppressed immune systems.

Trends

Herpes zoster rates among adults in the United States gradually increased over a long period of time. We do not know the reason for this increase. However, the rates across age groups have recently plateaued or declined.

CDC studies have found that herpes zoster rates started increasing before varicella vaccine was introduced in the U.S. and did not accelerate after the routine varicella vaccination program started.

Herpes Zoster in People Who Received Varicella Vaccine

Varicella vaccines contain live attenuated VZV, which results in latent infection. Although herpes zoster has always been uncommon among children, the rate of herpes zoster in U.S. children has declined since the routine varicella vaccination program started in 1996.

• Children (healthy and immunocompromised) vaccinated against varicella have lower rates of herpes zoster compared to children who had natural infection with varicella.
  • Vaccinated children are less likely to become infected with wild-type VZV.
  • The risk of reactivation of vaccine-strain VZV in children is lower compared with reactivation of wild-type VZV.
• Few older adults have received the varicella vaccine since it was licensed in 1995. There is very little information on the risk of herpes zoster in people who got varicella vaccine as adults.

CDC continues to monitor the impacts of the U.S. varicella and herpes zoster vaccination programs among adults and children.

References

1. CDC. Use of Recombinant Zoster Vaccine in Immunocompromised Adults Aged ≥19 Years: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Recomm Rep. 2022;71(3):80-84.
2. Leung et al. The Impact of Universal Varicella Vaccination on Herpes Zoster Incidence in the United States: Comparison of Birth Cohorts Preceding and Following Varicella Vaccination Program Launch. Journal of Infection Diseases. 2022.
3. Harpaz and Leung. The Epidemiology of Herpes Zoster in the United States During the Era of Varicella and Herpes Zoster Vaccines: Changing Patterns Among Older Adults. Clin Infect Dis.2019;69(2):341-344.
4. CDC. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP) Recommendations for use of Herpes Zoster Vaccines. MMWR Recomm Rep. 2018;67(03):103-108.
5. Thomas SL, Hall AJ. What does epidemiology tell us about risk factors for herpes zoster? Lancet Infect Dis. 2004;4(1):26-33.
6. Tseng HF, Smith N, Harpaz R, et al. Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease. JAMA. 2011;305(2):160-6.
7. Mahamud A, Marin M, Nickell SP, et al. Herpes zoster-related deaths in the United States: validity of death certificates and mortality rates, 1979-2007. Clin Infect Dis.2012;55(7):960-6.
8. Leung J, Harpaz R, Molinari NA, et al. Herpes zoster incidence among insured persons in the United States, 1993-2006: evaluation of impact of varicella vaccination. Clinical Infectious Diseases. 2011;52(3):332-340.
9. Yih W, Brooks D, Lett S, et al. The Incidence of varicella and herpes zoster in Massachusetts as measured by the Behavioral Risk Factor Surveillance System (BRFSS) during a period of increasing varicella vaccine coverage. BMC Public Health. 2005;5(68).
10. Jumaan AO, Yu O, Jackson LA, et al. Incidence of herpes zoster, before and after varicella vaccination-associated decreases in the incidence of varicella. Journal of Infectious Diseases. 2005;191:2002-7.
11. Hales CM, Harpaz R, Joesoef MR, Bialek SR. Examination of links between herpes zoster incidence and childhood varicella vaccination. Annals of Internal Medicine. 2013;159(11):739-45.
12. Russell ML, Dover DC, Simmonds KA, Svenson LW. Shingles in Alberta: before and after publicly funded varicella vaccination. Vaccine. 2014;32(47):6319-24.
13. Weinmann S, Chun C, Schmid DS, et al. Incidence and clinical characteristics of herpes zoster among children in the varicella vaccine era, 2005–2009. Journal of Infection Diseases. 2013;208(11):1859-68.
14. Hardy I, Gershon AA, Steinberg SP, LaRussa P. The incidence of zoster after immunization with live attenuated varicella vaccine. A study in children with leukemia. Varicella Vaccine Collaborative Study Group. N Engl J Med. 1991;325(22):1545-50.

