Prevention and Management of Herpes Zoster: A Case of Too Little Too Late

Authors:

Pamela Willson, PhD, APRN, FNP-BC, CNE, FAANP*

Kim Brown, BSN, RN

Peter Formusoh, BSN, RN

Mary Gonzales, BSN, RN

Janet MacTurk, BSN, RN

April Rodriquez, BSN, RN

Mikala Schooler, BSN, RN

Susan K. Lee, PhD, RN, CNE**

South University – Austin, Family Nurse Practitioner Program, Round Rock, Texas

*Texas State University, Clinical Professor, Round Rock, Texas

**Texas Board of Nursing, Education Consultant, Austin, Texas

 

Corresponding Author:  Pamela Willson

Email:  pcwillson@mac.com

A new, more effective Herpes Zoster (HZ) vaccine has been approved for use with patient populations 50 years of age and older.  This report illuminates the current guidelines, alternative medicine management strategies, and includes a HZ patient education tool.

Keywords: Herpes Zoster, vaccine, comfort, management.

Case Study. A 55-year-old female requested a “shingles” vaccination. To adhere to national guidelines, the patient request was postponed until age 60 (Hales, Harpaz, Orteg-Sanchez, & Bialek, 2014). Unfortunately, the patient experienced an episode of Herpes Zoster (HZ) rash that involved the trigeminal nerve’s ophthalmic branch and post-herpetic neuralgia (PHN) at 59 years of age.  At 6-months post outbreak, the PHN pain was rated as subsiding and at level 2 out of 10 on the pain scale, with 1 being little pain and 10 being severe pain.  The patient stated that the PHN was not interfering in her daily functioning or quality of life.  The patient’s initial management included antivirals and referral to an ophthalmologist due to the potential for corneal involvement.  What vaccination protocol and patient teaching should be implemented for this patient?

Herpes Zoster (HZ) is triggered by the reactivation of Varicella Zoster Virus (VZV) or “chickenpox”.  Nearly all Americans over 40 years of age have had chickenpox; the Advisory Immunization Practices (ACIP) considers all persons born in the United States (U. S.) prior to 1980 as immune to VZV [Center for Disease Control and Prevention (CDC), 2016a].  New cases of HZ are estimated to reach 1.2 million people annually, with 20% involving HZ ophthalmicus (HZO) (Suaya et al., 2014). Overall, annual HZ incidence rates across all ages are 4.47 per 1000 person-years (CI: 4.44-4.50).  Rates increase with age—from 50 years of age, HZ occurs 8.46 per 1000 person-years (CI: 8.39-8.52) while for 60 years of age and older, it is 10.46 per 1000 person-years (CI: 10.35-10.56). Women have higher HZ incidence rates with 5.25 per 1000 person-years versus 3.66 for men (Johnson, Palmer, Gatwood, Lenhart, Kawai, & Acosta, 2015).  The age of HZ onset is decreasing from the over 60 years of age group to those under 60 years (Chen, et al., 2014). In a Centers for Disease Control (CDC) study by Hernandez and colleagues (2011), the mean age of HZ onset was found to be 52 years.

Updated Recommendations for Herpes Zoster Prevention

Previous guidelines recommended initiating HZ vaccination based on incidence rates and vaccine efficacy. The Food and Drug Administration (FDA) approved the 1-dose, attenuated live vaccine, Zoster Vaccine Live (ZVL) [ZVL Merick (Zostavax)] for people over 50 years of age. However, considering vaccination cost effectiveness data, the CDC’s (2016a) recommendations were to vaccinate people 60 years or older to prevent and decrease complications of HZ (Hales, Harpaz, Orteg-Sanchez, & Bialek, 2014).

