NOTES ON HERPES ZOSTER/ZOSTER/SHINGLES

Dr. Saleh Mohammad Shoaib, Medical Officer, Fakirhat UHC, Bagerhat.

DMC (K – 67), MD resident (Phase – A, Neurology, NINS). Mob: 01757370094

PATHOGENESIS decades of life so that at age 80, the incidence is ≈ 10 cases per
1000 patient‐years. The mean age of zoster is about 60 years.
 Zoster is caused by → reactivation of Varicella Zoster Virus
(VZV).  Sex: Slightly F > M.

0
 Following 1 infection or vaccination, VZV remains latent in the CLINICAL FEATURES
sensory dorsal root ganglion cells.
1. DERMATOMAL DISTRIBUTION
 The virus begins to replicate at some later time, traveling
down the sensory nerve into the skin.  Herpes zoster classically occurs unilaterally within the
distribution of a cranial or spinal sensory nerve.
ETIOLOGY AND RISK FACTORS
 There is often some overflow into the dermatomes above and
 Commonest causes of zoster: Immuno-suppression (especially below.
hematologic malignancy and HIV infection) and age-related
deficiency of cell-mediated immunity.  Dermatomes most frequently affected → thoracic (55%),
cranial (20%), lumbar (15%), and sacral (5%).
 Other risk factors: family history, hemodialysis, comorbidities,
statin use, being white.  Commonest single nerve involved → trigeminal nerve.

EPIDEMIOLOGY  Scattered lesions can occur outside the dermatome, usually <
20 (if > 20, it is called disseminated herpes zoster).
 Age: Zoster is not common in childhood and young adult life.
Over 50 y age, incidence  and continues to  in successive
2. SKIN FEATURES  Lesions continue to appear for several days.

 The eruption initially presents as papules and plaques of  The eruption may have few lesions or reach total confluence in
erythema within the dermatome. the dermatome.

 Within hours, the plaques develop blisters.  Lesions may become hemorrhagic, necrotic or bullous.
 Zoster sine herpete: Rarely, the patient may have pain, but no
skin lesions.

 Pain severity correlates with extent of the skin lesions.

 Pain can even mimic angina or acute abdomen (i.e.

cholecystitis, biliary colic, pancreatitis, appendicitis etc.)

 Elderly persons tend to have severer pain (Age = Severity of

pain). In age < 30 y, the pain may be minimal.

4. DURATION OF SKIN LESIONS

 In the typical case, new vesicles appear for 1–5 days, become
pustular, crust and heal.

 The total duration of the eruption depends on 3 factors:

patient’s age, severity of eruption and presence of underlying
immunosuppression.

 Total duration to heal: Younger patients → 2–3 weeks, Elderly

patients → 6 weeks or more.

5. SKIN COMPLICATIONS

 Scarring is more common in elderly and immunosuppressed

patients. It also correlates with the severity of the initial eruption.

3. PAIN

 The cutaneous eruption is frequently preceded by one to

several days of pain in the affected area.

 Also, the pain may appear simultaneously or even following

the skin eruption, or the eruption maybe painless.
6. MUCOUS MEMBRANE INVOLVEMENT

 Lesions may develop on the mucous membranes within the

mouth in zoster of the maxillary division or mandibular division
of the facial nerve, or in the vagina with zoster in the S2 or S3
dermatome.

 Zoster may appear in recent surgical scars and may follow

injections of botulinum toxin.

TREATMENT OF HERPES ZOSTER

1. RESTRICTION OF PHYSICAL ACTIVITIES  Soothing topical preparations with dressings as blisters break
can relieve discomfort.
 Middle-age and elderly patients with herpes zoster are urged
to restrict their physical activities or even stay home in bed for a 3. ANTIVIRAL THERAPY
few days.
 It is the cornerstone in the management of herpes zoster.
 Bed rest → may have paramount importance in the prevention
of neuralgia.  Benefit: ↓ duration and severity of zoster-associated pain.

