Volume 109, Issue s62

The varicella-zoster virus (VZV) causes two diseases. The primary VZV infection, known as chickenpox, typically occurs during childhood. Herpes zoster infection results later in life from reactivation of VZV in the dorsal root ganglia. Herpes zoster characteristically results in a rash with a unilateral dermatomal distribution, which usually resolves within 2 to 4 weeks. If the infection does not resolve after its acute phase, long-term complications, such as postherpetic neuralgia, may develop. The author discusses the natural history and incidence of primary VZV infection and herpes zoster and details the epidemiology, clinical manifestation, diagnosis, and complications of this disease.

Treatment strategies for herpes zoster infection include limiting viral replication with anti-infective agents as well as limiting associated acute and chronic neuropathic pain with a variety of analgesics. The author outlines currently available pharmacotherapeutic options, from first-line (eg, anti-infective agents, tricyclic antidepressants, anticonvulsants, opioid analgesics, and topical agents) through adjuvant treatments (eg, oral corticosteroids). A summary of adverse event profiles is provided for each medication. Vaccination is recommended as a preventive measure.

Herpes zoster, or shingles, is a localized disease characterized by unilateral radicular pain and a vesicular rash limited to the area of skin innervated by a single dorsal root or cranial sensory ganglion. Whereas varicella, or chickenpox, results from primary exogenous varicella-zoster virus (VZV) infection, herpes zoster is caused by reactivation of endogenous VZV that has persisted in latent form within sensory ganglia following an earlier episode of chickenpox. In contrast to recurrent herpes simplex, herpes zoster is commonly associated with severe pain: prodromal pain often precedes the rash by several days; pain usually accompanies the dermatomal rash of herpes zoster; and clinically significant pain and allodynia may persist for weeks, months, or even years after the herpes zoster rash has healed, a debilitating complication known as postherpetic neuralgia (PHN). The incidence and severity of herpes zoster and PHN increase with age in association with an age-related decline in cell-mediated immunity to VZV. The Shingles Prevention Study—a randomized double-blinded placebo-controlled trial—sought to evaluate the capacity of a live attenuated VZV vaccine to protect older adults from herpes zoster and PHN by boosting their waning cell-mediated immunity to VZV. The study demonstrated that the zoster vaccine produced significant reductions in the incidence of herpes zoster, in the burden of illness caused by herpes zoster, and in the incidence of PHN.

The results of the Shingles Prevention Study, a Cooperative Studies Program conducted through the US Department of Veterans Affairs, are summarized. Also provided are general recommendations and contraindications for the use of zoster vaccine live among patients aged 60 years or older.

The incidence and severity of herpes zoster increases with advancing age, as does its most common complication—postherpetic neuralgia (PHN). The most effective management strategy for herpes zoster and PHN is prevention of the disease through vaccination, particularly in the most vulnerable patient population (ie, individuals aged 70 years or older). The Shingles Prevention Study demonstrated that vaccination reduced the incidence and severity of herpes zoster, as well as the incidence of PHN. Despite the benefits of zoster immunization, administration of the vaccine may be met by certain barriers, including issues related to reimbursement, storage, and availability of the vaccine. Educating physicians and the public about the importance of herpes zoster prevention, while underscoring the pain associated with this disease and the challenges in managing it, will help to overcome these barriers.

The herpes zoster vaccine has proven to reduce the incidence of herpes zoster and postherpetic neuralgia, a debilitating condition that can remain for years after zoster rash has resolved. However, few eligible adults have received the vaccine. Findings from survey-based studies on patient uptake of influenza and pneumococcal polysaccharide vaccines suggest that physician recommendations and standing orders can increase vaccine uptake. However, certain barriers unique to zoster vaccination (eg, reimbursement concerns) will need to be addressed.