What are the symptoms of shingles. How is shingles caused. What are the risk factors for developing shingles. How can shingles be prevented and treated with antiviral medicine. What complications can arise from shingles. How does shingles differ from chickenpox.

Understanding Shingles: Symptoms and Causes

Shingles, also known as herpes zoster, is a viral infection characterized by a painful rash. This condition is caused by the varicella-zoster virus, the same virus responsible for chickenpox. After recovering from chickenpox, the virus remains dormant in the nervous system and can reactivate years later, resulting in shingles.

The primary symptoms of shingles include:

• Pain, burning, or tingling sensation
• Sensitivity to touch
• A red rash that appears a few days after the initial pain
• Fluid-filled blisters that eventually break open and crust over
• Itching

Some individuals may also experience additional symptoms such as:

• Fever
• Headache
• Sensitivity to light
• Fatigue

Is shingles contagious? While shingles itself is not contagious, the varicella-zoster virus can be transmitted to individuals who have never had chickenpox or received the chickenpox vaccine. In such cases, the person exposed to the virus will develop chickenpox rather than shingles.

Recognizing the Shingles Rash: Appearance and Location

The shingles rash typically manifests as a stripe of blisters wrapping around one side of the torso, either on the left or right side. However, it can also appear on other parts of the body, including:

• Around one eye
• On one side of the neck
• On one side of the face

Why does the shingles rash have this distinctive pattern? The rash follows the path of the affected nerves, which is why it usually appears as a stripe or band on one side of the body. This characteristic distribution is a key factor in distinguishing shingles from other skin conditions.

When to Seek Medical Attention

It is crucial to contact a healthcare provider as soon as possible if you suspect you have shingles, especially in the following situations:

• The pain and rash occur near an eye, as untreated infections in this area can lead to permanent eye damage
• You are 50 years of age or older, as the risk of complications increases with age
• You or a family member has a weakened immune system due to cancer, medications, or chronic illness
• The rash is widespread and particularly painful

Risk Factors for Developing Shingles

While anyone who has had chickenpox can develop shingles, certain factors may increase the risk:

1. Age: The risk of shingles increases with age, particularly in individuals over 50 years old
2. Weakened immune system: Conditions such as HIV/AIDS and cancer can elevate the risk of shingles
3. Cancer treatments: Radiation and chemotherapy can lower resistance to diseases and potentially trigger shingles
4. Certain medications: Drugs used to prevent organ transplant rejection may increase the risk of developing shingles

How does age affect the severity of shingles? Individuals over 60 are more likely to experience severe complications from shingles, emphasizing the importance of early detection and treatment in older adults.

Antiviral Medications for Shingles: Types and Effectiveness

Antiviral medications play a crucial role in the treatment of shingles. These medications work by inhibiting the replication of the varicella-zoster virus, thereby reducing the severity and duration of the infection. The most commonly prescribed antiviral drugs for shingles include:

• Acyclovir
• Valacyclovir
• Famciclovir

How effective are antiviral medications in treating shingles? When started within 72 hours of rash onset, antiviral medications can significantly reduce pain, accelerate healing, and lower the risk of complications. These drugs are most effective when initiated as early as possible, underscoring the importance of prompt medical attention.

Dosage and Duration of Treatment

The typical treatment regimen for shingles involves taking antiviral medication for 7 to 10 days. The specific dosage and duration may vary depending on factors such as the severity of the infection, the patient’s age, and overall health status. It is essential to complete the full course of medication as prescribed, even if symptoms improve before the treatment is finished.

Prevention Strategies: Vaccines and Lifestyle Measures

While antiviral medications are effective in treating shingles, prevention remains a key strategy in managing this condition. Two primary approaches to prevention include vaccination and lifestyle measures.

Shingles Vaccines

There are currently two vaccines available to prevent shingles:

1. Shingrix: A recombinant zoster vaccine recommended for adults 50 years and older
2. Zostavax: An older live vaccine that is no longer available for use in the United States as of November 18, 2020

How effective is the Shingrix vaccine in preventing shingles? Clinical trials have shown that Shingrix is more than 90% effective in preventing shingles in adults 50 years and older. The vaccine’s effectiveness remains high even in older adults, making it a valuable tool in shingles prevention.

Lifestyle Measures for Shingles Prevention

In addition to vaccination, certain lifestyle measures may help reduce the risk of developing shingles:

• Maintaining a healthy diet rich in vitamins and minerals
• Managing stress through relaxation techniques and regular exercise
• Getting adequate sleep to support immune function
• Avoiding excessive sun exposure, which can trigger shingles outbreaks in some individuals

Complications of Shingles: Recognizing and Managing Long-Term Effects

While shingles itself is not life-threatening, it can lead to several complications, some of which can have long-lasting effects. The most common complication is postherpetic neuralgia (PHN), a condition characterized by persistent pain in the affected area long after the rash has healed.

Other potential complications of shingles include:

• Vision loss or other eye problems if the rash occurs near or in the eye
• Skin infections
• Balance or hearing problems
• Facial paralysis
• Encephalitis (inflammation of the brain)

How long can postherpetic neuralgia last? PHN can persist for months or even years after the initial shingles outbreak. The risk of developing PHN increases with age, affecting up to 20% of people over 60 who develop shingles.

Managing Postherpetic Neuralgia

Treatment options for PHN include:

1. Pain medications (over-the-counter and prescription)
2. Topical treatments such as lidocaine patches or capsaicin cream
3. Antidepressants and anticonvulsants, which can help alleviate nerve pain
4. Transcutaneous electrical nerve stimulation (TENS)
5. Physical therapy and acupuncture

Shingles vs. Chickenpox: Understanding the Connection and Differences

While shingles and chickenpox are caused by the same virus, they manifest differently and occur at different stages of life. Understanding the relationship between these two conditions is crucial for proper prevention and treatment.

Key Differences Between Shingles and Chickenpox

• Age of occurrence: Chickenpox typically affects children, while shingles is more common in adults over 50
• Rash appearance: Chickenpox causes itchy spots all over the body, while shingles usually produces a painful rash in a localized area
• Contagiousness: Chickenpox is highly contagious, while shingles is less so and can only transmit the virus to those who have never had chickenpox
• Recurrence: Chickenpox usually occurs only once, while shingles can recur multiple times in some individuals

Can you get shingles if you’ve never had chickenpox? It is extremely rare to develop shingles without having had chickenpox or being exposed to the varicella-zoster virus. However, it is possible for children who received the chickenpox vaccine to develop shingles later in life, although the risk is lower compared to those who had natural chickenpox infection.