 Younger patients may usually continue with their regular  Drawback: does not ↓ rate of zoster-associated pain.
activities.
 Indications:
2. LOCAL MEASURES
A. All immune-competent patients > age 50 y
B. Painful or severe zoster
 Local applications of heat (i.e. electric heating pad or hot
C. Ophthalmic zoster
water bottle) are recommended.
D. Ramsay Hunt syndrome
 Simple local application of gentle pressure with hand or with an E. Immunosuppression
abdominal binder often gives great relief. F. Cutaneous or Visceral dissemination
G. Motor nerve involvement.
 Initial IV therapy: Consider in the most severe cases, especially
in →
 In the patient with known or acquired renal failure, acyclovir
A. Ophthalmic zoster neurotoxicity can occur from IV acyclovir or oral valacyclovir
B. Disseminated zoster therapy. Features: In acute setting → hallucinations, With
prolonged elevated blood levels → disorientation, dizziness, loss
 When to start: Start therapy as soon as the diagnosis is of decorum, incoherence, photophobia, difficulty speaking,
suspected, pending laboratory confirmation. It is preferable to delirium, confusion, agitation, and death delusion.
st
treat within the 1 3 – 4 days. In immune-competent patients,
the efficacy of starting treatment beyond this time is unknown.  Because acyclovir can reduce renal function, the patient’s
baseline renal function may have been normal, but high doses of
 Benefit: The anti-herpes agents → acyclovir may have reduced renal function, leading to neurotoxic
acyclovir levels. (So, High dose acyclovir → AKI → further
A. causes more rapid resolution of the skin lesions
accumulation of acyclovir → neurotoxicity).
B. significantly decrease the total number of lesions
C. significantly decrease the duration of symptoms
D. significantly decrease the viral shedding in patients
with cutaneous zoster (if begun within 72 hours)
E. most importantly, substantially decreases the duration
of zoster-associated pain (especially if treatment is
initiated early).

DRUG REGIMENS

 There are 3 oral regimens: Valacyclovir 1000 mg 3 times daily,

Famciclovir 500 mg 3 times daily or Acyclovir 800 mg 5 times
daily.

 Preferred regimen: Valacyclovir and Famciclovir are preferred

over Acyclovir at these doses because of better absorption,
achievement of higher blood levels and a shorter duration of
zoster associated pain. However, they have similar efficacy &
safety (Famciclovir may ↓ in more rapid reduction in acute zoster
pain than Valacyclovir).

 Duration of therapy in the immunocompetent host: total 7

PATIENTS WHO MAY NOT NEED ANTIVIRALS
days treatment is as effective as 21 days.
 Rest and analgesics are sufficient for mild attacks of zoster in
RENAL ADJUSTMENT the young (but give antivirals in any zoster > 50 y age).

 Valacyclovir and famciclovir must be dose-adjusted in patients

with renal impairment.

 In an elderly patient, if the renal status is unknown, the

valacyclovir and famciclovir may be started at twice-daily dosing
(which is almost as effective), pending evaluation of renal
function, or acyclovir can be used.

 For patients with renal failure (CrCl <25 mL/min), acyclovir is

preferable.

RENAL ADJUSTMENT OF VARIOUS ANTIVIRALS

Creatinine Clearance and dose in zoster

Drug
25 – 50 10 - 25 < 10
5–10 mg/kg BD 5–10 mg/kg 2.5–5 mg/kg
IV
Acyclo BD daily
vir As in normal 800 mg BD 400–800 mg
Oral
renal function or TDS BD
30 – 59: 250 10 – 29: 125 < 10: 250 mg
Famcicyclovir
mg daily mg daily 3 times/week
30 – 50: 1 g BD 10 – 30: 1 g < 10: 500 mg
Valacyclovir
daily daily
4. CORTICOSTEROIDS

 Some of the pain during acute zoster may have an

inflammatory component → so corticosteroid might play a role.

 Benefit: In selected older patients, corticosteroid use is

associated with better quality-of-life measures, reduction in time
to uninterrupted sleep, quicker return to usual activities and
reduced analgesic use.

 Dose and duration: A tapering dose of systemic

corticosteroids, starting at about 1 mg/kg and lasting 10–14
days, is adequate to achieve these benefits.

 They should not be used without concomitant antiviral

therapy.

 Avoid: Systemic corticosteroids should not be used in

immunosuppressed patients or when there is a contraindication.

 Risk – benefit ratio: All factors considered, the benefits of

corticosteroid therapy during acute zoster appear to outweigh
the risks in treatment-eligible patients. (=benefits>risks)

ANTIVIRAL THERAPY IN THE IMMUNOSUPPRESSED  Effect on pain: Reduction in post-herpetic neuralgia by

PATIENT corticosteroids has never been documented (like antiviral therapy,
which reduces the severity and duration but not the prevalence of
 Absolution indication: An antiviral agent should always be post-herpetic neuralgia).
given*** because of the increased risk of dissemination and
zoster-associated complications. ZOSTER-ASSOCIATED PAIN (POST-HERPETIC
NEURALGIA)
 The doses are identical to those used in immune-competent
hosts.  Pain is the most troublesome symptom of zoster.

 IV acyclovir should be given to Immunosuppressed patients  Epidemiology: 84% of patients with age > 50 y will have pain
with → preceding the eruption, and 89% will have pain with the eruption.