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What Causes Shingles to Activate and What to Do About It

People over 50 are most susceptible to developing shingles as the primary risk factor for shingles is a weakened immune system.

If you contract the chickenpox virus, also known as varicella-zoster, your illness will typically clear up in a week or two. However, this virus remains in your body even after you’ve recovered.

The virus lies dormant when your immune system is strong. But if something causes you to become immunocompromised, the virus can reactivate. This triggers shingles.

Shingles, known by its medical name herpes zoster, presents as a painful rash. It typically shows up on only one side of your body.

According to the Centers for Disease Control and Prevention (CDC), the chance of getting shingles at some point in your life is 1 in 3.

When you first contract the varicella-zoster virus (VZV), you’ll get chickenpox. When you fight off this virus, your body creates immunity to it, so it’s very rare to get chickenpox a second time.

However, that doesn’t mean that your body rids itself of the virus entirely. Though a strong immune system will keep the virus inactive, it’s still there for the rest of your life.

If your immune system becomes weakened or compromised, it’s possible for this virus to reactivate. A painful shingles rash may result.

Prior to the development of the varicella vaccine, chickenpox was a common childhood illness. Most people were exposed to VZV in childhood and developed chickenpox in their younger years.

In fact, doctors once encouraged families to expose their kids to chickenpox at an early age — after age 10 or so, the disease can be much more severe. (You may remember “chickenpox parties,” where parents actively tried to get their children to contract the virus.)

Adults who come down with chickenpox can experience serious and even life threatening complications like lung or brain infections.

These days, children and adults can receive the varicella vaccine. This weaker version of the live virus causes the body to launch an immune response so that it recognizes — and fights off — VZV in the future.

Getting a varicella vaccine appears to reduce the risk of shingles, but it isn’t a guarantee against them. Though weakened, the virus does continue to stay in your body, so it’s possible for it to reactivate and cause shingles. However, this is uncommon.

One study found that the rate of shingles infection was 78 percent lower in vaccinated children than unvaccinated children.

The varicella vaccine became available in 1995, so only time will tell its effects on the rates of shingles in older adults.

If you’ve had chickenpox or gotten the varicella vaccine, you can develop shingles.

According to the CDC, over 99 percent of people in the United States born before 1980 have had chickenpox or been exposed to VZV.

The primary risk factor associated with getting shingles is a weakened immune system. When your immune system isn’t functioning properly, VZV can reactivate.

As you age, your immune system doesn’t fight off invaders as well. Older age is associated with greater likelihood of health problems, including:

• a natural decline in immunity
• the use of immunosuppressant medications like chemotherapy, long-term corticosteroids, and anti-inflammatory medications
• certain diseases and conditions that damage your immune system, such as HIV and hypogammaglobulinemia
• autoimmune diseases that are treated with immune-suppressing drugs, such as rheumatoid arthritis, Crohn’s disease, and lupus
• procedures like bone marrow transplants and kidney transplants, which may require treatment with immunosuppressants afterward

Starting around age 50, your chance of getting shingles goes up. The severity of the disease and the risk of complications also increase with age.

It’s important to remember, too, that stress can negatively affect your immune system. There’s been some interest in whether stressful life circumstances could weaken the immune system, leading to a shingles infection. However, research is contradictory and doesn’t yet offer firm conclusions.

Shingles isn’t a disease you “catch” in the traditional sense. It’s usually a case of VZV reactivating in your system. But people who’ve never had chickenpox can develop shingles after coming into contact with the fluid from shingles blisters. Shingles are no longer contagious after these blisters have crusted over.

Typically, shingles shows up as a painful rash on an area of skin that is supplied by a single nerve. This area, regardless of its location on the body, is known as a dermatome. Look for these hallmarks of a shingles rash:

• A band of blistering lesions may cover red, inflamed skin, often on one side of the torso or face.
• Pain starts out feeling tingly or burning. Other common sensations include itching and numbness.
• The pain progresses in severity over several days.
• It feels like the pain is coming from the organs in your abdomen, like your heart, gallbladder, appendix, or kidneys.
• Sometimes (though rarely) people experience severe pain without a rash, known as zoster sine herpete.