Emerging Research and Future Directions in Shingles Treatment

As our understanding of the varicella-zoster virus and shingles continues to evolve, researchers are exploring new avenues for prevention and treatment. Some areas of ongoing research include:

1. Development of more effective antiviral medications with fewer side effects
2. Investigation of novel vaccine formulations to provide longer-lasting protection against shingles
3. Exploration of immunomodulatory therapies to prevent virus reactivation
4. Studies on the genetic factors that may influence susceptibility to shingles and its complications
5. Research into the potential link between shingles and other neurological conditions

What potential breakthroughs can we expect in shingles treatment? While it’s difficult to predict specific outcomes, ongoing research may lead to more targeted therapies, improved vaccines, and better strategies for managing complications like postherpetic neuralgia. These advancements could significantly improve the quality of life for individuals affected by shingles and reduce the overall burden of the disease.

The Role of Artificial Intelligence in Shingles Diagnosis and Management

Artificial intelligence (AI) is increasingly being applied to various aspects of healthcare, including the diagnosis and management of shingles. Some potential applications of AI in this field include:

• Automated image analysis to assist in early detection of shingles rashes
• Predictive models to identify individuals at high risk of developing shingles or its complications
• AI-powered decision support systems to guide treatment choices and optimize patient outcomes
• Machine learning algorithms to analyze large-scale patient data and identify new patterns or risk factors associated with shingles

How might AI transform the landscape of shingles management? By leveraging advanced analytics and machine learning techniques, AI has the potential to enhance diagnostic accuracy, personalize treatment approaches, and improve overall patient care in the context of shingles and other herpes zoster-related conditions.

As research in this field progresses, it is crucial for healthcare providers and patients alike to stay informed about the latest developments in shingles prevention, diagnosis, and treatment. By combining traditional medical knowledge with cutting-edge technologies and innovative approaches, we can hope to reduce the impact of shingles and improve outcomes for those affected by this challenging condition.

Shingles – Symptoms & causes

Overview

Shingles is a viral infection that causes a painful rash. Shingles can occur anywhere on your body. It typically looks like a single stripe of blisters that wraps around the left side or the right side of your torso.

Shingles is caused by the varicella-zoster virus — the same virus that causes chickenpox. After you’ve had chickenpox, the virus stays in your body for the rest of your life. Years later, the virus may reactivate as shingles.

Shingles isn’t life-threatening. But it can be very painful. Vaccines can help lower the risk of shingles. Early treatment may shorten a shingles infection and lessen the chance of complications. The most common complication is postherpetic neuralgia. This is a painful condition that causes shingles pain for a long time after your blisters have cleared.

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Symptoms

Shingles symptoms usually affect only a small section on one side of your body. These symptoms may include:

• Pain, burning or tingling
• Sensitivity to touch
• A red rash that begins a few days after the pain
• Fluid-filled blisters that break open and crust over
• Itching

Some people also experience:

• Fever
• Headache
• Sensitivity to light
• Fatigue

Pain is usually the first symptom of shingles. For some people, the pain can be intense. Depending on the location of the pain, it can sometimes be mistaken for problems with the heart, lungs or kidneys. Some people experience shingles pain without ever developing the rash.

Most commonly, the shingles rash develops as a stripe of blisters that wraps around either the left or right side of the torso. Sometimes the shingles rash occurs around one eye or on one side of the neck or face.

Shingles

Shingles is characterized by pain or a tingling sensation in a limited area on one side of the face or torso, followed by a red rash with small, fluid-filled blisters.

When to see a doctor

Contact your health care provider as soon as possible if you suspect shingles, especially in the following situations:

• The pain and rash occur near an eye. If left untreated, this infection may lead to permanent eye damage.
• You’re 50 or older. Age increases your risk of complications.
• You or someone in your family has a weakened immune system. This may be due to cancer, medications or chronic illness.
• The rash is widespread and painful.

Causes

Shingles is caused by the varicella-zoster virus — the same virus that causes chickenpox. Anyone who’s had chickenpox may develop shingles. After you recover from chickenpox, the virus enters your nervous system and stays inactive for years.

Sometimes the virus reactivates and travels along nerve pathways to your skin — producing shingles. But not everyone who’s had chickenpox will develop shingles.

The reason for shingles is unclear. It may be due to lowered immunity to infections as people get older. Shingles is more common in older adults and in people who have weakened immune systems.

Varicella-zoster is part of a group of viruses called herpes viruses. This is the same group that includes the viruses that cause cold sores and genital herpes. As a result, shingles is also known as herpes zoster. But the virus that causes chickenpox and shingles isn’t the same virus that causes cold sores or genital herpes, which is a sexually transmitted infection.

Shingles affects the nerves

The shingles rash is associated with an inflammation of nerves beneath the skin.

Are you contagious?

A person with shingles can pass the varicella-zoster virus to anyone who isn’t immune to chickenpox. This usually occurs through direct contact with the open sores of the shingles rash. Once infected, though, the person will develop chickenpox rather than shingles.

Chickenpox can be dangerous for some people. Until your shingles blisters scab over, you are contagious. Avoid physical contact with anyone who hasn’t yet had chickenpox or the chickenpox vaccine. That includes people with weakened immune systems, pregnant women and newborns.

Risk factors

Anyone who has ever had chickenpox can develop shingles. Most adults in the United States had chickenpox when they were children. That was before the availability of the routine childhood vaccination that now protects against chickenpox.

Factors that may increase your risk of developing shingles include:

• Age. The risk of developing shingles increases with age. Shingles typically occurs in people older than 50. And people over the age of 60 are more likely to experience more-severe complications.
• Some diseases. Diseases that weaken your immune system, such as HIV/AIDS and cancer, can increase your risk of shingles.
• Cancer treatments. Radiation or chemotherapy can lower your resistance to diseases and may trigger shingles.
• Some medications. Drugs that prevent rejection of transplanted organs can increase your risk of shingles. Long-term use of steroids, such as prednisone, may also increase your risk of developing shingles.

