Medical Minute: So your patient has Shingles…

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September 18, 2014 by dailybolusoflr

By Anneliese Cuttle, MD

Treatment:
  • Patients with disseminated disease, disease in more than one dermatome, or ophthalmic zoster should receive intravenous acyclovir (10-12.5 mg/kg IV q 8 h for 10-14 days).
  • For uncomplicated mild cases of herpes zoster, acyclovir (800 mg five times a day for 10 days) or famciclovir (500 mg tid for 7 days) is recommended. 
  • Providing treatment of the disease within 72 hours of rash onset will result in a more rapid resolution of cutaneous lesions and decrease viral shedding, but WILL NOT change the incidence of postherpetic neuralgia.
  • Consult ophthalmology for patients with potential ophthalmic zoster. Vesicles on the tip of the nose (Hutchinson sign, see below) indicates involvement of the nasociliary branch of cranial nerve V and is associated with a higher risk of ocular involvement. These patients can develop conjunctivitis, keratitis, uveitis and ocular cranial nerve palsies. Permanent sequelae may include chronic inflammation or loss of vision. 
Photo from http://quizem.org/quizem-17-answers/
  • Immunocompromised patients should not be placed on glucocorticoids. Narcotics, capsaicin cream, and tricyclic antidepressants can be used for pain control.
  •  Famciclovir and valacyclovir are not licensed for the treatment of varicella in the U.S.

Disposition:

  • Admission for those who require IV acyclovir

Discharge considerations:

  • Patient education is very important. They must understand that they are contagious to those who are not immune to VZV (have not had chickenpox or immunization). This infective state lasts until the vesicles have dried and crusted, or approximately 1 week from the onset of the rash. During this time, patients should avoid pregnant women, those who are immunocompromised, and those who have never had chickenpox.
  • Ensure follow-up for patients diagnosed with shingles who are less than 50 years old, since they may require workup of a potential underlying immunodeficiency.
  • About 40% of patients over age 60 will develop postherpetic neuralgia (PHN). Defined as persistent pain > 30 days after resolution of the rash, PHN was found to persist over 1 year in 5% of elderly patients.
  • Predictors of PHN are age, acute pain and rash severity, prodromal pain, the presence of virus in peripheral blood as well as adverse psychosocial factors.
  • A 2013 Cochrane review found NO DIFFERENCE between placebo and acyclovir in preventing PHN. 

Special Considerations:

  • Pregnant women who get chickenpox are at risk for serious complications. For example, 10-20% of pregnant women who get chickenpox develop pneumonia, with the chance of death as high as 40%.
  • If a pregnant woman gets chickenpox while in the first or early second trimester of pregnancy, there is a small chance (0.4 – 2.0%) that the baby could be born with birth defects known as “congenital varicella syndrome.” Babies born with congenital varicella syndrome may be of low birthweight and have scarring of the skin and problems with arms, legs, brain, and eyes.
References
1.      Johnson RW, Whitton TL: Management of herpes zoster (shingles) and postherpetic neuralgia. Expert Opin Pharmacother 2004;5:551–559 [PubMed: 15013924] .
2.      Ballester J, Morrison R (2010). Chapter 20. HIV Conditions. In Knoop KJ, Stack LB, Storrow AB, Thurman R. Knoop K.J., Stack L.B., Storrow A.B., Thurman R (Eds), The Atlas of Emergency Medicine, 3eRetrieved September 09, 2014 from http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=351&Sectionid=39619720.
3.      Hardin J (2010). Chapter 13. Cutaneous Conditions. In Knoop KJ, Stack LB, Storrow AB, Thurman R. Knoop K.J., Stack L.B., Storrow A.B., Thurman R (Eds), The Atlas of Emergency Medicine, 3eRetrieved September 09, 2014 from http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=351&Sectionid=39619712.
4.      Chen N, Li Q, Yang J, et al. (2014). “Antiviral treatment for preventing postherpetic neuralgia”. In He, Li. Cochrane Database Syst Rev 2 (2): CD006866. doi:10.1002/14651858.CD006866.pub3PMID 24500927.

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