Herpes zoster: Causes, Symptoms, Treatments

Choose the content to read

• What causes herpes zoster (shingles)
• Who is at risk for herpes zoster
• What are the symptoms of herpes zoster/shingles
• How is herpes zoster treated?
• Is the myth if the herpes zoster wrapped around the body will cause you to die true?
• What are the preventions for herpes zoster/shingles?
• Herpes zoster vaccine
• FAQ

Herpes Zoster (Shingles)

Herpes zoster, or shingles, is a viral infection caused by the reactivation of a dormant VZV that is quiescent in the sensory ganglia of people who had previously had chickenpox. When a person recovers from chickenpox, the VZV remains dormant in the nerve ganglia. However, when body immunity is weakened, the latent VZV reactivates, resulting in herpes zoster symptoms including itching, burning pain, and a flare-up stripe of red rashes along the sensory ganglia, followed by protruding clear blisters that may be associated with a fever. If left untreated, herpes zoster can cause complications such as herpes zoster ophthalmicus, postherpetic neuralgia (PHN), and neurological problems. Those who suspect they have herpes zoster should seek medical attention as soon as possible for appropriate treatment and antiviral drugs.

What causes herpes zoster (shingles)?

Herpes zoster, or shingles, is caused by the reactivation of the varicella-zoster virus (VZV), which causes chickenpox when first infected. Once recovered, the VZV remains dormant in the sensory ganglia for decades without causing symptoms. As the body's immunity deteriorates, the latent VZV reactivates by dividing, multiplying, and spreading numbers along the sensory ganglia as well as the sensory nerve endings, resulting in nerve inflammation, pain along the sensory nerve ganglion, and a stripe of red rash on the skin, followed by clear fluid-filled blisters lying in a band-like distribution along the length of the nerve ganglia, causing itching, burning pain, sharp pain on the sensory nerve, headaches, and possibly fever. Everyone who has ever had chickenpox is at risk of developing herpes zoster.

Who is at risk for herpes zoster?

• Those aged 50 years and up
• Those with low body immunity
• Those who take immune-suppressing medications.
• HIV-infected individuals
• Those who have cancer
• Bedridden patients
• Those under stress
• Those who do not get enough sleep.
• Those who have suffered serious injuries.
• Those who have received an organ transplant.
• Those who are undergoing chemotherapy.
• Those who have used steroids for a long time.
• Those suffering from chronic diseases such as diabetes, autoimmune diseases, SLE, heart disease, or kidney disease.

What are symptoms of herpes zoster/shingles?

Herpes zoster/shingles symptoms are classified into 3 stages:

1. Preeruptive phase: The preeruptive phase (or preherpetic neuralgia stage) occurs when the latent VZV spreads through the sensory ganglion and the sensory nerve endings, resulting in nerve inflammation, peripheral neuropathy, numbness, acute pain, and burning pain on one side (unilateral) of the skin along the nerve ganglion, as well as itching, body aches, and headaches. In some cases, there may be associated symptoms such as fever, fatigue, diarrhea, or light sensitivity (photophobia). During the preeruptive phase of herpes zoster, symptoms typically last 1-3 days. However, there will be no skin lesions.
2. Acute eruptive phase: The acute eruptive phase occurs when red rash lesions appear on the skin along the sensory nerve ganglia, followed by clear fluid-filled blisters (vesicles) lying in a band-like distribution along the sensory nerve ganglia, typically on the left or right side of the body as well as the back or legs, or on one side of the face, eyes, or neck with herpes zoster rash. Unlike the chickenpox rash, the herpes zoster rash typically does not disperse as widely throughout the body and will fully develop within 3-5 days. Those with a herpes zoster infection rash will experience a headache, fever, fatigue, and acute pain along the sensory ganglia even after minor contact or simply touching the clothes. Within 10–15 days, the rash will break off and become sore, then gradually dry, scab over, and eventually fall off the skin. In those with normal body immunity, herpes zoster rash typically appears on one side of the body (unilateral). Conversely, rashes are more likely to be severe and may form on both sides of the body in those with low body immunity, including those with cancer or AIDS or those receiving chemotherapy.
3. Chronic phase: The chronic phase (or postherpetic neuralgia: PHN) occurs after the herpes zoster rash has subsided and the skin lesions along the sensory ganglia have faded. However, most people with herpes zoster will still experience some symptoms, such as burning pain, tingling sensations, or acute pain along the nerve that ranges from moderate to severe. Pain may occur all the time or come and go. In some cases, pain may persist for decades.