Complications

Complications from shingles can include:

• Postherpetic neuralgia. For some people, shingles pain continues long after the blisters have cleared. This condition is known as postherpetic neuralgia. It occurs when damaged nerve fibers send confused and exaggerated messages of pain from your skin to your brain.
• Vision loss. Shingles in or around an eye (ophthalmic shingles) can cause painful eye infections that may result in vision loss.
• Neurological problems. Shingles may cause inflammation of the brain (encephalitis), facial paralysis, or problems with hearing or balance.
• Skin infections. If shingles blisters aren’t properly treated, bacterial skin infections may develop.

Prevention

A shingles vaccine may help prevent shingles. People who are eligible should get the Shingrix vaccine, which has been available in the United States since its approval by the Food and Drug Administration in 2017. The Zostavax vaccine is no longer available in the U.S., but other countries may still use it.

Shingrix is approved and recommended for people age 50 and older, whether they’ve had shingles or not. People who’ve had the Zostavax vaccine in the past or don’t know whether they’ve had chickenpox may also receive the Shingrix vaccine.

Shingrix is also recommended for people who are 19 years of age and older who have weakened immune systems due to disease or medication.

Shingrix is a nonliving vaccine made of a virus component. It’s given in two doses, with 2 to 6 months between doses. The most common side effects of the shingles vaccine are redness, pain and swelling at the injection site. Some people also experience fatigue, headache and other side effects.

The shingles vaccine doesn’t guarantee that you won’t get shingles. But this vaccine will likely reduce the course and severity of the disease. And it will likely lower your risk of postherpetic neuralgia. Studies suggest that Shingrix offers protection against shingles for more than five years.

Talk to your health care provider about your vaccination options if you:

• Have had an allergic reaction to any component of the shingles vaccine
• Have a weakened immune system due to a condition or medication
• Have had a stem cell transplant
• Are pregnant or trying to become pregnant

The shingles vaccine is used only as a way to prevent shingles. It’s not intended to treat people who currently have the disease.

More Information

Management of Herpes Zoster (Shingles) and Postherpetic Neuralgia

SETH JOHN STANKUS, MAJ, MC, USA, MICHAEL DLUGOPOLSKI, MAJ, MC, USA, AND DEBORAH PACKER, MAJ, MC, USA

Herpes zoster (commonly referred to as “shingles”) and postherpetic neuralgia result from reactivation of the varicella-zoster virus acquired during the primary varicella infection, or chickenpox. Whereas varicella is generally a disease of childhood, herpes zoster and post-herpetic neuralgia become more common with increasing age. Factors that decrease immune function, such as human immunodeficiency virus infection, chemotherapy, malignancies and chronic corticosteroid use, may also increase the risk of developing herpes zoster. Reactivation of latent varicella-zoster virus from dorsal root ganglia is responsible for the classic dermatomal rash and pain that occur with herpes zoster. Burning pain typically precedes the rash by several days and can persist for several months after the rash resolves. With postherpetic neuralgia, a complication of herpes zoster, pain may persist well after resolution of the rash and can be highly debilitating. Herpes zoster is usually treated with orally administered acyclovir. Other antiviral medications include famciclovir and valacyclovir. The antiviral medications are most effective when started within 72 hours after the onset of the rash. The addition of an orally administered corticosteroid can provide modest benefits in reducing the pain of herpes zoster and the incidence of postherpetic neuralgia. Ocular involvement in herpes zoster can lead to rare but serious complications and generally merits referral to an ophthalmologist. Patients with postherpetic neuralgia may require narcotics for adequate pain control. Tricyclic antidepressants or anticonvulsants, often given in low dosages, may help to control neuropathic pain. Capsaicin, lidocaine patches and nerve blocks can also be used in selected patients.

Herpes zoster results from reactivation of the varicella-zoster virus. Unlike varicella (chickenpox), herpes zoster is a sporadic disease with an estimated lifetime incidence of 10 to 20 percent. The incidence of herpes zoster increases sharply with advancing age, roughly doubling in each decade past the age of 50 years. Herpes zoster is uncommon in persons less than 15 years old. In a recent study,¹ patients more than 55 years of age accounted for more than 30 percent of herpes zoster cases despite representing only 8 percent of the study population. In this same study, children less than 14 years old represented only 5 percent of herpes zoster cases.

The normal age-related decrease in cell-mediated immunity is thought to account for the increased incidence of varicella-zoster virus reactivation. Patients with disease states that affect cell-mediated immunity, such as human immunodeficiency virus (HIV) infection and certain malignancies, are also at increased risk. Chronic corticosteroid use, chemotherapy and radiation therapy may increase the risk of developing herpes zoster.

The incidence of herpes zoster is up to 15 times higher in HIV-infected patients than in uninfected persons, and as many as 25 percent of patients with Hodgkin’s lymphoma develop herpes zoster.^2,3 The occurrence of herpes zoster in HIV-infected patients does not appear to increase the risk of acquired immunodeficiency syndrome (AIDS) and is less dependent on the CD4 count than AIDS-related opportunistic infections.² There is no evidence that herpes zoster heralds the onset of an underlying malignancy. ³

Race may influence susceptibility to herpes zoster. Blacks are one fourth as likely as whites to develop this condition.⁴ Although herpes zoster is not as contagious as the primary varicella infection, persons with reactivated infection can transmit varicella-zoster virus to nonimmune contacts. Household transmission rates have been noted to be approximately 15 percent.⁵

About 20 percent of patients with herpes zoster develop postherpetic neuralgia. The most established risk factor is age; this complication occurs nearly 15 times more often in patients more than 50 years of age. Other possible risk factors for the development of post-herpetic neuralgia are ophthalmic zoster, a history of prodromal pain before the appearance of skin lesions and an immunocompromised state.⁶

Pathophysiology

Varicella-zoster virus is a highly contagious DNA virus. Varicella represents the primary infection in the nonimmune or incompletely immune person. During the primary infection, the virus gains entry into the sensory dorsal root ganglia. How the virus enters the sensory dorsal root ganglia and whether it resides in neurons or supporting cells are not completely understood. The varicella-zoster virus genome has been identified in the trigeminal ganglia of nearly all seropositive patients.⁷

The virus remains latent for decades because of varicella-zoster virus–specific cell-mediated immunity acquired during the primary infection, as well as endogenous and exogenous boosting of the immune system periodically throughout life.⁸ Reactivation of the virus occurs following a decrease in virus-specific cell-mediated immunity. The reactivated virus travels down the sensory nerve and is the cause for the dermatomal distribution of pain and skin lesions.