A. Ophthalmic zoster  Classification: All pain occurring immediately before or after

B. Disseminated zoster zoster are called “zoster-associated pain” (ZAP). In another
C. Ramsay Hunt syndrome system, Acute pain = within first 30 days, sub-acute pain = 30–120
days, chronic pain = >120 days.
 Anyone failing oral therapy should also receive IV acyclovir.
 Quality of pain: 3 basic types →
 Dose of IV acyclovir: 10 mg/kg three times daily, adjusted for
renal function. A. Constant, monotonous, usually burning or deep, aching
pain
B. Shooting, lancinating (neuritic) pain
C. Triggered pain → allodynia (pain with normal non-
painful stimuli such as light touch) or hyperalgesia
(severe pain produced by a stimulus normally producing
mild pain).

 The character and quality of acute zoster pain are identical to

the pain that persists after the skin lesions have healed.

 Age and pain resolution: Usually duration of pain  with age.

MANAGEMENT OF ZAP/PHN

 Adequate medication should be provided to control the pain

from the first visit.
 Chronic pain may lead to depression, complicating pain  If needed, use a long-acting agent, treat for minimum duration
management. and switch to another class of agent.

 Patients with persistent, moderate to severe pain may benefit  Constipation is a major side effect in elderly persons. During
from referral to a pain clinic. painful zoster, these patients ingest less fluid and fiber,
enhancing the constipating effects of the opiates. Bulk laxatives
DIFFICULTY IN MANAGEMENT should be recommended.

 PHN is typically very difficult to treat (especially if of long  Tramadol is an option for acute pain control, but drug
duration) mainly for 2 reasons. interactions with the TCAs must be monitored (Tramadol + any
serotonergic drugs e.g. TCA/SSRI/SNRI = serotonin syndrome!).
1. Lack of efficacy: Drugs are simply often not effective.
N.B. If the patient fails to respond to local measures, oral
2. Intolerable side effects: These drugs have significant and often analgesics (including opiates), TCAs, gabapentin, and venlafaxine,
intolerable side effects (especially in elders), limiting the dose referral to a pain center is recommended.
that can be prescribed. If multiple agents are combined to reduce
the toxicity of any one agent, their side effects overlap (sedation, OTHER RELATED AGENTS
depression, constipation) and drug–drug interactions may occur,
limiting combination treatment options. 1. ANTIVIRAL AGENTS
Standard therapy  Recommended in all patients > age 50 y with pain who still
have blisters, even if the drugs are not given within the first 96 h
 3 classes of drugs are used as standard therapies to manage
of the eruption.
ZAP and PHN: TCAs and related medications, anticonvulsants and
opiates.
2. ORAL ANALGESIA
1. TCAS AND RELATED MEDICATIONS  Should be maximized using paracetamol, NSAIDs and opiate
analgesia as required.
TCAS
3. TOPICAL MEASURES
 Agents: TCAs e.g. Amitriptyline, nortriptyline and desipramine
are proved as effective for the management of PHN and are  Capsaicin: applied topically every few hours may ↓ pain, but
considered first-line agents. the application itself may cause burning, and the benefits are
modest.
 Dose titration: The TCAs are dosed at 25 mg/night (or 10 mg for
age > 65–70 y). The dose is increased by the same amount nightly  Local anesthetics e.g. 10% lidocaine gel, 5% lidocaine-
until pain control is achieved or the maximum dose is reached or prilocaine, or lidocaine patches (Lidoderm), may acutely ↓ pain,
intolerable side effects develop. The ultimate dose is between 25 but only for short term.
and 100 mg in a single nightly dose.
4. OTHERS
Related medications
 Patients with PHN have lower vitamin C levels than controls,
 Venlafaxine: may be used in patients who do not tolerate TCAs,
and IV vitamin C supplementation (not orally) reduces PHN.
at a starting dose of 25 mg/night, gradually titrated upward as
required.  Sub-lesional anesthesia, epidural blocks (with or without
ketamine), and sympathetic blocks with and without
 Gabapentin: ↓ ZAP. Usual starting dose: 300 mg three times
corticosteroids provide acute relief of pain.
daily, escalating up to 3600 mg/day. A minimum total dose > 600
mg is needed to obtain optimal benefit.  A trans-cutaneous electrical nerve stimulation (TENS) unit may
be beneficial for persistent neuralgia.
 Pregabalin: ↓ ZAP. It is given at 300 mg or 600 mg daily
(depending on renal function). It has better absorption and  Botulinum toxin: 100 U, spread out over the affected area in a
steadier blood levels than gabapentin. checkerboard or fanlike pattern with 5 U per route, has
dramatically improved PHN in anecdotal reports.
2. ANTICONVULSANTS AND RELATED MEDICATIONS
ZOSTER IN CHILDREN
 Diphenylhydantoin, carbamazepine, valproate, chlorprothixene,
phenothiazines, cimetidine → cannot be recommended because  Zoster is uncommon in childhood.
they have been not been studied critically, many are poorly
tolerated by elderly patients, and some are associated with  Very rare in healthy children of age < 10 y. But, infants who
significant side effects. were infected in utero or in the 1st year of life, have  risk for
st
development of zoster in the 1 years of life.
3. OPIOIDS
 Zoster in children tends to be milder than disease in adults and  Appx. 4% of patients suffer a 2nd episode of herpes zoster; 3 or
is less frequently associated with post-herpetic neuralgia. more episodes are rare.