Zoster Sine Herpete (ZSH): Some people with herpes zoster may experience zoster sine herpete (ZSH) or herpetic neuralgia without a rash. There may be numbness, itching, and burning pain along the nerves, but there will be no rash appearing on the skin. Anyone who suspects they have zoster sine herpete should seek medical attention as soon as possible for further diagnosis.

How is herpes zoster diagnosed?

Doctors will diagnose herpes zoster by taking a history and performing a physical examination to look for herpes zoster lesions by examining the appearance of the rash or body blisters to see if they are dispersed widely or appear in clusters along one side of the body with symptoms of itching, burning pain, or fever. In cases where there are no lesions on examination or there is a suspicion of zoster sine herpete (ZSH), the doctor will use the following methods to perform additional diagnostic tests for herpes zoster:

• Tzanck smear: The Tzanck smear is a method of diagnosing herpes zoster that involves puncturing the blisters, scraping off a sample of tissue cells at the blister's base, sending it to the laboratory for microscopic examination, placing the sample on the slide, leaving it to dry, and smearing it with Wright-Giemsa to examine cell characteristics. The Tzanck smear is considered a quick and easy test, but it may be unable to distinguish between herpes simplex and herpes zoster rash.
• Viral culture entails taking a sample of vesicle cells and culturing them in a special medium to look for VZV. The accuracy of the test results ranges between 60 and 90%.
• Polymerase chain reaction (PCR) is an immunological test that looks for specific antibodies that the body produces to fight the virus after being suspected of having herpes zoster symptoms. The PCR test is highly sensitive and specific, with results that are 2-3 times more accurate than the viral culture method.

How is herpes zoster treated?

The doctor will treat herpes zoster with the gold standard of reducing the severity of the disease, reducing painful and burning pain, preventing complications, and assisting the patient in recovering from the disease as quickly as possible. The doctor will consider herpes zoster treatment and medications based on the duration of the disease and detected symptoms. However, the most effective treatment for herpes zoster is to begin treatment within 48-72 hours after the rash appears. Herpes zoster treatments include the following:

• Antiviral drugs: Doctors may prescribe antiviral drugs such as Acyclovir, Famciclovir, or Valaciclovir to reduce the severity of the disease, inflammation, and virus spread on the skin, as well as reduce burning pain, accelerate blister subsidence, minimize the risk of recurrence, promote a quick recovery, and reduce the risk of complications associated with herpes zoster.
• Antibacterial drugs: The doctor may consider giving antibacterial drugs such as prednisolone or antibiotics, both oral and topical, to those with herpes zoster who become infected with bacterial complications to reduce inflammation and pain and hasten the herpes zoster rash to subside quickly, particularly those with zoster sine herpete or herpes zoster rash flare-ups on any part of the face.
• Pain reliever: In severe cases of pain, the doctor may consider combining antiviral drugs with pain reliever medications such as paracetamol or NSAIDs such as ibuprofen to help relieve pain faster.

What are the complications of herpes zoster (shingles)?

• Postherpetic neuralgia (PHN) It was discovered that 5-30% of herpes zoster patients aged 50 and older will experience persistent nerve pain for more than 3 months after the rash has disappeared. The severity of the symptoms is frequently related to the patient's age. The elderly will experience more severe and prolonged symptoms than younger people. In some cases, pain may persist throughout life, resulting in insomnia, difficulty moving, pain along the sensory ganglion, weakness, or the ability to move a limb on a painful part only slightly.
• Herpes zoster ophthalmicus/ocular shingles is a herpes zoster complication in which the herpes zoster rash flares up in the eyes, causing eye irritation, eye inflammation, corneal ulcers, or retinal inflammation, resulting in blurred vision, eye sensitivity to light (photophobia), vision problems, or cataracts. In severe cases, ocular shingles can result in blindness, Ramsay-Hunt syndrome, or facial hemiplegia. Those experiencing ocular shingles symptoms should seek medical attention as soon as possible to avoid further complications.
• Neurological problems: Herpes zoster can cause neurological issues such as facial paralysis, hearing loss, and balance problems.
• Bacterial skin infections: If not kept clean, herpes zoster can cause a bacterial skin infection, which causes a slowing of healing, rash, redness, and scarring.
• Severe pain: For those with low body immunity, HIV, or cancer patients receiving chemotherapy, when they have herpes zoster, the pain is likely to be more severe than in others, and they can spread the disease to others more easily.
• Stroke, cerebral artery blockage, and cerebral hemorrhage (found in those suffering from severe chronic pain)
• Pneumonia and encephalitis are very rare complications of herpes zoster.