The U.S. Food and Drug Administration (FDA) has now approved  a new 2-dose adjuvant subunit, HZ/su vaccine from GlaxoSmithKline, Shingrix, (2017) for the prevention of HZ and PHN.  The ACIP recommends HZ/su vaccination for healthy adults 50 years and older and for those adults previously immunized with the live attenuated 1-dose ZVL (CDC, 2016).  Additionally, the ACIP reported that HZ/su is the preferred vaccine for the prevention of shingles and its morbidity.  Table 1 highlights major differences between the two vaccines.

Table 1. Comparison of Herpes Zoster Vaccines

 

Zostavax – Zoster Live Vaccine (ZLV) by Merck

 

Herpes Zoster Subunit (HZ/su) vaccine by GlaxoSmithKline

FDA licensed in 2006 FDA licensed in 2017
Recommended for ≥ 60 years Recommended for ≥ 50 years
Live attenuated vaccine containing all viral strains of shingles virus Non-live recombinant subunit vaccine and contains a single strain of shingles
Cannot be given to immune-compromised patients Can be given to immune-compromised patients
0.65ml given subcutaneously x1 dose 0.5ml given intramuscularly x2 doses

2-4 months apart

Overall efficacy is:

67.5% in 1 year post-vaccination

31% in 7-8 years post-vaccination

Overall efficacy is 97.2%
Efficacy decreases with increased age

 

60-69 year-old patients 

Placebo: Of 10,356 patients, 334 still suffered shingles

Zostavax: Of 10,370 patients, 122 still suffered shingles

 

70-79 year-old patients

Placebo: Of 7.559 patients, 261 still suffered shingles

Zostavax: Of 7,621 patients, 156 still suffered shingles

 

80+ year patients

Placebo: Of 19,247 patients, 642 suffered from shingles

Zostavax: Of 19,254 patients, 315 suffered from shingles

 

Overall in subjects 60+ years-old: 51% of the cases had a significant reduction of shingles

Efficacy does not decrease with increased age

 

50-59 year-old patients

Placebo: Of 7,415 patients, 87 suffered from shingles

HZ/su: Of 7,344 patients, 3 suffered from shingles

 

60-69 year-old patients

Placebo: Of 7,415 patients, 75 suffered from shingles

HZ/su: Of 7,344 patients, 2 suffered from shingles

 

70-79 year-old patients

Placebo: Of 7,415 patients, 48 suffered from shingles

HZ/su: Of 7,344 patients, 1 suffered from shingles

 

Overall in subjects 50+ years-old: 97.2% of the cases had a significant reduction of shingles

Cost estimate is $ 223* Cost estimate is $280*
Covered by Medicare Part D and some insurance companies Unknown coverage

 

*Note:  Branswell, H. (2017).

Clinical Decisions

The clinical questions that may arise for the case study (see Table 2) are:

  • What HZ vaccine schedule is best for this patient?
  • Is it too early or is it too late for vaccination?
  • What follow-up/teaching is needed?

Table 2. Herpes Zoster Patient Presentation, Clinical Decisions, and Management.

 

Patient Presentation

 

Clinical Decisions

 

Management Recommended

59-year-old female presents after 2 days prodromal pain of the scalp that progressed to a painful unilateral grouped macular-papular-vesicular rash following the first ophthalmic branch of the trigeminal nerve.

 

Hutchinson’s sign positive for one lesion on right side of nose.

 

Presumptive diagnosis: Herpes zoster ophthalmicus (HZO).

·         History of chickenpox age 8 years

·         HZ ophthalmicus occurs in 10-20% of episodes and can cause keratitis, scarring, and vision loss.

·         Antivirals started within 72 hours of rash onset decrease duration and severity of disease

·         Corticosteroids do NOT reduce post-herpetic neuralgia; minimally reduce severity of disease

·         Opioid pain management may be needed

·         HZ/su occurrence may boost immunity

·         Considering additional HZ/su vaccination post-episode is recommended

Acute management

·         Antivirals started within 72 hours of rash onset

·         Corticosteroids

·         Pain management

·         Self-care strategies*

·         Referral to ophthalmologist

·         Follow-up 7-10 days for post-herpetic neuralgia

 

Patient will return to clinic for annual visit. ·         HZ/su vaccine reduces outbreak and post-herpetic neuralgia pain ·         Follow-up with re-vaccination of HZ/su 2-dose vaccine.