IMMUNOCOMPROMISED CHILDREN

 Zoster occurs more frequently, occasionally multiple times,

and may be severe in children receiving immune-suppressive
therapy (e.g. for malignancy or other diseases) and HIV infected
ones.

 Disease intensity may be similar to adults, including post-

herpetic neuralgia.

 Immunocompromised patients may also experience

disseminated cutaneous disease that mimics varicella as well as
visceral dissemination with pneumonia, hepatitis, encephalitis,
and disseminated intravascular coagulopathy.

 Severely immunocompromised children, particularly those with

advanced HIV infection, may have unusual, chronic or relapsing
cutaneous disease, retinitis, or central nervous system (CNS)
disease without rash.

TREATMENT OF ZOSTER IN CHILDREN

OTHERWISE HEALTHY AND IMMUNE-COMPETENT

CHILDREN

 Treatment of uncomplicated zoster in a child with an antiviral

agent may not always be necessary (Zoster in healthy children is
less severe than adults and post-herpetic neuralgia is rare,
remember?)

 Some experts would treat with oral acyclovir (20 mg/kg/dose,

maximum 800 mg/dose) to shorten the duration of the illness.

 It is important to start antiviral therapy as soon as possible.

 Delay beyond 72 hr from onset of rash limits its effectiveness.

IMMUNOCOMPROMISED CHILDREN

CLINICAL FEATURES  In contrast, Zoster in immunocompromised children can be

severe, and disseminated disease may be life threatening.
 Unlike in adults, zoster in children is infrequently associated
with localized pain, hyperesthesia, pruritus and low-grade fever.  High risk for disseminated disease: give IV acyclovir (10 mg/kg
every 8 hr).
 In children, rash is mild, with new lesions appearing for a few
days; symptoms of acute neuritis are minimal; and complete  Uncomplicated zoster and low risk for visceral dissemination:
resolution usually occurs within 1-2 wk. options are oral acyclovir, famciclovir or valacyclovir.

 Unlike in adults, post-herpetic neuralgia is very unusual in  Corticosteroids: not recommended for treating zoster in
children. children.

DRUG THERAPY FOR HERPES ZOSTER

Group Name Dose Cost Comment
Antivirals Valacyclovir 1000 mg TDS for 7 – 500 mg/40 tk  Generally well tolerated.
(Tab. Revira, 10 days 1 g/75 tk  S/E: Nausea, headache, vomiting, rash. High doses →
Valovir, Zostiva) confusion, hallucinations and seizures.
 Probably safe during pregnancy.
Famcicyclovir 500 mg TDS for 7 – 10 250 mg/230 tk  Generally well tolerated.
(Tab. Famvir) days  S/E: Headache, nausea, diarrhea.
Acyclovir (Tab./ 800 mg 5 times daily 200 mg/14 tk  Generally well tolerated.
Syp. Virux, Xovir, for 7 – 10 days 400 mg/22 tk  S/E: Nausea, diarrhea, headache.
Simplovir) 200 mg/5 ml =  IV infusion → may cause reversible renal toxicity (i.e.
126 tk (70 ml) crystalline nephropathy or interstitial nephritis) or neurologic
Acyclovir IV (Inj. 10 – 15 mg/kg TDS for 250 mg/400 tk effects (e.g. tremors, delirium, seizures). These are uncommon
Simplovir vial) > 7 days 500 mg/700 tk with adequate hydration and avoiding rapid infusion.
1 g/1000 tk  Can be used near term.
 Avoid concurrent use of nephrotoxic agents → chance of AKI.
Steroids Prednisolone Start at 1 mg/kg. Give 2 mg/0.80 tk  Avoid in immunosuppressed patients or when there is a
(Tab. Cortan, a tapering course for 5 mg/1.72 tk contraindication.
Adam 33, 10 – 14 days. 10 mg/3.23 tk  Benefit > Risk in case of Zoster.
Deltasone, 20 mg/6.27 tk
Precodil, Pred)
st
TCA Amitriptyline Starting dose: 10 – 25 10 mg/0.9 tk  1 line agents for PHN.
(Tab. Tryptin) mg/night 25 mg/1.8 tk  Proved as effective for the management of PHN.
Nortriptyline Target dose: 25 – 100 10 mg/1 tk  S/E (Amitriptyline > Nortriptyline): Drowsiness, dry mouth,
(Cap. Nortin) mg/night*. 25 mg/1.5 tk constipation, orthostatic hypotension, cognitive dulling, blurred
vision, urinary retention, weight gain, seizure threshold lowering
(The anticholinergic side effects may ↓ with time)
Others Venlafaxine Starting dose: 25 37.5 mg/6 tk  May be used in patients who do not tolerate TCAs.
(Tab. Venlax) mg/night 75 mg/11 tk  Shouldn’t be combined with other serotonin or NE uptake
inhibitors (i.e: SSRI, SSNRI, TCA)
 Can be combined with pregabalin or gabapentin
 Side Effects: HTN, ECG changes (Start with caution if CV risk),
other serotonergic and noradrenergic side effects
Gabapentin (Tab. Starting dose: 300 mg 300 mg/16 tk  Pregabalin has better absorption and steadier blood levels
Gaba) TDS, up-titrate up to 600 mg/30 tk than gabapentin.
3600 mg/day. (Min.  No significant drug interaction.
effective dose = 600  Adjust dose in kidney dysfunction.
mg/d)  Both preferred over TCA in h/o HF/arrhythmia/suicide risk
Pregabalin (Cap. 300 – 600 mg daily in 25 mg/10 tk  S/E: Pregabalin - Sedation, dizziness, peripheral edema,
Pregaba) 3 divided doses 50 mg/14 tk weight gain. Gabapentin – nausea, somnolence, dizziness
75 mg/18 tk
100 mg/22 tk
150 mg/32 tk
Tramadol (Cap. Start 50 mg PO OD. 50 mg/8 tk  Drug interactions with the TCAs must be monitored (Tramadol
Anadol) Slowly up-titrate to 100 mg SR/12 + any serotonergic drugs e.g. TCA/SSRI/SNRI = serotonin
max. 100 mg PO QDS. tk syndrome!).
Topical Calamine lotion Apply 3-4 times daily 100 ml  Local anti - pruritic
(Calamine + Zinc for 3-5 days bottle/38 tk
oxide +
Glycerine)
Related Vitamin C (Inj. 500 mg/5 ml =  IV vitamin C supplementation (not orally) reduces PHN.
Ascoson) 6 tk
TDS = 3 times daily, * = give single nightly dose