Is the myth “if the herpes zoster wraps around the body will cause you to die” true?

The myth “if the herpes zoster wraps around the body will cause you to die” is untrue. In some cases, herpes zoster rash can develop simultaneously on the left and right sides of the body, eventually giving the appearance that it is wrapping around your body and seeming to constrict you to death. In fact, most people who die from herpes zoster are secondary to their low body immunity, leading to complications associated with herpes zoster infection, which later cause their bodies to weaken and eventually cause death. Therefore, patients 50 years of age or older, as well as those with low immunity, are more likely to contract it.

How to manage herpes zoster at home?

• See a doctor right away to receive an antiviral drug within 48–72 hours of the onset of sharp pain or burning pain associated with fever.
• Take medicine and apply tropical medicine strictly as prescribed by the doctor to help reduce the severity of the disease, lesions, and complications.
• Apply a cold compress with cold compress gel and cover the rash loosely.
• Avoid using herbal medicines, inhalers, or other medications obtained without a doctor's prescription for the herpes zoster rash or itchy rash, as they may cause complications from a bacterial infection, slowing wound healing and possibly leaving a scar.
• Avoid scratching a herpes zoster or itchy rash. If your nails are long, trim them short to reduce bacteria buildup, which can lead to complications and recurrent bacterial infections.
• Cover an open wound to prevent bacterial infection.
• Always wash your hands thoroughly and keep your hands clean on a regular basis.
• Wear loose, not tight clothing to prevent skin from rubbing against clothing.

What are the preventions for herpes zoster/shingles?

1. Herpes zoster vaccine: Those who have or have not previously had chickenpox as a child, those aged 50 years and older, those with low body immunity, and all those at high risk of herpes zoster can prevent herpes zoster by receiving vaccination against the disease, which can cause a variety of complications.
2. Avoid direct contact with high-risk people: Those with herpes zoster should avoid direct contact with high-risk people to prevent the virus from spreading to others, such as the elderly, those who have never had chickenpox, those with weakened immune systems, young children, or pregnant women. Furthermore, personal items such as bedding, clothes, and clothing of those with herpes zoster should be kept separate from others.
3. Maintain a healthy body: Eating all five food groups, exercising regularly, keeping your mind stress-free and relaxed, and getting enough rest will help your immune system remain strong and keep you away from herpes zoster.

Herpes zoster vaccine

With current medical advancements, the Herpes Zoster Vaccine was developed and designed to be more effective in preventing and reducing herpes zoster complications. There are 2 types of herpes zoster vaccines available in Thailand.

1. Zoster vaccine live (ZVL) is a live attenuated vaccine. The recommended dosage is 1 dose. ZVL is a vaccine that is 69.8% effective in preventing herpes zoster in people aged 50–59 years.
2. Shingrix vaccine, a recombinant subunit zoster vaccine (RZV), is a new type of herpes zoster vaccine with a recommended dosage of 2 doses. Shingrix is non-live vaccine made from glycoprotein E, a protein component of the VZV, that has been developed to effectively prevent herpes zoster.

Instructions for administering the new Herpes Zoster Vaccine: Shingrix vaccine.

• Adults over the age of 50: Give 2 RZV injections spaced 2–6 months apart.
• Anyone over the age of 18 with a weakened immune system due to disease or treatment: Give 2 RZV injections 1-2 months apart.