The pathophysiology of postherpetic neuralgia remains unclear. However, pathologic studies have demonstrated damage to the sensory nerves, the sensory dorsal root ganglia and the dorsal horns of the spinal cord in patients with this condition. ⁹

Clinical Presentation

Herpes zoster typically presents with a prodrome consisting of hyperesthesia, paresthesias, burning dysesthesias or pruritus along the affected dermatome(s). The prodrome generally lasts one to two days but may precede the appearance of skin lesions by up to three weeks.

During the prodromal phase, herpes zoster may be misdiagnosed as cardiac disease, pleurisy, a herniated nucleus pulposus or various gastrointestinal or gynecologic disorders. Some patients may have prodromal symptoms without developing the characteristic rash. This situation, known as “zoster sine herpete,” may further complicate the eventual diagnosis.

The prodromal phase is followed by development of the characteristic skin lesions of herpes zoster. The skin lesions begin as a maculopapular rash that follows a dermatomal distribution, commonly referred to as a “belt-like pattern.” The maculopapular rash evolves into vesicles with an erythematous base (Figure 1). The vesicles are generally painful, and their development is often associated with the occurrence of anxiety and flu-like symptoms.

Pain is the most common complaint for which patients with herpes zoster seek medical care. The pain may be described as “burning” or “stinging” and is generally unrelenting. Indeed, patients may have insomnia because of the pain.¹⁰ Although any vertebral dermatome may be involved, T5 and T6 are most commonly affected. The most frequently involved cranial nerve dermatome is the ophthalmic division of the trigeminal nerve. Twenty or more lesions outside the affected dermatome reflect generalized viremia. Of these patients, approximately one half manifest other neurologic or visceral involvement, and as many as one in seven with viremia may die.

The vesicles eventually become hemorrhagic or turbid and crust over within seven to 10 days. As the crusts fall off, patients are generally left with scarring and pigmentary changes.

Ocular complications occur in approximately one half of patients with involvement of the ophthalmic division of the trigeminal nerve. These complications include mucopurulent conjunctivitis, episcleritis, keratitis and anterior uveitis. Cranial nerve palsies of the third, fourth and sixth cranial nerves may occur, affecting extraocular motility.

The most common chronic complication of herpes zoster is postherpetic neuralgia. Pain that persists for longer than one to three months after resolution of the rash is generally accepted as the sign of postherpetic neuralgia.¹¹ Affected patients usually report constant burning, lancinating pain that may be radicular in nature. Patients may also complain of pain in response to non-noxious stimuli. Even the slightest pressure from clothing, bedsheets or wind may elicit pain.

Postherpetic neuralgia is generally a self-limited disease. Symptoms tend to abate over time. Less than one quarter of patients still experience pain at six months after the herpes zoster eruption, and fewer than one in 20 has pain at one year.

Treatment of Herpes Zoster

The treatment of herpes zoster has three major objectives: (1) treatment of the acute viral infection, (2) treatment of the acute pain associated with herpes zoster and (3) prevention of postherpetic neuralgia. Antiviral agents, oral corticosteroids and adjunctive individualized pain-management modalities are used to achieve these objectives.

ANTIVIRAL AGENTS

Antiviral agents have been shown to decrease the duration of herpes zoster rash and the severity of pain associated with the rash.¹² However, these benefits have only been demonstrated in patients who received antiviral agents within 72 hours after the onset of rash. Antiviral agents may be beneficial as long as new lesions are actively being formed, but they are unlikely to be helpful after lesions have crusted.

The effectiveness of antiviral agents in preventing postherpetic neuralgia is more controversial. Numerous studies evaluating this issue have been conducted, but the results have been variable. Based on the findings of multiple studies, acylovir (Zovirax) therapy appears to produce a moderate reduction in the development of postherpetic neuralgia.¹³ Other antiviral agents, specifically valacyclovir (Valtrex) and famciclovir (Famvir), appear to be at least as effective as acyclovir.

Acyclovir, the prototype antiviral drug, is a DNA polymerase inhibitor. Acyclovir may be given orally or intravenously. Major drawbacks of orally administered acyclovir include its lower bioavailability compared with other agents and its dosing frequency (five times daily). Intravenously administered acyclovir is generally used only in patients who are severely immunocompromised or who are unable to take medications orally.

Valacyclovir, a prodrug of acyclovir, is administered three times daily. Compared with acyclovir, valacyclovir may be slightly better at decreasing the severity of pain associated with herpes zoster, as well as the duration of postherpetic neuralgia.¹⁴ Valacyclovir is also more bioavailable than acyclovir, and oral administration produces blood drug levels comparable to the intravenous administration of acyclovir.

Famciclovir is also a DNA polymerase inhibitor. The advantages of famciclovir are its dosing schedule (three times daily), its longer intracellular half-life compared with acyclovir and its better bioavailability compared with acyclovir and valacyclovir.

The choice of which antiviral agent to use is individualized. Dosing schedule and cost may be considerations. The recommended dosages for acyclovir, famciclovir and valacyclovir are provided in Table 1. All three antiviral agents are generally well tolerated. The most common adverse effects are nausea, headache, vomiting, dizziness and abdominal pain.

Medication	Dosage	Average cost (generic)*
Acyclovir (Zovirax)†	800 mg orally five times daily for 7 to 10 days 10 mg per kg IV every 8 hours for 7 to 10 days‡	$174 to 248 (129 to 200)
Famciclovir (Famvir)†	500 mg orally three times daily for 7 days	140
Valacyclovir (Valtrex)†	1,000 mg orally three times daily for 7 days	84
Prednisone (Deltasone)	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	2 (2 to 4) for days 1 through 7 2 (1 to 3) for days 8 through 14 1 (1 to 2) for days 15 to 21

CORTICOSTEROIDS

Orally administered corticosteroids are commonly used in the treatment of herpes zoster, even though clinical trials have shown variable results. Prednisone used in conjunction with acyclovir has been shown to reduce the pain associated with herpes zoster.¹⁵ The likely mechanism involves decreasing the degree of neuritis caused by active infection and, possibly, decreasing residual damage to affected nerves.