DISSEMINATED HERPES ZOSTER  Occurs chiefly in older or debilitated individuals, especially in

patients with lympho-reticular malignancy or AIDS.
 Defined as > 20 lesions outside the affected dermatome
(Cutaneous dissemination).  Low levels of Anti-VZV antibody in serum are a highly significant
risk factor in predicting dissemination of disease.
 The dermatomal lesions are sometimes hemorrhagic or  These complications are reduced from 50% of patients to 20–
gangrenous. The outlying vesicles or bullae, which are usually not 30% with effective antiviral therapy.
grouped, resemble varicella and are often umbilicated and may
be hemorrhagic.

 Visceral dissemination: to the lungs and CNS may occur in the

patient with disseminated zoster.

TREATMENT

 Careful evaluation

 Systemic antiviral therapy: Initially, IV acyclovir is given, which

may be changed to an oral antiviral agent once visceral
involvement has been excluded and the patient has received at
least 2–3 days of IV therapy.

OPHTHALMIC ZOSTER/HERPES ZOSTER

OPHTHALMICUS

 Here, the ophthalmic division of trigeminal nerve is involved.

 If the external division of the nasociliary branch is affected,

with vesicles on the side and tip of the nose (Hutchinson’s sign),
the eye is involved 76% of the time, compared with 34% when it is
PROGNOSIS
not involved.
 Unlike the cutaneous lesions, ocular lesions of zoster and their
 Vesicles on the lid margin are virtually always associated with
complications tend to recur, sometimes as long as 10 years after
ocular involvement.
the zoster episode.

TREATMENT HERPES ZOSTER OTICUS

 In any case, the patient with ophthalmic zoster should be seen  Facial nerve has sensory fibres supplying the external ear
by an ophthalmologist. (including pinna and meatus) and tonsillar fossa and adjacent
soft palate.
 Systemic antiviral therapy should be started immediately,
pending ophthalmologic evaluation. Consider IV therapy in severe  Presentation: Pain and vesicles in part or all of above
cases. distribution, though the skin involvement may be minimal and
limited to the external auditory meatus.
 Ocular involvement is most often in the form of uveitis (92%)
and keratitis (50%). Less common but more severe complications  Herpes zoster oticus accounts for about 10% cases of facial
include glaucoma, optic neuritis, encephalitis, hemiplegia and palsy (Ramsay hunt syndrome). The paralysis is usually complete
acute retinal necrosis. and full recovery occurs in only about 20% of untreated cases.
RAMSAY HUNT SYNDROME  Maxillary and mandibular alveolar bone necrosis may occur an
average of 30 days after zoster of the maxillary or mandibular
 Results from involvement of the facial and auditory nerves by branches of the trigeminal nerve. Limited or widespread loss of
VZV. teeth may result.

