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Shingles (herpes zoster): What you should know


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CE credit is no longer available for this article. (Expired June 2009)


Originally Posted June 2007

By Ellen Novatnack, RN, BSN, CIC, and Steve Schweon, RN, MPH, CIC

ELLEN NOVATNACK is an infection control nurse at St. Luke’s Hospital, Bethlehem, PA, and STEVE SCHWEON is an RN editorial board member and infection control and prevention coordinator at St Luke’s Hospital. The authors have no financial relationships to disclose.

Shingles is on the rise. The good news is, we now have a vaccine to protect against this infection; the bad news is, it's not for everyone. Just who's eligible and what can you do to help those who suffer from this painful condition?

Herpes zoster, better known as shingles, is a reactivation of the varicella zoster virus (VZV), the same organism that causes chicken pox.1 While chicken pox is a usually mild and self-limiting childhood infection, shingles is more likely to afflict adults, causing severe pain and suffering, and in some cases, death.

Unfortunately, many of those at risk have never heard of shingles. Of those who have, most are unaware of the serious complications linked to this virus.2 Many patients delay seeking treatment, which reduces its effectiveness and promotes complications.

The good news is that we now have better drugs to treat shingles, plus a recently approved herpes zoster vaccine (Zostavax) that may prevent an episode. In cases where the vaccine doesn't prevent shingles, it can minimize the complications in those who develop an infection despite immunization.3 (For a close-up on the vaccine, see the box on page 29.)

Because of the vaccine's success in phase III clinical trials, the Advisory Committee on Immunization Practices recently recommended immunizing everyone over 60 years of age with a history of chicken pox. The recommendation should go into effect this month.4 Nurses are in the best position to raise patient awareness of shingles and encourage vaccination.

For patients under age 60, and anyone who develops shingles, you need to know how to manage their care and prevent complications. Here is an overview of the latest evidence-based treatments.

One virus, two clinical presentations

Like other members of the herpes family, VZV can persist in the body long after a patient recovers from the symptoms of the initial infection.2,5 Exposure is followed by an incubation period of about 10 – 21 days. The virus typically enters though the upper respiratory tract, migrates to the bloodstream, and travels to the skin. Initial infection results in chicken pox. The first sign of chicken pox in adults is usually a fever, but the classic pox, or blister-like vesicles, are often the first sign in children.

From the skin, VZV travels to the cranial nerves and dorsal root ganglion cells.2,5 There, the virus remains dormant, establishing a latent, asymptomatic infection, until conditions are right for it to wake up and strike again.

The patient who has VZV living in his nerve roots is at risk for an outbreak of shingles whenever his cellular immunity becomes compromised. Those at highest risk include the elderly, because cellular immunity declines with age. Also at increased risk are patients who have a condition or take medication that suppresses the immune system. These include patients who have HIV, cancer, or systemic lupus erythematosus; organ transplant recipients; or those taking immunosuppressant medications such as steroids or antineoplastic agents.6,7

Children generally don't get shingles. But there's an increased risk among children whose mothers had chicken pox during pregnancy, or among children who've had chicken pox within the first year of life.7 In addition, there's been a rise in the incidence of shingles among children since the advent of the varicella (Varivax) vaccine.7 Research shows that the trend may be caused by the loss of natural boosting that their immune systems would get from periodic exposures.7 When shingles does occur in children, the infection is often less severe and is less likely to cause chronic and long-term pain.7

One or more dermatomes may be affected

Once VZV is reactivated, it travels back up the nerve fibers to the innervated skin site. The dermatomes most commonly affected are those of the abdomen, thorax, and ophthalmic branch of the trigeminal nerve.

Symptoms of shingles may include fever, headache, and malaise.7 But most patients experience one or two days of numbness, itching, and stabbing or throbbing pain in the area where the skin lesions eventually appear.7 Shingles are blister-like vesicles that look like chicken pox only smaller. They appear in clusters that crop up within a week of the onset of symptoms. The vesicles are filled with active virus for about three to five days, and then dry and crust.7 New lesions crop up over the next few days, causing the rash to last as long as two to four weeks.1,8

During the active infection, VZV inflames the ganglia and destroys nerve endings. The result is postherpetic neuralgia (PHN), a residual pain syndrome from shingles and the most common complication. PHN is described as burning, throbbing, or stabbing, which is further complicated by intense itching in the area of the rash. PHN, with or without pruritis, can last for months to years after the infection resolves.

