Herpes Zoster Follow-up

  • Author: Joseph S Eastern, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: May 11, 2011
 

Further Outpatient Care

  • After initial treatment, further care consists solely of monitoring the patient and remaining alert for complications, such as secondary infection, eye involvement, meningeal or visceral involvement, and for sequelae such as PHN.
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Deterrence/Prevention

  • Since 1995, live attenuated varicella-virus vaccine (Varivax) has been available in the US and has been up to 99% effective in protecting susceptible individuals from varicella infection. The new higher-potency zoster vaccine has likewise proven effective in prevention of zoster.
  • It has been proposed that zoster occurs when varicella antibody titers and varicella-specific cellular immunity drop to a level at which they no longer are completely effective in preventing viral invasion. Evidence for this hypothesis includes observation that pediatricians, who presumably are reexposed to varicella virus routinely and thus maintain high levels of immunity, seldom develop zoster. Indeed, administration of varicella vaccine to older individuals whose antibody titers and cellular immunity have fallen over time appears to decrease their risk of developing zoster. The high-potency, live attenuated varicella-zoster virus (VZV) vaccine introduced by Merck has demonstrated a reduction in the incidence rate of herpes zoster of 51.3% during 3 years of follow-up in one study.
  • Varicella-zoster immune globulin: The CDC currently recommends administration of VZIG to prevent or modify clinical illness in persons with exposure to varicella or zoster who are susceptible or immunocompromised. VZIG provides maximum benefit when administered as soon as possible after the presumed exposure, but VZIG may be effective if administered as late as 96 hours after exposure. Protection after VZIG administration lasts for an average of approximately 3 weeks, according to the CDC.
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Complications

  • Pain within the affected dermatome can be severe and can persist well beyond the duration of active disease (PHN). Eye involvement (zoster ophthalmicus) temporarily or permanently can cause decreased visual acuity or blindness. Complications such as secondary infection and meningeal or visceral involvement can produce further morbidity in the form of infections and scarring.
  • Zoster is rarely, if ever, fatal, although in individuals who are severely debilitated, zoster may be considered a contributing factor to death.
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Prognosis

  • Prognosis is excellent, although the pain of PHN, when it occurs, can range in intensity from uncomfortable to debilitating.
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Patient Education

  • First, instruct patients to ignore the advice of well-meaning relatives, neighbors, and friends who will regale them with tales of pain, suffering, and even death. For example, many of the author's patients have been told that if shingles blisters travel around both sides of the body and meet in the middle, the patient will die.
  • As done at the author's institution, inform patients that zoster almost always is confined to 1 side of the body and that if a rash crosses the midline, it probably is not shingles, which alone makes "blisters meeting in the middle" pretty much impossible. Patients are informed that while zoster often is painful (and that pain can persist if not treated properly or early enough), shingles rarely is dangerous or life threatening.
  • Inform patients that zoster is caused by the same virus that causes chickenpox and that the pox rash resolves but the virus remains, lying dormant in the nerve roots of the spine. Years later, a stimulus (which can be illness, medications, injury, stress, or some undiscovered factor) triggers the virus into action. The virus springs forth from a spinal nerve root and inflames that nerve.
  • Inform patients that the nerve in question normally supplies feeling to a band of skin immediately above it, which can be on 1 side of the face or body or on 1 arm or 1 leg. When the chickenpox virus inflames a nerve, the band of skin it supplies becomes inflamed, too. The result is pain, tenderness, and groups of painful blisters on a red base. The reason 19th-century French physicians dubbed zoster the band of roses from hell is easy to imagine.
  • Inform patients that a person exposed to someone who has shingles can contract chickenpox if the person exposed has never had chickenpox before.
  • Instruct patients that treatment should be started within 72 hours of onset if at all possible, not only to speed resolution of the shingles itself, but to prevent PHN. Once PHN begins, treatment is much more difficult and often unsuccessful.
  • Finally, at the author's institution, special attention is given to HZO. Patients are informed that HZO often is more inflamed and more painful than shingles in other areas and occasionally results in pocklike scarring on the face if treatment is delayed. A close watch must be kept on the involved eye (sometimes in the hospital) to be sure the virus does not damage it. Severe cases require treatment by an eye specialist as well.
  • For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Shingles and Chickenpox.
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Contributor Information and Disclosures
Author

Joseph S Eastern, MD  Clinical Assistant Professor, Department of Internal Medicine, Section of Dermatology, University of Medicine and Dentistry of New Jersey

Joseph S Eastern, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, International Society for Dermatologic Surgery, and Medical Society of New Jersey

Disclosure: Abbott Honoraria Speaking and teaching; Amgen Honoraria Speaking and teaching; Aqua Honoraria Consulting; Stiefel Honoraria Speaking and teaching; Medicis Honoraria Speaking and teaching; Quinnova Honoraria Consulting; Graceway Speaking and teaching; Abbott Grant/research funds Clinical Research; Amgen Grant/research funds Clinical Research

Specialty Editor Board

Franklin Flowers, MD  Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, Affiliate Associate Professor of Pediatrics and Pathology, University of Florida College of Medicine

Franklin Flowers, MD, is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Paul Krusinski, MD  Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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Typical zoster in the vicinity of right popliteal fossa in a vertebral nerve L4 distribution.
Suspected zoster of the hand.
 
 
 
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