 Thought to be caused by herpetic inflammation of the B. DELAYED COMPLICATIONS OF ZOSTER

geniculate ganglion.
 Usually caused by vasculopathies affecting the CNS or
 Presentations → peripheral arteries.

A. Zoster of the external ear or tympanic membrane; Delayed contralateral hemiparesis (Stroke mimic)
B. Herpes auricularis with ipsilateral facial paralysis;
C. Herpes auricularis, facial paralysis and auditory  Is a rare but serious complication of zoster.
symptoms.
 Occurs weeks to months (mean 7 weeks) after an episode of
 Auditory symptoms include mild to severe tinnitus, deafness, zoster affecting the first branch of the trigeminal nerve.
vertigo, nausea, vomiting and nystagmus.
 Pathogenesis: Direct extension along the intracranial branches
of the trigeminal nerve → VZV gains access to the CNS and infects
the cerebral arteries → infective vasculopathy → focal infarct →
clinical features.

 Clinical features → headache & hemiplegia (Simulates stroke).

 Diagnosis: Arteriography (CTA/MRA/DSA) is diagnostic →

demonstrates thrombosis of the anterior or middle cerebral
artery.

OTHER DELAYED COMPLICATIONS

 May present as changes in mental status, aphasia, ataxia,

hemisensory loss and both hemianopia and monocular visual
loss.

 Monocular vision loss can occur up to 6 months following

zoster.

OTHER COMPLICATIONS OF ZOSTER  Aneurysm, subarachnoid or cerebral hemorrhage, carotid

dissection and even peripheral vascular disease are other
A. MOTOR NERVE NEUROPATHY recognized forms of VZV vasculopathy.

 Occurs in ≈ 3% of patients with zoster (3x times more common  The vasculopathy may be multifocal and involve both large and
if zoster + underlying malignancy). small arteries.

rd
 Prognosis: ≈ 75% slowly recover, 25% have some residual  In > 1/3 cases, VZV vasculopathy occurs without a rash.
motor deficit.
 Investigations: Magnetic resonance imaging (MRI) → virtually
 Post-herpetic pseudotumor: In thoracic zoster, there may be always abnormal. Diagnosis is confirmed by VZV PCR and anti-VZV
motor neuropathy of the abdominal muscles → resulting in a IgG antibody testing of the CSF.
bulge on the flank or abdomen (pseudotumor).
Treatment
 If the sacral dermatome S3, or less often S2 or S4, is involved,
 Since this is caused by active viral replication in the vessels, the
urinary hesitancy or actual urinary retention may occur.
treatment is IV acyclovir, 10–15 mg/kg three times daily for a
Hematuria and pyuria may also be present. The prognosis is good
minimum of 14 days.
for complete recovery.
 In some patients, months of oral antivirals are given if
 Similarly, pseudo-obstruction, colonic spasm, dilation,
symptoms are slow to resolve.
constipation, obstipation (severe constipation where patient
can’t pass stool or gas), and reduced anal sphincter tone can  A short burst of systemic corticosteroids is also given in some
occur with thoracic (T6–T12), lumbar, or sacral zoster. Recovery is cases.
complete.
SUMMARY OF TREATMENT B. Treatment of post-herpetic neuralgia
A. Treatment of Zoster 1. TCAs/Venlafaxine/Pregabalin/Gabapentin
1. Restriction of physical activities 2. Antiviral agents
2. Local measures 2. Oral analgesia
3. Antiviral therapy (IV acyclovir in severe cases) 3. Topical measures: Capsaicin, Local anesthetics
4. Corticosteroids 4. Others: IV vitamin C supplementation, Sub-lesional anesthesia,
epidural blocks, sympathetic blocks, TENS, Botulinum toxin.