·         HZ/su and influenza vaccine may be given simultaneously

 

*Note: See Patient Self-Management Handout

Medical Management

The goals of HZ treatment are symptomatic treatment of lesions and to prevent secondary infection.  Initiation of antiviral therapy within 72 hours of rash onset is an essential part of HZ management.  Rash severity and pain are reduced with prompt medical intervention. All the listed medications (Table 3) are effective, but drug regimen should be based on patient needs and cost.  The use of oral corticosteroids is controversial and should be used with caution on a case-by-case basis.  Studies have shown there may be an increased risk of dissemination with steroid use, however, modest reduction of duration and severity of pain is found in some patients (Buttaro, 2013).

Table 3. Medication Regimen for Herpes Zoster Management

Medication Dosage Purpose
Acyclovir* 800 mg PO every 4 hours while awake for 7-10 days Anti-viral
Famciclovir* 500 to 750 mg PO TID for 7 days Anti-viral
Valacyclovir* 1,000 mg PO TID for 7 days Anti-viral
Gabapentin 100-600 mg mg TID Long-term pain control for post-herpetic neuralgia
Amitriptyline 25 mg PO nightly Tricyclic antidepressant for post-herpetic neuralgia
Sulfadiazine topical cream 1% cream apply Q12 hours or daily to area For secondary bacterial infection of skin

 

*Note: Antiviral therapy should be initiated within 72 hours of rash onset to reduce duration and severity of rash and pain.

Self-Care Strategies

HZ is often an uncomfortable, itchy, and painful disorder.  Patient self-care strategies that provide symptom relief are available and provide effective comfort measures.  Soothing skin soaks in a tepid or warm bath with baking soda, uncooked oatmeal, or finely ground or colloidal oatmeal (Mayo Clinic, 2017) may be suggested.  Calamine lotion applied to the lesions (Cash & Glass, 2014) provides an antipruritic and mild antiseptic effect.  A printable patient educational tool is provided for use in counseling patients. (See patient self-care tool).

Nutrition, vitamins, and minerals may reduce the inflammatory response of the HZ outbreak.   Good sources of these are fish (salmon, tuna, trout, mackerel), which are high in Omega 3 fatty acids.  Foods high in antioxidants are: leafy green vegetables, avocados, beets, and berries.  Along with antioxidants, these foods also include beneficial vitamins and minerals, such as: vitamin E, carotene, lycopene, and flavonoids.  Lentils, beans, nuts, seeds, whole grains, green tea, and spices, such as ginger and turmeric, aid in reducing inflammatory response (Mayo Clinic, 2016).

Conclusion

With the advancement of HZ vaccine development, providers are able to offer effective HZ primary prevention to a larger number of patients.  While it may be “too late” for some patients’ HZ outbreak, it does not need to be “too little” when providing care and comfort measures.

PATIENT EDUCATION MATERIAL

These medications can be prepared at home without a prescription for symptom relief:

  • Warm bath with 1 cup ground raw oatmeal or baking soda
  • Calamine lotion can be applied directly to affected areas
  • Burrow’s solution compresses for 30-60 minutes on affected areas. This solution can be found at your local drugstore
  • Vitamin B12 1,000-2,000 mcg daily to reduce itching
  • Foods high in Omega 3 fatty acids, such as fish and green leafy vegetables, can reduce inflammation
  • Acetaminophen, as directed, for discomfort or fever

Prescription Medications

  • Antiviral medication-

 famciclovir      mg by mouth every 8 hours for 7 days

 valacyclovir      mg by mouth every 8 hours for 7 days

 acyclovir      mg by mouth every 4 hours while awake for 7-10 days

  •  Gabapentin mg by mouth       times daily for       days may be prescribed to manage postherpetic neuralgia.
  • Prescription creams may be needed if rash becomes infected
  • ________________________________________                                                

Follow Up

  • The shingles vaccine can be administered after the rash has completely disappeared to protect from future flare-ups.
  • You received SHINGRIX first dose on ________________ .
  • Return to clinic in 2-6 months for second dose.
  • Call for an appointment

Did you know…

Shingles affects millions of people yearly.