Those at greatest risk for PHN are the elderly. About half of the cases of shingles that develop in those over age 60 are complicated by PHN. The most severe and longer-lasting cases are found among older women and those who've had a severe course of the acute infection.6

PHN can lead to reduced physical and social activity, increased anxiety, sleep problems, and depression.6 Other serious complications from shingles include bacterial skin infections, scarring and loss of sensation in the affected area, and muscle weakness. A decrease, or even loss, of vision or hearing if the affected area is near the eyes or ears. And permanent neurologic damage, such as cranial nerve palsy, is possible if the motor nerves are involved. Pneumonia, encephalitis, meningitis, and vasculopathy have been reported rarely.5,6

Diagnosis and management of acute infection

Since the rash produced by shingles is distinctive, diagnosis can often be made based on clinical presentation alone. For confirmation, though, a sample should be taken from a fresh, fluid-filled vesicle and sent to the lab for testing.1 The direct fluorescence antibody or polymerase chain reaction (PCR) assay are the most common tests chosen. Of the two, the PCR is the most sensitive and specific, and results can be obtained within a few hours.1

Antiviral medication—the mainstay of treatment9 —should be given promptly. If started within 72 hours of the rash onset, antivirals can limit nerve damage and prevent PHN. They work by reducing both the duration of viral shedding and the formation of new lesions. In addition, they accelerate healing, and decrease the severity and duration of the acute pain.7,9

The best evidence recommends using one of the following regimens: acyclovir (Zovirax) 800 mg, PO, five times a day for seven to 10 days; famciclovir (Famvir) 500 mg, PO, three times a day for seven days; or valacyclovir (Valtrex) 1,000 mg, PO, three times a day for seven days.9

Intravenous acyclovir is used for severely immunocompromised patients. An infusion is given until the infection is controlled. Then, the patient switches to oral therapy. Topical antiviral therapy is not effective, nor is it recommended. An ophthalmologist should be consulted when there is ocular involvement. If healing is delayed, an infectious disease specialist may be consulted. Varicella zoster immune globulin (VZIG) can be used prophylactically in susceptible, immunocompromised patients who have been exposed to chicken pox or shingles.

For a pregnant patient, the benefits of treatment must outweigh the potential risks to the fetus.7 There is no evidence that maternal varicella is transmitted to the fetus; nor has the safety of antiviral therapy during pregnancy been fully established.

Controlling the infection, preventing complications

Fluid in the vesicles contains live virus, so the shingles patient is infectious until all lesions are dry and crusted. Standard precautions (hand hygiene, gloves, gowns, mask or face shield, as needed) are recommended for the immunocompetent patient with shingles.10,11 Airborne isolation precautions (use of N95 respirator masks, contact precautions, and a private room with negative air pressure) are recommended for patients who are immunocompromised and for those who have a disseminated case.10,11

Healthcare workers and visitors who have never had chicken pox or the varicella vaccine should not be permitted in the patient's room. To help dry out the lesions, you should apply wet-to-dry compresses of Burow's solution three or four times a day, as ordered.12 Antihistamines may help relieve itching, and thus prevent a secondary bacterial infection from scratching.12,13

Still, you'll need to monitor for signs of infection, and give additional antibiotics as ordered if a secondary skin infection develops. Be alert, too, for lesions in the eye. Because involvement of the ophthalmic branch of the trigeminal nerve can lead to blindness, refer a patient with these lesions to an ophthalmologist promptly.

Patients who have shingles in the sacral dermatomes are at risk for acute urinary retention. Monitoring intake and output will help detect this complication, and catheterizing the patient will relieve the problem. Watch for anxiety and depression, too. They can complicate treatment and hamper disease resolution.7

Strategies for managing acute and chronic pain

Pain linked to shingles is often described as excruciating and may be difficult to manage. While the need for pain relief may vary, the pain often becomes severe as the infection progresses.7 There are a number of options—both pharmacologic and nonpharmacologic—and you may need to combine strategies for best results. Always monitor the patient's response to therapy, so that the strategies can be adjusted as needed.

The first-line treatments of choice include opioid analgesics, such as oxycodone (Oxycontin) or morphine (MS Contin), combined with acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs, such as ibuprofen (Motrin, Advil, others). A laxative or stool softener may be needed to manage the constipation that occurs with opiate use.

Early steroid therapy has been beneficial in reducing acute pain. In fact, one study showed that pain was effectively relieved in patients who received a single epidural steroid injection along with topical anesthetics.7 But two double-blind, randomized, controlled trials concluded that steroids did not prevent PHN.9 Steroids did, however, improve the quality of life for those patients who received them, as evidenced by a quicker return to normal activities.

Additionally, tricyclic antidepressants (TCAs), particularly amitriptyline (Elavil), have proven helpful in reducing acute pain and PHN.7,9 However, the use of TCAs to relieve neuropathic pain is investigational. Patients should be informed of the benefits and potential side effects before taking these drugs.

Gabapentine (Neurontin) has met with some success in lessening the intensity of PHN. So have topical lidocaine sprays (Xylocaine spray) or patches (Lidoderm), or topical capsaicin (Zostrix).9

Nonpharmacologic strategies include everything from transcutaneous electrical nerve stimulation (TENS) of the affected areas to simple diversionary tactics (watching TV, knitting, board games, etc.) or relaxation techniques.10 You can also try splinting the area by covering the lesions with a snug, nonadherent dressing and then wrapping the area in an elastic bandage. If the patient has oral lesions, he may benefit from a soft diet and regular rinsing and swishing with a non-alcohol-based mouthwash. You should also encourage him to use a soft toothbrush.