SAMPLE PRESCRIPTIONS

Example 1 – Zoster in immunocompetent children: A 5 y old controlled or intolerable side effects develop. Target
otherwise healthy boy (wt. = 25 kg) presented with vesicles over dose is 25 – 100 mg/night.
right lateral back along T7 dermatome. There is mild pain. 4. Cap. Pregaba 25 mg 1 + 1 + 1, quickly up-titrate until
Firstly decide. Should you give antivirals or not? In this pain is controlled or intolerable side effects develop.
uncomplicated case, Antivirals may not be necessary. Target dose is 300 – 600 mg/day in 2/3 divided doses.
But if you give antivirals → 5. Tab. Napa One 1000 mg 1 + 1 + 1 + 1 – for pain
1. Tab. Virux 400 mg 1 + 1 + 1 + 1 + 1 for 7 – 10 days. 6. Cap. Reumacap (Indomethacin) SR 75 mg 1 + 0 + 1
(A/M) – for pain
7. Tab. Xorel 20 mg 1 + 0 + 0 – 1 month
Example 2 – Zoster in immunosuppressed children: A 3 y old boy
(wt. = 15 kg) receiving chemotherapy for acute lymphoblastic
leukemia presented with widespread vesicles over left chest along Example 5 – Ophthalmic zoster: A 59 y old man presented with
and outside (>20 lesions) T3 dermatome. There is severe pain over plaques and blisters over left side of forehead along V1
affected site. dermatome. There is severe pain over affected site. He has also
Admit in pediatric HDU/ICU. gritty sensation and photophobia in left eye. On ocular
As there is cutaneous dissemination and immunosuppression, examination, there is redness and ciliary congestion in left side.
there is high chance of visceral dissemination also. Drugs:
Bed rest. 1. Inj. Simplovir (1000 mg) 10 – 15 mg/kg IV stat and 8 hrly
Drugs: for 7 – 10 days.
1. Inj. Simplovir (1000 mg): 150 mg IV stat and 8 hrly for 7 2. Tab. Tryptin 25 mg 0 + 0 + 1, up-titrate until pain is
– 10 days. controlled or intolerable side effects develop. Target
2. Syp. Napa 2 tsf 4 times daily dose is 25 – 100 mg/night.
3. Syp. Flamex/Advel (Ibuprofen) 3 tsf 4 times daily 3. Cap. Pregaba 25 mg 1 + 1 + 1, quickly up-titrate until
pain is controlled or intolerable side effects develop.
Target dose is 300 – 600 mg/day in 2/3 divided doses.
Example 3 – Mild zoster in young: A 25 y old intern doctor 4. Tab. Napa One 1000 mg 1 + 1 + 1 + 1 – for pain
presented with vesicles over right iliac fossa along T11 5. Cap. Reumacap (Indomethacin) SR 75 mg 1 + 0 + 1
dermatome. He has moderate pain over the affected site. (A/M) – for pain
Rest. 6. Tab. Xorel 20 mg 1 + 0 + 0 – 1 month
Drugs: 7. Optimox 0.5% 1 drop in left eye every 3 hrs
1. Tab. Napa One 1000 mg 1 + 1 + 1 + 1 – for pain 8. Todol 0.5% 1 drop 3 times a day in left eye
2. Cap. Reumacap (Indomethacin) SR 75 mg 1 + 0 + 1 Urgently refer to an ophthalmologist.
(A/M) – for pain
3. Tab. Xorel 20 mg 1 + 0 + 0 – 1 month
4. Tab. Tryptin 25 mg 0 + 0 + 1, up-titrate until pain is Example 6 – Disseminated zoster: A 70 y old female presented
controlled or intolerable side effects develop. Target with multiple blisters and vesicles along C6 dermatome. Lesions
dose is 25 – 100 mg/night. spread over a wide area outside the dermatomal area. There is
severe pain over affected area.
Admission in medicine ward/HDU.
Example 4 – Zoster in elderly: A 65 y old retired army person Restriction of physical activities.
presented with blisters over C7 dermatome. He has severe pain Bed rest.
over affected area. HbA1C – 5.6%. Local applications of heat (i.e. electric heating pad or hot water
Restriction of physical activities. bottle).
Bed rest. Simple local application of gentle pressure with hand.
Local applications of heat (i.e. electric heating pad or hot water Soothing topical preparations with dressings as blisters break can
bottle). relieve discomfort.
Simple local application of gentle pressure with hand. Drugs:
Soothing topical preparations with dressings as blisters break can 1. Inj. Simplovir (1000 mg) 10 – 15 mg/kg IV stat and 8 hrly
relieve discomfort. for 3 days, exclude any visceral involvement, then switch
Drugs: to –
1. Tab. Revira/Zostiva 1000 mg 1 + 1 + 1 for 7 – 10 days or Tab. Revira/Zostiva 1000 mg 1 + 1 + 1 for 7 days or