Some studies designed to evaluate the effectiveness of prednisone therapy in preventing postherpetic neuralgia have shown decreased pain at three and 12 months.^16,17 Other studies have demonstrated no benefit.^15,18

If the use of orally administered prednisone is not contraindicated, adjunctive treatment with this agent is justified on the basis of its effects in reducing pain, despite questionable evidence for its benefits in decreasing the incidence of postherpetic neuralgia. Given the theoretic risk of immunosuppression with corticosteroids, some investigators believe that these agents should be used only in patients more than 50 years of age because they are at greater risk of developing postherpetic neuralgia.¹⁵ The recommended dosage for prednisone is given in Table 1.

ANALGESICS

The pain associated with herpes zoster ranges from mild to excruciating. Patients with mild to moderate pain may respond to over-the-counter analgesics. Patients with more severe pain may require the addition of a narcotic medication. When analgesics are used, with or without a narcotic, a regular dosing schedule results in better pain control and less anxiety than “as-needed” dosing.

Lotions containing calamine (e.g., Caladryl) may be used on open lesions to reduce pain and pruritus. Once the lesions have crusted over, capsaicin cream (Zostrix) may be applied. Topically administered lidocaine (Xylocaine) and nerve blocks have also been reported to be effective in reducing pain.

OCULAR INVOLVEMENT

Ocular herpes zoster is treated with orally administered antiviral agents and corticosteroids, the same as involvement elsewhere. Although most patients with ocular herpes zoster improve without lasting sequelae, some may develop severe complications, including loss of vision. When herpes zoster involves the eyes, ophthalmologic consultation is usually recommended.

PREVENTIVE TREATMENT

The morbidity and mortality of herpes zoster could be reduced if a safe and effective preventive treatment were available. It is unusual for a patient to develop herpes zoster more than once, suggesting that the first reactivation of varicella-zoster virus usually provides future immunologic protection. Studies are currently being conducted to evaluate the efficacy of the varicella-zoster vaccine in preventing or modifying herpes zoster in the elderly.

Treatment of Postherpetic Neuralgia

Although postherpetic neuralgia is generally a self-limited condition, it can last indefinitely. Treatment is directed at pain control while waiting for the condition to resolve. Pain therapy may include multiple interventions, such as topical medications, over-the-counter analgesics, tricyclic antidepressants, anticonvulsants and a number of nonmedical modalities. Occasionally, narcotics may be required. Dosage recommendations are provided in Table 2.

Medication	Dosage
Topical agents
Capsaicin cream (Zostrix)	Apply to affected area three to five times daily.
Lidocaine (Xylocaine) patch	Apply to affected area every 4 to 12 hours as needed.
Tricyclic antidepressants
Amitriptyline (Elavil)	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.
Nortriptyline (Pamelor)	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 (Tofranil)	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.
Desipramine (Norpramin)	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.
Anticonvulsants
Phenytoin (Dilantin)	100 to 300 mg orally at bedtime; increase dosage until response is adequate or blood drug level is 10 to 20 μg per mL (40 to 80 μmol per L).
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.)

ANALGESICS

Capsaicin, an extract from hot chili peppers, is currently the only drug labeled by the U.S. Food and Drug Administration for the treatment of postherpetic neuralgia.¹⁹ Trials have shown this drug to be more efficacious than placebo but not necessarily more so than other conventional treatments.²⁰

Substance P, a neuropeptide released from pain fibers in response to trauma, is also released when capsaicin is applied to the skin, producing a burning sensation. Analgesia occurs when substance P is depleted from the nerve fibers. To achieve this response, capsaicin cream must be applied to the affected area three to five times daily. Patients must be counseled about the need to apply capsaicin regularly for continued benefit. They also need to be counseled that their pain will likely increase during the first few days to a week after capsaicin therapy is initiated. Patients should wash their hands thoroughly after applying capsaicin cream in order to prevent inadvertent contact with other areas.

Patches containing lidocaine have also been used to treat postherpetic neuralgia. One study found that compared with no treatment, lidocaine patches reduced pain intensity, with minimal systemic absorption. Although lidocaine was efficacious in relieving pain, the effect was temporary, lasting only four to 12 hours with each application.²¹

Over-the-counter analgesics such as acetaminophen (e.g., Tylenol) and nonsteroidal anti-inflammatory drugs have not been shown to be highly effective in the treatment of post-herpetic neuralgia. However, these agents are often useful for potentiating the pain-relieving effects of narcotics in patients with severe pain. Because of the addictive properties of narcotics, their chronic use is discouraged except in the rare patient who does not adequately respond to other modalities.

TRICYCLIC ANTIDEPRESSANTS

Tricyclic antidepressants can be effective adjuncts in reducing the neuropathic pain of postherpetic neuralgia. These agents most likely lessen pain by inhibiting the reuptake of serotonin and norepinephrine neurotransmitters.²²

Tricyclic antidepressants commonly used in the treatment of postherpetic neuralgia include amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil) and desipramine (Norpramin). These drugs are best tolerated when they are started in a low dosage and given at bedtime. The dosage is increased every two to four weeks to achieve an effective dose.

The tricyclic antidepressants share common side effects, such as sedation, dry mouth, postural hypotension, blurred vision and urinary retention. Nortriptyline and amitriptyline appear to have equal efficacy; however, nortriptyline tends to produce fewer anticholinergic effects and is therefore better tolerated. Treatment with tricyclic antidepressants can occasionally lead to cardiac conduction abnormalities or liver toxicity. The potential for these problems should be considered in elderly patients and patients with cardiac or liver disease.

Because tricyclic antidepressants do not act quickly, a clinical trial of at least three months is required to judge a patient’s response. The onset of pain relief using tricyclic antidepressants may be enhanced by beginning treatment early in the course of herpes zoster infection in conjunction with antiviral medications.²⁰

ANTICONVULSANTS

Phenytoin (Dilantin), carbamazepine (Tegretol) and gabapentin (Neurontin) are often used to control neuropathic pain. A recent double-blind, placebo-controlled study showed gabapentin to be effective in treating the pain of postherpetic neuralgia, as well as the often associated sleep disturbance.²³

The anticonvulsants appear to be equally effective, and drug selection often involves trial and error. Lack of response to one of these medications does not necessarily portend a poor response to another. The dosages required for analgesia are often lower than those used in the treatment of epilepsy.