Patient education enhances prevention

The sooner the patient with shingles seeks medical attention, the more likely he will be able to limit the disease and avoid complications.

As a patient advocate, you have the opportunity to inform older people about shingles and its complications so that they can assess their risk and take preventive action. Encourage your elderly patients to talk to their doctors or nurse practitioners about their risk, and what they can do to help avoid the disease.2 A free informational brochure is available through the American Pain Foundation's campaign called "Spotlight on Shingles." Patients can request a copy by calling 1-877-RISK-4-SHINGLES or by visiting the Web site at www.spotlightonshingles.com/.

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REFERENCES

1. Centers for Disease Control and Prevention (CDC). "National Immunization Program. Epidemiology and prevention of vaccine preventable diseases." The pink book (9th ed.)." 2006. www.cdc.gov/nip/publications/pink/def_pink_full.htm (19 Dec. 2006).

2. Society for Women's Health Research. "Americans are in the dark about shingles". 2007. www.vpico.com/articlemanager/printerfriendly.aspx?article=138459 (1 Jan. 2007).

3. U.S. Food and Drug Administration. Center for Biologics Evaluation and Research. "Product approval information—Licensing Action. Zostavax questions and answers." 2006. www.fda.gov/Cber/products/zosmer052506qa.htm (20 Dec. 2006).

4. Personal letter from Dr. Leonard Silverstein from Merck. Dec. 20, 2006.

5. Heymann, D. (2004). Control of communicable diseases manual. Washington, DC: American Public Health Association.

6. Holodniy, M. (2006). Prevention of shingles by varicella zoster virus vaccination. Expert Rev Vaccines, 5(4), 431.

7. Dworkin, R. H., Johnson, R. W., et al. (2007). Recommendations for the management of herpes zoster. Clin Infect Dis, 44(2007), S1.

8. Centers for Disease Control and Prevention (CDC). "Shingles (herpes zoster)." 2006. www.cdc.gov/nip/diseases/varicella/faqs-gen-shingles.htm (2 May 2007).

9. Mounsey, A. L., Matthew, L. G., & Slawson, D. C. (2005). Herpes zoster and post herpetic neuralgia: Prevention and management. Am Fam Physician, 72(6), 1075.

10. Bolyard, E. "Guideline for infection control in health care personnel, 1998." 1998. www.cdc.gov.mill1.sjlibrary.org/ncidod/dhqp/pdf/guidelines/InfectControl98.pdf (20 Dec. 2006).

11. Garner, J. (1996). Guideline for isolation precautions in hospitals. Infec Control Hosp Epidemiol, 17(1), 53.

12. Sommers, M., Johnson, S., & Beery, T. (2007). Diseases and disorders (3rd ed.). Philadelphia: F. A. Davis.

13. Tamparo, C., & Lewis, M. (2005). Diseases of the human body (4th ed.). Philadelphia: F. A. Davis.

New vaccine targets shingles

The herpes zoster vaccine (Zostavax) was recently approved to prevent shingles or reduce the risks associated with it, particularly in persons 60 years of age and older. While there is no available data on usage in younger individuals, it has been documented that the vaccine can prevent shingles from occurring in most of the targeted population. For those who develop the infection despite being immunized, Zostavax has been proven to stave off post-herpetic neuralgia (PHN).

Administered subcutaneously in the upper arm, this single dose vaccine is not to be used as a treatment for shingles or PHN. In addition, Zostavax shouldn't be used to prevent chicken pox in lieu of the Varivax vaccine. The need for revaccination has not been determined.

Zostavax should not be administered to persons allergic to gelatin, neomycin, or other vaccine components; immunocompromised or undergoing immunosuppressive therapy; and women who are currently or may become pregnant. Common side effects reported include redness, pain and tenderness, injection site swelling, and headache.

While the FDA originally discouraged immunization of people who've had shingles, a phase III clinical trial is currently under way that's proving the vaccine is effective in individuals with a history of shingles. And on October 25, 2006, the Advisory Committee on Immunization Practices (ACIP) recommended the vaccine for adults regardless if they had a prior history of shingles. ACIP recommendations become policy when they are accepted by the CDC's director and published in the Morbidity and Mortality Weekly Report (MMWR), slated for June 2007.

Nurses are in the best position to educate patients and direct them to the shingles Vaccine Information Statement, which is available at http://immunize.org/vis/#shingles.pdf, prior to receiving the vaccine.

Sources:

1. Immunization Action Coalition. "Shingles vaccine: What you need to know." http://immunize.org/vis/#shingles.pdf (20 Dec. 2006).

2. Merck & Co. "Zostavax." www.merck.com/product/usa/pi_circulars/z/zostavax/zostavax_pi.pdf (20 Dec. 2006).

3. Immunization Action Coalition. "ACIP provisional recommendations for the use of zoster vaccine." www.cdc.gov/nip/recs/provisional_recs/zoster-11-20-06 .pdf (20 Dec. 2006).

 

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