Some people also have other, more general symptoms, like:

• fever
• chills
• headache

Shingles symptoms can last up to 4 weeks or longer.

To diagnose shingles, your doctor will ask you some questions about your symptoms. These may include:

• When did your symptoms start?
• Which symptom did you notice first?
• Are you experiencing pain?
• Where are you having pain?
• Have you had chickenpox?
• Have you had the chickenpox vaccine?
• Have you had the shingles vaccine?

They’ll also evaluate your rash, looking at its pattern, appearance, and location. Doctors can usually diagnose shingles by its distinctive rash and unique symptoms.

In rare cases, though, if your doctor is uncertain whether you have shingles, you may undergo a diagnostic test. Testing is more common for people with greater risk factors for complications, including:

• people with a weakened immune system
• pregnant people
• newborns

To test for shingles, your doctor will use a swab to take a sample from a skin lesion. This will then be tested for VZV. A positive test indicates that you have shingles.

How to feel better if you have shingles

When you have shingles, you can feel better by trying the following:

• Eat a balanced diet, get lots of rest, and try some gentle exercise.
• Relieve pain and itching by soaking in a bathtub of lukewarm water and ground-up oatmeal.
• Reduce pain and promote healing of lesions by applying a cool, wet washcloth or compress to the rash.
• Do what you can to limit stress. A stressful lifestyle can weaken your immune system, worsening your symptoms.
• Wear loose-fitting clothes that won’t irritate the rash.
• Keep the lesions covered with a bandage. Prior to putting on the bandage, apply a thin layer of petroleum jelly to prevent irritation.

Although there’s no cure for shingles, the good news is that it resolves on its own. Your doctor may recommend certain medications to alleviate pain or treat infection.

Antiviral medication

Three antiviral medications are used to treat shingles:

• valacyclovir
• famciclovir
• acyclovir

Valacyclovir and famciclovir are taken three times per day. They’re usually preferred over acyclovir, which must be taken five times a day.

All three have a 7-day course if you have an uncomplicated case of shingles. If the shingles is complicated — if it’s affecting your eyes, for example — your doctor will prescribe the medication for longer than 7 days.

Antiviral medication can help:

• you recover faster
• limit the severity of your symptoms
• reduce your risk for complications

Antiviral medications offer the most benefit for people over 50 and those who are immunocompromised, since these risk factors are associated with more persistent, severe shingles symptoms.

It’s best to start an antiviral while you’re still developing new skin lesions, usually within 72 hours of noticing your first symptom. Antivirals won’t be effective after your lesions have begun to crust over.

Some people may need to take a longer course of antiviral medications or even be treated in the hospital with antivirals. This is more likely if you have the following:

• a weakened immune system
• a severe case of shingles
• a high risk of complications

Some people experience shingles on the face. This can lead to serious complications, such as:

• blindness
• hearing impairment
• brain swelling

Seek immediate medical attention if you think you have shingles on your face.

Pain medication

Mild shingles pain may improve with over-the-counter anti-inflammatory medications. Your doctor may recommend ibuprofen or acetaminophen or weak opioids, such as codeine or tramadol.

Stronger prescription opioid pain medication, such as hydrocodone, may be prescribed to treat moderate to severe shingles pain.

Another option is topical pain relievers, such as lidocaine. These are applied directly to your skin for relief. You can find topical pain relievers as ointments, creams, gels, sprays, or patches. Capsaicin, which comes in a cream or a patch, may also be helpful.

Other medications that may be used for relief include:

• diphenhydramine
• hydroxyzine
• calamine lotion to soothe itching
• antibiotics, if a bacterial infection develops around the rash

Shingix (recombinant zoster vaccine) is currently the only shingles vaccine available in the United States. It’s given to people over age 50.

Previously, an additional vaccine, Zostavax, was used, but it was phased out in the United States as of November 2020.