Anticonvulsants are associated with a variety of side effects, including sedation, memory disturbances, electrolyte abnormalities, liver toxicity and thrombocytopenia. Side effects may be reduced or eliminated by initiating treatment in a low dosage, which can then be slowly titrated upward.

There are no specific contraindications to using anticonvulsants in combination with antidepressants or analgesics. However, the risk of side effects increases when multiple medications are used.

Effective treatment of postherpetic neuralgia often requires multiple treatment approaches. In addition to medications, modalities to consider include transcutaneous electric nerve stimulation (TENS), biofeedback and nerve blocks.

Final Comment

Herpes zoster and postherpetic neuralgia are relatively common conditions, primarily in elderly and immunocompromised patients. Although the diagnosis of the conditions is generally straightforward, treatment can be frustrating for the patient and physician. Approaches to management include treatment of the herpes zoster infection and associated pain, prevention of postherpetic neuralgia, and control of the neuropathic pain until the condition resolves. Primary treatment modalities include antiviral agents, corticosteroids, tricyclic antidepressants and anticonvulsants.

main causes, symptoms, treatment

Dermatological diseases are distinguished by a specific clinical picture. However, it is not always possible to accurately verify the virus, based only on anamnestic and clinical data. Modern methods of diagnostics are offered for identification. For treatment, groups of effective and safe antiviral drugs are used.

Herpes zoster (herpes zoster) is a dermatological disease characterized by lesions of the skin and nervous system. It occurs more often in adults, older people with a weakened immune system. In severe cases and the absence of medical treatment, it can lead to transverse myelitis.

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Causes

Herpes zoster is caused by the Varicella Zoster virus. It causes 2 diseases. With primary contact at a young age, chicken pox develops, which has a benign course. However, after recovery, it does not eliminate from the body, it remains in the regional nerve ganglia. You can find the herpes virus in the branch of the trigeminal nerve or near the spinal cord. Due to a decrease in immunity, it is reactivated.

Predisposing factors may be overheating or hypothermia. Quite often reactivation of the virus can be caused by traumatization of the corresponding dermatome.

Epidemiology

Pathology is rare in dermatological practice. The frequency averages about 5-10%. With a pronounced immunodeficiency state, re-infection is possible. Children who have not previously been ill develop a classic version of chickenpox with vesicles on the skin of the whole body upon contact.

Clinical manifestations

Herpes zoster has several clinical stages that follow each other. The first is incubation. The second is the period of prodromal phenomena, the third is the peak. The final one is the restoration of the body.

In clinical practice, there are several forms of herpes zoster in adults: mild, severe, and hemorrhagic. The first is also called abortive. It is characterized by a mild clinical picture, but the virus can be identified using laboratory tests. The abortive form does not lead to rashes on the skin, there is no pain.

The severe form of herpes zoster has a characteristic localization, while the lesion develops near the trigeminal nerve. Inflammation affects the skin of the forehead, eyelids and nose area. With involvement in the pathological process of the eye, conjunctivitis develops. A patient with a severe form of herpes zoster will complain of pain and burning, increased lacrimation. Eyelid edema develops. The pain is burning. In the hemorrhagic form, profuse rashes appear on the skin, the vesicles are filled with bloody contents.

The incubation period for herpes zoster in adults is on average about 12-14 days. The prodromal stage of herpes zoster is characterized by the appearance of the following symptoms:

• severe pain in the region of the spinal column and on the face;

• pain accompanied by burning;

• increase in body temperature;

• skin redness;

• headache;

• weakness;

• decrease in performance.

The immediate cause of the onset of pain during the period of prodromal phenomena is considered to be the multiplication of the virus in the nervous tissue.

During the height of herpes zoster, fuzzy pink spots first appear on the skin. Then, in their place, several grouped bubbles form. More often they are located near the intercostal nerves or on the face. Localized on one side.

Pain in herpes zoster is paroxysmal in nature. When pressed, it does not increase. The nature of the pain can be dull or pressing.

At first, the contents of the vesicles are serous, after a few days they become pink due to the accumulation of blood. After 2-3 weeks, the rashes gradually disappear, leaving no scars on the skin. A herpes infection can progress to a generalized form with severe symptoms or end in recovery with proper treatment.

Diagnostic criteria

In mild cases of herpes zoster, the diagnosis is made on clinical grounds. Typical symptoms of the disease:

• pain along the nerves near the spine;

• unilateral asymmetric rashes;

• pain does not tend to increase with pressure;

• rashes under the influence of therapy dry up and disappear.

Modern laboratory tests can confirm the diagnosis of herpes zoster. Among them are the following methods:

• virological;

• viroscopy;

• serological.

Molecular genetic studies can also be used to establish the diagnosis.

If there are complaints of pain, rashes along the nerves, it is recommended to perform viroscopy. This is one of the main methods for detecting and identifying viral agents using microscopy. The method of staining the prepared smears is according to Romanovsky-Giemsa.

Viroscopy evaluates the presence or absence of syncytium and intracellular inclusions. The first smears include Tzank’s acantholytic cells. They are widely investigated for suspected blistering dermatoses, which have characteristic external symptoms. Outwardly, the cells are rounded formations of large sizes. They contain large nuclei.

With herpes zoster, Lipshütz bodies are also found in smears-imprints. These are inclusions that are found inside the nucleus.

The virological method is not widely used. This is due to the fact that the study takes a long time. In virology, a biological fluid containing a virus is taken for analysis. It can be blood, swabs from the nasopharynx and other secrets of the body. With herpes zoster and other herpes infections, saliva is used as the main substrate.

Then they are cultivated on specially prepared tissues. The final step is the detection and identification of the virus using modern serological testing. To do this, use the reaction of immunofluorescence and other methods.

Cultivation on biological models is not always available, which is why the virological method is not widely used in clinics, hospitals and other medical institutions.

Serological methods of laboratory diagnostics are distinguished by high information content. However, they are rarely used to detect herpes zoster virus. In most cases, they are used for controversial issues for differential diagnosis.

Among the serological studies are the following:

• linked immunosorbent assay;

• complement fixation reaction;

• neutralization reaction.