Tab. Famvir 250 mg 2 + 2 + 2 for 7 – 10 days or Tab. Famvir 250 mg 2 + 2 + 2 for 7 days or
Tab. Virux/Xovir 400 mg 2 + 2 + 2 + 2 + 2 for 7 – 10 days Tab. Virux/Xovir 400 mg 2 + 2 + 2 + 2 + 2 for 7 days
2. Tab. Cortan 20 mg 2 + 0 + 0 (A/M) – 5 days, then 1 + 0 + 2. Tab. Tryptin 25 mg 0 + 0 + 1, up-titrate until pain is
0 (A/M) – 5 days, then ½ + 0 + 0 – 5 days. controlled or intolerable side effects develop. Target
3. Tab. Tryptin 25 mg 0 + 0 + 1, up-titrate until pain is dose is 25 – 100 mg/night.
3. Cap. Pregaba 25 mg 1 + 1 + 1, quickly up-titrate until Example 9 – Severe zoster in immunosuppressed adult: A 66 y
pain is controlled or intolerable side effects develop. old male receiving chemotherapy for small cell lung carcinoma
Target dose is 300 – 600 mg/day in 2/3 divided doses. presented with hemorrhagic vesicles and blisters over and outside
4. Tab. Napa One 1000 mg 1 + 1 + 1 + 1 – for pain T4 dermatome. There is severe pain over the affected site.
5. Cap. Reumacap (Indomethacin) SR 75 mg 1 + 0 + 1 Admission in medicine ward/HDU/ICU.
(A/M) – for pain Restriction of physical activities.
6. Tab. Xorel 20 mg 1 + 0 + 0 – 1 month Bed rest.
Local applications of heat (i.e. electric heating pad or hot water
bottle).
Example 7 – Ramsay hunt syndrome: A 54 y old male presented Simple local application of gentle pressure with hand.
with loss of wrinkling in left side of forehead and deviation of Soothing topical preparations with dressings as blisters break can
angle of mouth to the right. He also complains of tinnitus and relieve discomfort.
hearing loss in left ear and vertigo. On examination, there are Drugs:
vesicles and blisters over left external auditory meatus and 1. Inj. Simplovir (1000 mg) 10 – 15 mg/kg IV stat and 8 hrly
tympanic membrane. Signs of left sided LMN type of facial nerve for 7 - 10 days
palsy are found. 2. Tab. Tryptin 25 mg 0 + 0 + 1, up-titrate until pain is
Restriction of physical activities. controlled or intolerable side effects develop. Target
Bed rest. dose is 25 – 100 mg/night.
Drugs: 3. Cap. Pregaba 25 mg 1 + 1 + 1, quickly up-titrate until
1. Tab. Revira/Zostiva 1000 mg 1 + 1 + 1 for 7 – 10 days or pain is controlled or intolerable side effects develop.
Tab. Famvir 250 mg 2 + 2 + 2 for 7 – 10 days or Target dose is 300 – 600 mg/day in 2/3 divided doses.
Tab. Virux/Xovir 400 mg 2 + 2 + 2 + 2 + 2 for 7 – 10 days 4. Tab. Napa One 1000 mg 1 + 1 + 1 + 1 – for pain
2. Tab. Cortan 20 mg 2 + 0 + 0 (A/M) – 5 days, then 1 + 0 + 5. Cap. Reumacap (Indomethacin) SR 75 mg 1 + 0 + 1
0 (A/M) – 5 days, then ½ + 0 + 0 – 5 days. (A/M) – for pain
3. Tab. Tryptin 25 mg 0 + 0 + 1, up-titrate until pain is 6. Tab. Xorel 20 mg 1 + 0 + 0 – 1 month
controlled or intolerable side effects develop. Target
dose is 25 – 100 mg/night.
4. Cap. Pregaba 25 mg 1 + 1 + 1, quickly up-titrate until Example 10 – Mild zoster in CKD: A 51 y old CKD stage V patient
pain is controlled or intolerable side effects develop. (CrCl = 8) presented with few vesicles over C3 dermatome,
Target dose is 300 – 600 mg/day in 2/3 divided doses. diagnosed as herpes zoster.
5. Tab. Napa One 1000 mg 1 + 1 + 1 + 1 – for pain Drugs:
6. Cap. Reumacap (Indomethacin) SR 75 mg 1 + 0 + 1 Tab. Virux/Xovir 400 mg 1 – 2 tab BD for 7 – 10 days
(A/M) – for pain
7. Tab. Xorel 20 mg 1 + 0 + 0 – 1 month
Example 11 – Severe zoster in CKD: A 45 y old CKD stage IV
patient (CrCl = 20) presented with ophthalmic zoster.
Example 8 – Mild Zoster in immunosuppressed adult: A 56 y old Drugs:
diabetic male who has been recently on prednisolone for 1. Inj. Simplovir (1000 mg) 5 – 10 mg/kg IV stat and 12 hrly
rheumatoid arthritis presented with herpetic vesicles over T6 for 7 days.
dermatome. There is no pain. 2. Tab. Napa One 1000 mg 1 + 1 + 1 – for pain
Drugs: 3. Cap. Anadol SR 100 mg 1 + 0 + 1 (A/M) – for pain
1. Tab. Revira/Zostiva 1000 mg 1 + 1 + 1 for 7 – 10 days or 4. Optimox 0.5% 1 drop in left eye every 3 hrs
Tab. Famvir 250 mg 2 + 2 + 2 for 7 – 10 days or 5. Todol 0.5% 1 drop 3 times a day in left eye
Tab. Virux/Xovir 400 mg 2 + 2 + 2 + 2 + 2 for 7 – 10 days Urgently refer to ophthalmologist and nephrologist.