According to the CDC, two doses of Shingrix are over 90 percent effective at preventing shingles. You’ll retain at least 85 percent protection for 4 years after being vaccinated.

If you get shingles after being vaccinated, your symptoms will likely be less severe. You’ll also have a lower chance of developing postherpetic neuralgia — a complication where pain remains even after a shingles rash goes away.

Shingles usually follows a pattern of development. It typically progresses with the following symptoms:

• First, you may notice a tingling or burning sensation in your skin.
• One to 5 days later (or concurrent with the initial pain) a rash appears as small red spots.
• Fluid-filled blisters develop a few days later.
• After 7 to 10 days, the lesions crust over.
• The rash disappears over the next 2 to 4 weeks.

In some cases, pain may persist for several months or even years after the rash has disappeared. This complication, known as postherpetic neuralgia (PHN), can be severe enough to affect your quality of life.

Certain antiseizure medications can help manage the pain. Gabapentin and pregabalin are two that are commonly used.

It’s unlikely to get shingles more than once — but it’s possible. That’s why it’s recommended to get the shingles vaccine at age 50 and older, even if you’ve already had the disease. Getting shingles three times is extremely rare.

Shingles occurs when the varicella-zoster virus is reactivated due to a weakened immune system. This can create a painful, blistering rash. The risk of getting shingles goes up with age, with increased likelihood after age 50.

Shingles often doesn’t require treatment to make it go away, but some antiviral medications can help you recover faster and reduce your risk for complications.

Shingles (herpes) – causes, symptoms, diagnosis, treatment of lichen in Moscow

• Signs of herpes zoster
• Lichen forms
• Causes
• Incipient disease
• Eruption period
• Crust
• Diagnosis of herpes zoster
• How to treat infection?
• What are antivirals used for?
• Possible consequences of herpes
• Is shingles contagious?
• When lichen is transmitted
• Disease prevention
• Which doctor to contact with herpes zoster

Shingles , also known as herpes zoster or herpes zoster, is a viral disease that occurs as a result of reactivation of the herpes simplex virus type 3. It is characterized by inflammation of the skin, on which a large number of vesicles appear, as well as inflammation of the nervous tissue surrounding the posterior roots of the spinal cord and ganglia of peripheral nerves. This disease usually occurs in a specific area of ​​the skin known as the “dermatome” and has vivid and painful symptoms.

Most often, the disease is detected in the elderly. Unfavorable ecology contributes to the development of infection in young people with weak immunity. Shingles often develops against the background of oncological processes, especially in people with weakened immune systems (after chemotherapy, for example).

Signs of herpes zoster

The onset of the disease is quite pronounced – there is a burning sensation and soreness of a certain area of ​​\u200b\u200bthe skin. Often these areas coincide with the location of the trigeminal facial nerve, affect the forehead, back of the head, neck, and can be located in accordance with the course of the nerves.

Lichen forms

The disease can be typical and atypical.

With an atypical form, the symptoms may be mild:

• In the abortive form, rashes are absent or there is a single focus;
• Bullous form – multiple vesicles with a clear liquid;
• Hemorrhagic form – vesicles with bloody fluid, in place of which scars remain.
• The gangrenous form leaves hard-to-heal ulcers and rough scars.

Causes

Infections that are present in the body in a dormant state are activated. The following factors provoke the development of the process:

• Immunosuppressive drugs;
• Heavy workload, stress;
• Cancer processes;
• Radiation therapy;
• HIV;
• Organ transplant.

Repeated episodes require special attention, as rashes are often localized at the site of the tumor. The development of shingles goes through certain stages.

Early disease

From the incubation to the active period takes about four days. At this time there is:

• Malaise, weakness. chills;
• Pain;
• Temperature increase;
• Burning and itching;
• Enlarged lymph nodes;
• Possible disorders of the organs and systems of the body.

Subsequently, the disturbances subside.

Eruption period

The type of rash depends on the severity of the disease. At the initial stage, the rash looks like small pink spots located on healthy skin.