These laboratory tests can detect viral antigen. If atypical symptoms appear in a patient, they are recommended. Patients are scheduled for examination after 1-2 weeks.

In the presence of pain and other characteristic symptoms of pathology, it is necessary to conduct a molecular genetic study. The polymerase chain reaction identifies the DNA of the shingles virus.

Basic treatments

Herpes zoster requires the appointment of a complex drug treatment. The following groups of drugs are used:

The main treatment is the use of antiviral agents. The duration of therapy depends on the form of pathology. However, on average, treatment is carried out for 7-10 days. Dosage forms may be presented as tablets for oral administration or ointments for external use. However, combined treatment of shingles is more often recommended. Tablet forms can be taken several times a day.

Antiviral agents can be used not only during treatment, but also to prevent relapses. Duration of administration and dosage is determined by a specialist. The concentration of the substance in pregnant women and nursing mothers is different.

The next group is painkillers. The attending physician prescribes them in order to relieve pain in the region of the intercostal and facial nerves. Preference is given to non-narcotic analgesics, which rarely cause side effects from the nervous system.

Herpes zoster treatment also includes the use of synthetic dyes. A classic example is a solution of brilliant green and potassium permanganate. They are applied locally to vesicles to prevent infection. Otherwise, bacterial complications may join.

Corticosteroids have an anti-inflammatory effect. In addition, they also reduce the severity of itchy skin. Preference in treatment is given to local ointments.

Surgical methods of therapy are not currently used. Ultraviolet irradiation and other physiotherapeutic procedures are prescribed during the recovery period.

Indications for treatment

It is recommended to carry out even with a mild pathology. Antiviral, painkillers and other drugs for treatment can not only stop the symptoms, but also alleviate the patient’s condition.

Contraindications to treatment

In what cases should you refuse to take medications. The first is the development of an acute allergic reaction. This should be reported to the doctor who is involved in the treatment in order to select the optimal remedy. The second is pregnancy and lactation. In this case, consultation of related specialists is required to determine the correct dosage and select a safe drug. In other cases, interrupting therapy is not recommended.

Possible side effects of therapy

When taking antiviral drugs, patients may complain of a rash, severe itching, or other allergic reactions. When using synthetic dyes, local irritation on the skin may occur.

Among the side effects that occur when taking non-narcotic analgesics, there are:

• dyspeptic disorders;

• dizziness;

• allergic reactions;

• dry eyes and others.

When taking topical corticosteroids, the development of erythema on the skin is possible.

Possible complications

To prevent the development of complications from the nervous and other systems of the body, therapy should be started in a timely manner. However, in some cases, even properly selected therapy does not exclude the development of postherpetic changes.

Most often, complications affect the nervous tissue. The following violations occur:

Often the organs of vision are also involved. Among the complications are: retinitis, retinal necrosis and ophthalmic herpes. In severe cases, these pathological changes can lead to complete loss of vision.

The most common complication is postherpetic neuralgia. Occurs in 10-15% of patients. Among the risk factors are female gender, advanced age, as well as the appearance of a pronounced painful syndrome during the period of prodromal phenomena. The main clinical sign is the appearance of severe pain that has a burning character.

During therapy, antiviral agents are used. From the group of painkillers, local, adjuvant analgesics are used.

Forecast

In the vast majority, the pathology ends in recovery. But the virus is not eliminated. With a decrease in the protective forces of immunity, frequent relapses are possible.

Herpes during pregnancy – consequences of lichen for pregnant women

Herpes viruses are many-sided and very dangerous for humans. Of particular concern is the infection in a woman expecting a baby.

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• Genital herpes in early pregnancy
• Genital herpes in late pregnancy
• Herpes Pregnancy Test
• Chicken pox and herpes zoster during pregnancy
• Prevention of infection of the newborn with chickenpox
• Treatment and prevention of exacerbations of herpes

There is an opinion that if a pregnant woman is infected with the herpes simplex virus, then the unborn baby will
danger! But everything is not so scary if the disease does not manifest itself (is in stable remission)
or a pregnant woman with an active form of the disease is observed by an infectious disease specialist. Today approaches to maintaining
patients with genital herpes changed

Why is herpes dangerous during pregnancy

I am short term pregnant and have genital herpes. Does this mean that I
need to terminate the pregnancy?

No way! Genital herpes is not an indication for abortion. Virus
crosses the placenta extremely rarely. But for a child, herpes is dangerous if it first appeared a month before birth.
or repeated a few days before the birth, since there is a risk of infection of the baby at the time of his
passage through the infected birth canal. If infected, the infant will develop severe
the disease is neonatal herpes, often occurring with damage to the central nervous system.

Although the risk of transmission of herpes virus from mother to fetus during pregnancy
minimal, tolerate the manifestations of genital herpes and not take antiviral drugs, being afraid
the consequences of treatment for the unborn child are not worth it.

After 14 weeks of pregnancy, if genital herpes occurs, treatment with an antiviral drug is possible
acyclovir. After 22 weeks, therapy with valaciclovir is possible.

In the vast majority of cases, the herpes simplex virus is transmitted from the mother
child during childbirth, so the closer to the end of pregnancy there is a recurrence of genital herpes,
the higher the risk of infection of the child and the more relevant the treatment of the disease.

If primary genital herpes or recurrence occurs at or after 36 weeks of gestation, clinicians
do not limit treatment to 5-10 days, but continue the entire period until the moment of delivery. As in the case
very frequent recurrences of genital herpes during pregnancy (one outbreak in 1-2 months) –
at week 36, proactive treatment with acyclovir or its analogues begins and continues until the moment
childbirth. The goal of proactive treatment is to prevent recurrence shortly before delivery and to reduce
the likelihood of asymptomatic carriage.

It must be remembered that it is the asymptomatic shedding of the virus from the urogenital tract that can often be
cause of infection of the child during childbirth.

Even when there seems to be no cause for concern, since the manifestations
genital herpes are absent in the last months of pregnancy, still at 32-34 weeks
pregnancy, it is necessary to conduct a smear (scraping) examination from the cervical canal for the presence of DNA
herpes simplex virus types 1 and 2 by PCR.

This analysis is necessary for primary genital herpes or its recurrence in the 1st and / or 2nd trimester, relapses
genital herpes before pregnancy, relapses of genital herpes in a sexual partner, lesions
urogenital tract of unknown cause, antibodies to herpes simplex virus type 1 and type 2 IgM class,
detected during a routine examination during pregnancy.

