Herpes zoster (HZ) is an acute dermatomal infection associated with reactivation of varicella-zoster (VZV) and is characterized by unilateral pain and a vesicular or bullous eruption limited to a dermatome(s) innervated by a corresponding sensory ganglion. The major morbidity is postherpetic neuralgia (PHN).
Causes of Herpes Zoster
Most physicians believe there is a temporary weakness in the body’s ability to fight off disease. This allows the virus to start reproducing and move along nerve fibers toward the skin. The fact that the disease occurs more often in people older than age 50 (although children can get it, too) supports this since the immune response is believed to be weaker in older people. Trauma or possibly stress may also trigger a zoster attack.
Symptoms of Herpes Zoster
Symptoms may include:
- skin hypersensitivity in the area where the herpes zoster appears
- mild rash, which appears after five days and first looks like small, red spots that turn into blisters
- blisters which turn yellow and dry
- rash which usually goes away in one to two weeks
- rash is usually localized to one side of the body
Diagnosis
Prodromal Stage Suspect HZ in older or immunocompromised individual with unilateral pain.
Active Vesiculation Clinical findings usually adequate; may be confirmed by Tzanck test and possible DFA or viral culture to rule out HSV infection.
PHN By history and clinical findings.
Treatment
Goals of management Relieve constitutional symptoms; minimize pain; reduce viral shedding; prevent secondary bacterial infection; speed crusting of lesions and healing; ease physical, psychological, emotional discomfort; prevent viral dissemination or other complications; prevent or minimize PHN.
Antiviral therapy In individuals at high risk for reactivation of VZV infection, oral acyclovir can reduce the incidence of HZ. In prodromal stage: begin antiviral agent if diagnosis is considered likely; analgesics. With active vesiculation: antiviral therapy begun ≤72 h accelerates healing of skin lesions, decreases the duration of acute pain, and may decrease the frequency of PHN when given in adequate dosage.
- Acyclovir 800 mg PO qid for 7-10 days. The 50% viral inhibitory concentration of acyclovir is three to six times higher for VZV than for HSV in vitro, and drug dose must be increased appropriately. The bioavailability of acyclovir is only 15 to 30% of the orally administered dose. For ophthalmic zoster and HZ in the immuno compromised host, acyclovir should be given intravenously. Acyclovir hastens healing and lessens acute pain if given within 48 h of the onset of the rash.
- Valacyclovir 1000 mg PO tid for 7 days, 70 to 80% bioavailable.
Supportive therapy for acute HZ
- Constitutional symptoms Bed rest, NSAIDs.
- Sedation Pain often interferes with sleep. Sleep deprivation and pain commonly result in depression. Doxepin, 10 to 100 mg hs, is an effective agent.
Chronic stages (PHN) Pain is that of reflex sympathetic dystrophy.
- Pain management Severe prodromal pain or severe pain on the first day of rash is predictive of severe PHN. Gabapentin: 300 mg tid. Tricyclic antidepressants such as doxepin, 10 to 100 mg PO hs. Capsaicin cream every 4 h. Topical anesthetic such as EMLA or 5% lidocaine patch for allodynia. Nerve block to area of allodynia. Analgesics.
Herbal Therapy
To numb the area, try smoothing calendula lotion or ointment over lesions several times a day. Alternatively, peppermint oil or a commercially prepared licorice gel can be applied.
You can decrease pain with an over-the-counter cream made with cayenne. The treatment works by sending the brain conflicting, or confusing, pain messages. Use only on healed lesions.
A combined tincture of oatstraw, St. John’s wort, and skullcap also can bring relief. Take 1 teaspoon of the blend a day. Or mix equal parts lemon balm tincture and water; dab on lesions.
Herbal products are available in health food stores and in some pharmacies and supermarkets. Follow package directions.
Homeopathy
A homeopathic practitioner may recommend one of the following three well-regarded remedies, depending on your symptoms:
- Arsenicum album-for severe burning pain that lessens if you apply warm compresses; also helpful if you feel very restless, anxious, and find it difficult to sleep
- Mezereum-for severe pain and itching; also helpful if scratching the lesions causes a burning sensation and the lesions have brown scabs
- Ranunculus bulbosus-for severe burning pain that worsens when you move or touch the lesions
Hydrotherapy
Apply ice packs, 10 minutes on and 5 minutes off, several times a day to relieve pain. Never leave the ice on for more than 20 minutes at a time; prolonged exposure to cold can damage skin. Applying ice along the spine (not on the blisters) will help. To lessen inflammation, splash apple cider vinegar on eruptions several times a day. You also can take a neutral bath (slightly cooler than body temperature) for its calming and soothing effects.
Traditional Chinese Medicine
Acupuncture – Acupuncture can alleviate the pain and reduce the duration of a shingles attack. The practitioner focuses on the lung, back of head, adrenal gland, and internal secretion acupuncture points in the ear, along with points that correspond to the affected area.
Body acupuncture also may be used to treat this condition. In fact, if given at the first sign of symptoms, acupuncture has been shown to preVent post-herpetic syndrome, a chronic and very painful form of neuralgia that continues to plague the individual long after the shingles attack has abated.
Acupressure – Although the rash itself should never be massaged directly, a practitioner may be able to relieve pain and accelerate the healing process by applying pressure to Liver 3, and to points that lie around the rash and in the ear.
As with acupuncture, acupressure-if administered in the early stages of the condition may help prevent the development of post-herpetic syndrome, a chronic and very painful form of neuralgia.
Chinese Herbal Therapy – In Chinese medicine, shingles is believed to be caused by a damp-heat imbalance, so herbs in formulas, such as gentiana (or the combination medicine, Gentiania Formula), are typically prescribed to rectify this underlying condition.
Yoga and Meditation
Use deep breathing, meditation, and yoga exercises to reduce stress and lessen the intense pain and other symptoms of shingles. Choose three or four poses that you enjoy, being sure to include at least one relaxation pose, such as the Child, Corpse, or Wind Removal. Perform daily, even after symptoms subside.
Prevention
- Immunization Immunization with VZV vaccine may boost humoral and cell-mediated immunity and decrease the incidence of zoster in populations with declining VZV-specific immunity.
References