If the process develops typically, then the next day they are replaced by bubbles with a clear liquid – grouped vesicles. After 3 days, their contents become cloudy. Rashes occur in jerks, with interruptions of several days.

If a severe gangrenous form develops, then the filling of the vesicles may be mixed with blood. It seems that the bubbles move to another place, located around the body.

If the form of inflammation is mild, the manifestation of the disease can only be neurological in nature, when the patient feels pain, but there is no rash. This is herpetic neuralgia.

Crust

As a rule, after 2-3 weeks from the onset of rashes, crusts form. The areas of rashes turn pale and dry up. In place of the fallen crusts, a slight pigmentation remains.

Herpes zoster diagnosis

With a pronounced manifestation of skin forms of the disease, it is not difficult to make a diagnosis. Errors occur at the initial stage, when angina pectoris, pulmonary infarction, pleurisy, acute appendicitis are mistakenly diagnosed.

Laboratory confirm the diagnosis using a microscope or immunofluorescent method. In general practice, laboratory diagnostics is not used.

How to treat an infection?

If young people who do not have chronic diseases are sick, then treatment is not carried out. The disease will completely disappear within a month. To eliminate the pain of herpes, the doctor may prescribe painkillers. With intense pain, painkillers are used along with antiviral drugs. It is possible to use non-steroidal drugs. Assign antiherpetic drugs in tablets, creams, ointments or intramuscular injections.

What are antivirals used for?

The goal is to avoid the development of complications. Antiherpetic treatment helps the rapid healing of ulcers and improves the patient’s condition.

The course of treatment and dosage of drugs is determined by the doctor, taking into account the general condition of the patient. On average, the treatment time does not exceed 10 days.

If a gangrenous form develops with a bacterial infection, antibiotics, immunomodulators, physiotherapy and vitamins are prescribed.

As for the treatment of rashes, there are different opinions about the use of drying agents. In any case, they should be used with caution so as not to worsen the condition of the skin with a burn.

Do not use hormonal drugs, as they suppress the immune system.

Treatment of the disease in elderly patients is not always successful, since antiviral drugs do not justify themselves.

Possible consequences of herpes

• Paralysis of the facial or other nerves.
• Reduced vision.
• Violations of the internal organs.
• Disabling meningoencephalitis.
• For bacterial infections, treatment is delayed for months.

Is shingles contagious?

Most often, cases of the development of the disease are recorded in the off-season. If a person has previously had chickenpox and has good immunity, then the likelihood of contracting infection through contact with a patient is minimal.

If immunity to the herpes virus is weakened or not formed, then there is a chance of getting sick upon contact, including again.

When lichen is transmitted

• A sick person can infect those who have not had chickenpox – adults and children.
• In the presence of strong immunity and good health, the probability of getting infected is zero.
• Most often children get sick.
• Almost anyone can get shingles if their defenses are weakened.
• Viral during the formation of fresh blisters. During the formation of crusts, there is no danger of infection.

Disease prevention

It is necessary to isolate the sick, avoid contact with the sick (applies to those who have not had chickenpox), observe hygiene rules, and take measures to strengthen immunity.

Which doctor to contact with herpes zoster

You should first contact a therapist, then an infectious disease specialist or a dermatologist. If the form of herpes is severe, the help of a neurologist is needed, if the eyes are affected, an ophthalmologist.

We recommend making an appointment at the neurological department of the clinic of the Russian Academy of Sciences (Moscow). You will be examined by the best doctors, they will study the signs of the disease, determine the causative agent of the infection, make a diagnosis, consult, give clinical recommendations and prescribe an effective treatment.

Don’t put off going to a specialist! Specialists of the Neurological Department of the NCC No. 2 (CCH RAS) in Moscow remind you that any symptoms that disturb you are a reason for consulting a neurologist. In this case, the doctor will be able to recognize and stop the disease at an early stage, until the situation worsens and becomes irreversible. You can make an appointment with a neurologist by calling the clinic, as well as using the form on the website.

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