Shingrix is a vaccine that is 97% effective in preventing herpes zoster in people over the age of 50. It is 68-91% effective in preventing herpes zoster in immunocompromised people aged 18 and older, up to 91.2% effective in preventing postherpetic neuralgia (PHN), and up to 89% effective in preventing herpes zoster up to 10 years after vaccination.

How long does herpes zoster last?

Typically, from the preeruptive phase to the chronic phase, herpes zoster can be cured within 3-5 weeks. However, individuals who have received antiviral medication within 72 hours of the onset of symptoms may recover from herpes zoster within 2 weeks.

Herpes Zoster, a Vaccine-Preventable Viral Infection

Anyone who has ever had chickenpox is at risk for herpes zoster, particularly as they get older, when their bodies weaken, or when their natural immunity declines. Herpes zoster causes excruciating pain, complications, and a negative impact on one's quality of life. Anyone experiencing herpes zoster symptoms should seek medical attention as soon as possible to receive appropriate treatment and recover from the disease as quickly as possible.

Herpes zoster can be prevented by getting vaccinated against the disease, in conjunction with getting enough rest, eating nutritious foods, and exercising regularly to keep the body strong and maintain natural immunity. Those over the age of 50, as well as those with weakened immune systems and those at risk for herpes zoster, are advised to get vaccinated against herpes zoster at available leading hospitals. Early herpes zoster vaccination can help prevent herpes zoster and its complications in the long run, as well as promote long-term good health.

FAQ

What are the first symptoms of herpes zoster/shingles?

The first symptoms of herpes zoster/shingles include itching, sharp pain, tingling, and a burning sensation within 1-3 days before the appearance of a red rash occurs in clusters lying along the sensory nerve ganglia before becoming clear fluid-filled blisters that gradually break off and subside within 10-15 days. In addition, some people may experience fever, chills, and headaches, while others may later experience pain along the nerves. 

What is the difference between herpes zoster and herpes simplex?

Both herpes zoster and herpes simplex are caused by infection with the human herpesvirus (HHV), which is the same virus in the herpesvirus family but differs in the type of virus and the nature of the lesions that appear on the skin. Herpes zoster is caused by the VZV virus, which causes clear, fluid-filled blisters along the nerve ganglia, whereas herpes simplex is caused by HSV-1 or HSV-2 virus infection, which causes clear, fluid-filled blisters on the mouth or genital areas.

Is herpes zoster/shingles contagious?

Herpes zoster/shingles can be transmitted from person to person who has never had chickenpox by inhaling virus droplets, coughing or sneezing, or direct contact with blisters or lymph from sores on the skin in those with herpes zoster infected with VZV. Therefore, herpes zoster patients should be separated from high-risk groups such as those with weakened immune systems, the elderly, young children, or pregnant women to reduce the risk of possible infection with the herpes zoster virus.

Which food should be avoided during herpes zoster?

Patients with herpes zoster should refrain from eating the following foods

• Patients with herpes zoster should refrain from eating the following foods
• High glycemic carbohydrate foods such as white flour, bakery goods, cakes, desserts, candies, and syrups.
• Foods high in saturated fat, such as fast food and fatty meat.
• Foods high in arginine such as red meat, poultry, dried beans, and chocolate.
• Highly processed foods, such as processed meats, butter, margarine, and ice cream
• Alcoholic beverages such as liquor, beer, and wine

Can herpes zosters go away on their own?

Herpes zoster may heal and go away on its own in those with strong immunity. However, if not treated properly by a doctor, untreated herpes zoster can lead to complications such as postherpetic neuralgia (PHN), neurological problems, etc.

What is the difference between herpes zoster and chickenpox?

Herpes zoster and chickenpox differ in the appearance of the rash. Herpes zoster rash typically appears in a long line and does not spread throughout the body as does chickenpox rash. Typically, the rash of herpes zoster appears only along the sensory ganglia, where the varicella-zoster virus is dormant. It starts out as a red rash and progresses to a swollen, clear, fluid-filled blister that eventually breaks off and scabs over. Herpes zoster rashes are commonly found in the waistline or ribcage, back, legs, and one side of the face, eyes, or neck. Herpes zoster symptoms are frequently more severe than chickenpox symptoms and can lead to complications if left untreated.