For rashes or viral shedding on Wednesday within 7 days before delivery,
especially in the presence of genital herpes by the beginning of childbirth, a caesarean section is performed to reduce the risk of transmission
virus from mother to child.

I’m just planning a pregnancy. And I want to get rid of herpes recurrences that have been haunting me for a long time
me. How do you feel about the treatment of genital herpes with interferon inducers
and immunomodulators?

Widespread use of immunomodulators and interferon preparations in Russian medical centers
(viferon, polyoxidonium, isoprinosine, etc.) for the treatment of herpesvirus infections is completely unreasonable.
The so-called “ozone therapy” will not help the patient either. You will not find these methods in international
protocols, recommendations for the treatment of viral infections in children and adults, including pregnant women
women. Neither in Russia nor abroad have studies been conducted proving the effectiveness of these
drugs in accordance with all international regulations.

An infectious disease specialist, a professional in his field, will never turn to immunomodulators and inducers
interferon, but will look for the cause of the disease and prescribe therapy that acts on the pathogen itself –
drugs acyclovir, valaciclovir or famaciclovir. With primary genital herpes for 10 days, with relapses
diseases – in appropriate doses for 5 days.

Therapy should be started as early as possible at the very first signs of an exacerbation. Application possible
antiherpetic drugs as a preventive treatment – 2-3 days before the expected
relapse, if the patient is aware of the factors that provoke it, and for the entire period of the risk factor.
If genital herpes disturbs a person more than 6 times a year and / or relapses reduce the quality of life of the patient and bring
him not only physical, but also serious psychological discomfort, should be discussed with the patient
long-term (at least 12 months) daily suppressive antiviral therapy (for example,
valaciclovir). The effectiveness of such treatment tactics for the prevention of recurrence of herpes infection has been proven.
all international rules.

Sequelae of chickenpox during pregnancy

How dangerous are chicken pox and shingles for a pregnant woman?

These diseases are caused by the varicella-zoster virus (VZV), which also belongs to the herpesvirus family. infect
women are most often children who easily tolerate the disease. At the same time, chickenpox in an adult
can be severe and dangerous to his health.

The infection is transmitted by airborne droplets from person to person already
48 hours before the onset of the rash, during the entire period of the rash and for a week after
appearance of the last bubbles.

Expectant mothers who catch chickenpox may develop severe herpes pneumonia. Therefore, when sick
chickenpox during pregnancy should be observed by an infectious disease specialist and in most
cases of antiviral therapy.

In maternal varicella at 8 to 20 weeks gestation infection
fetus with the varicella-zoster virus can lead to fetal chickenpox with the development of a “syndrome
congenital chicken pox” with severe malformations – damage to the brain, eyes,
skeletal defects. Therefore, if a woman falls ill with chicken pox in the 1-3rd month of pregnancy, the doctor
the woman should be informed about all possible risks of the disease for the fetus and discussed with her
the question of a possible termination of pregnancy.

Second and third trimesters
infectious disease doctor monitors the state of the future
mothers. If the infection is severe or the infection occurred in the last month of pregnancy, prescribe
antiviral treatment with acyclovir or its analogues. If ultrasound does not detect
fetal pathology, pregnancy is not interrupted.

Within 96 hours (preferably within the first 48 hours) after contact
a pregnant woman with chickenpox in the absence of IgG class antibodies to VVZ
it is possible to introduce a specific VVZ-immunoglobulin as a measure to prevent the development of the disease. Immunity
persists for 3-4 weeks, may be re-introduced after 21 days.

If the mother-to-be has chickenpox in the last month of pregnancy , the baby may
be born with skin rashes. If a woman falls ill in the last few days of pregnancy or in the first
days after childbirth in a newborn infected during childbirth, the symptoms of chickenpox appear in the first
11 days of life. Chickenpox is most severe in infants whose mothers fell ill 5 days before or
2-3 days after delivery. In case of chickenpox in mothers, newborn children are given a specific
immunoglobulin to prevent the development of the disease. In case of its severe course – appoint
acyclovir for intravenous administration.

Infection of a child with VVV a few days after birth may manifest as postnatal varicella in the period of 12-28
day of his life. This form of the disease is less severe, it is possible to introduce a specific immunoglobulin with
the risk of the disease and the appointment of intravenous acyclovir for destructive skin lesions.

Vaccination against the varicella-zoster virus is not given to pregnant women because
this is a live vaccine. Therefore, if a young woman does not have IgG antibodies to VVZ before planning
pregnancy, it is advisable to vaccinate against chicken pox.

Herpes zoster (“secondary” VVZ infection) in a pregnant woman is not dangerous for a child. Contact
seronegative pregnant woman with herpes zoster is not desirable, although the threat of her infection
There is practically no VVZ.

I’m just planning a pregnancy. And I want to get rid of herpes recurrences that have been haunting me for a long time
me. How do you feel about the treatment of genital herpes with interferon inducers
and immunomodulators?

Widespread use of immunomodulators and interferon preparations in Russian medical centers
(viferon, polyoxidonium, isoprinosine, etc.) for the treatment of herpesvirus infections is completely unreasonable.
The so-called “ozone therapy” will not help the patient either. You will not find these methods in international
protocols, recommendations for the treatment of viral infections in children and adults, including pregnant women
women. Neither in Russia nor abroad have studies been conducted proving the effectiveness of these
drugs in accordance with all international regulations.

Infectionist, a professional in his field will never turn to immunomodulators
and interferon inducers, but will look for the cause of the disease and prescribe an effective
pathogen therapy – drugs acyclovir, valaciclovir or famaciclovir. With primary genital
herpes for 10 days, with relapses of the disease – in appropriate doses for 5 days.

Therapy should be started as early as possible at the very first signs of an exacerbation. Application possible
antiherpetic drugs as a preventive treatment – 2-3 days before the expected
relapse, if the patient is aware of the factors that provoke it, and for the entire period of the risk factor.
If genital herpes disturbs a person more than 6 times a year and / or relapses reduce the quality of life of the patient and bring
him not only physical, but also serious psychological discomfort, should be discussed with the patient
long-term (at least 12 months) daily suppressive antiviral therapy (for example,
valaciclovir).