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A previously healthy 69-year-old man presents to his primary care physician with a painful vesicular eruption of 24 hours' duration. He recalls that his 65-year-old brother had a similar rash one year earlier, which had been diagnosed as shingles. He wants to know what can be done to prevent the development of the severe pain experienced by his brother and whether his 62-year-old wife would be a candidate for the "shingles vaccine."
How do we know if this patient has herpes zoster (shingles)?
Herpes zoster, caused by varicella zoster virus, most commonly presents as a unilateral dermatomal, vesicular eruption. A sensory prodrome, ranging from minor tingling to severe pain, precedes the rash by 1-5 days.1,2 Typically, the rash involves a single dermatome and does not cross the midline. The presence of the characteristic rash (Figure 1) is sufficient to allow for clinical diagnosis.1,2
What risk factors does this patient have for herpes zoster?
After acute infection by varicella zoster virus, typically as chickenpox in childhood, the virus remains dormant in the dorsal nerve root ganglia. 1,2 When viral suppression is interrupted by mechanisms that impair cell-mediated immunity, varicella zoster virus can propagate distally along sensory neurons to cause shingles. The most common risk factor for reactivation, and the one most likely responsible for this patient's presentation, is advancing age (immunosenescence). The incidence of herpes zoster dramatically increases with age, with an incidence of 1.3-4.2 cases per 1000 personyears in those aged less than 60 years to 6.0- 10.7 cases per 1000 person-years in those aged 60 or older.3 Other risk factors include HIV infection, hematologic malignancy and the use of drugs that impair cellular immune function, such as corticosteroids.1,2
How should this patient's herpes zoster be treated?
Pain, as described by this patient, is the most common morbidity associated with herpes zoster.1,2 In a population-based study of herpes zoster before the introduction of zoster vaccine, 18% of patients reported pain lasting more than 30 days following onset of the rash, termed post herpetic neuralgia.3 The incidence and severity of postherpetic neuralgia increases with age and occurs in...