Any person who was infected with chicken pox is able to have shingles. The virus can remain dormant for decades.

Shingles typically affects older people and those with weakened immune systems- such as HIV and cancer patients.

Things to remember:

  • The rash may last up to 3 weeks.
  • Symptoms (such as discomfort) may last longer than 3 weeks.
  • The goal of shingles therapy is to relieve discomfort.
  • Avoid touching the rash. If you do, wash your hands.
  • Do not share clothing or towels.
  • While the blisters are oozing, you are contagious. Tell anyone who has contact with you that you have shingles, especially pregnant women and people with weak immune systems.

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References

Branswell, H. (2017, October 25). New shingles vaccine endorsed over competitor by expert panel, a boost for GSK. STAT News. Retrieved from https://www.statnews.com/2017/10/25/shingles-vaccine-acip/

Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary Care. (4th ed.) San Louis: Mosby Publishing Company.

Cash, J., & Glass, C. (2014). Family practice guidelines (3rd ed.). New York, NY: Springer Publishing Company.

Center for Disease Control and Prevention (CDC). (2016a). Shingles/Herpes Zoster vaccine recommendations. Retrieved from https://www.cdc.gov/vaccines/vpd/shingles/hcp/recommendations.html

Chen, M., Wei, H., Su, T.,….Bai, Y. M. (2014). Risk of depressive disorder among patients with herpes zoster: A nationwide population-based prospective study. Psychosomatic Medicine 76, p. 285-91.

Chan, A., Conrady, C., Ding, K., Dvorak, J. D.., & Stone, D. U. (2015). Factors associated with age of onset of herpes zoster ophthalmicus. Cornea, 34, p. 535-540.

GlaxoSmithKline. (2017). Shingrix. Prescribing Information. Retrieved from https://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Shingrix/pdf/SHINGRIX.PDF

Hales, C., Harpaz, R., Orteg-Sanchez, I., & Bialek, S. (2014). Update on recommendations for use of herpes zoster vaccine. Morbidity and Mortality Weekly Report (MMWR). 63(33), p. 729-731.

Hernandez, P., Javed, S., Mendoza, N., Lapolla, W., Hicks, L. D., & Tyring, S. K. (2011). Family history and herpes zoster risk in the era of shingles vaccination. Journal of Clinical Virology, 52, p. 344-348.

Johnson, B., Palmer, L., Gatwood, J., Lenhart, G., Kawai, K., & Acosta, C. (2015). Annual incidence rates of herpes zoster among an immunocompetent population in the United States. BMC Infectious Diseases15, p. 502. doi.org/10.1186/s12879-015-1262-8

Mayo Clinic. (2016). Nutrition and pain. Retrieved from http://www.mayoclinic.org/nutrition-and-pain/art-20208638

Mayo Clinic. (2017). Chickenpox – Self-management. Retrieved from http://www.mayoclinic.org/diseases-conditions/chickenpox/manage/ptc-20191407

Merck. (2017, May). Zostavax Zoster Vaccine Live. Retrieved from https://www.merckvaccines.com/Products/Zostavax

Suaya, J. A., Chen, S., Li, Q., Burstin, S. J., & Myron, J. L. (2014). Incidence of herpes zoster and persistent post-zoster pain in adults with or without diabetes in the United States. Open Forum Infectious Disease, 1, p. 49.

 

 

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