Shingles: Vaccination and Treatment Guidelines for Herpes Zoster

Dr. BCK Patel MD, FRCS

For physicians and patients

How to manage herpes zoster and its complications, with considerations for COVID-19 and the COVID vaccine. Christine Kanownik

• There may be a link between the COVID-19 vaccine and the reactivation of HZ, however, a COVID-19 infection itself puts the patient in much more danger.
• Timely vaccinations against COVID-19 are recommended in all patients, and HZ vaccination is recommended for all patients 50 and older.
• It is important to be aware of a patient’s risk of HZ reactivation before they receive any vaccine.

Shingles is the common name for herpes zoster (HZ), a viral disease typically occurring in older adults. HZ is caused by the varicella-zoster virus (VZV), the same virus responsible for chickenpox.1 VZV lies dormant in an individual’s nerve tissue, usually for several decades, until the event of its reactivation.2

Up to 90% of adults carry the HZ virus after the original chickenpox infection.3 Common risk factors for reactivation revolve around the weakening of the immune system, and include:1

• aging
• stress
• immunosuppression
• other infections, such as COVID-19

VZV is extremely common, spreading rapidly among populations, regardless of season or geography. It is considered one of the most contagious human diseases, transmitted through respiratory droplets.1

However, Bhupendra C. Patel, MD, with University of Utah Health, explained, “It is not possible to ‘catch’ shingles from someone who has the rash. But if you have never had chickenpox or gotten the chickenpox vaccine, it is possible to ‘catch’ the virus and then get sick with chickenpox.”

Despite its low risk of mortality, there is a significant cost associated with HZ, both in terms of medical treatment and the painful long-term side effects.3
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Since most people will end up with a VZV infection, preventing the reactivation is key, and medical professionals should be prepared to advise patients on HZ treatment and prevention.
​

The Risk of Reactivation of Herpes Zoster

While the biggest risk of reactivation of HZ is advanced age, some people are more at risk than others. Individuals with a lowered immune system, taking a new medication, or going through an especially emotionally stressful event are at increased risk.2
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There is also a long list of other conditions that increase a person’s chances of experiencing HZ. These include:

• diabetes
• solid cancers1
• COPD
• asthma3
• hypertension
• atrial fibrillation4

HZ often occurs shortly after another infection or illness. Individuals at higher risk should be monitored for up to 2 weeks after a related event.
​

A complicated diagnosis

The most common symptoms are the painful cutaneous lesions on the skin. These generally present on only one half of the person's body. Rashes develop, become inflamed, burst, and dry out within a few days and reoccur in up to three waves.1

Dr. Patel explains that before the rash emerges, the patient “might feel itching, burning, pain, or tingling. Some people get a fever, feel sick, or get a headache.”
Other symptoms include:

• malaise
• headache
• sensitivity to light1

​However, there are variables in HZ’s clinical presentation, so not all cases will be immediately apparent. A polymerase chain reaction (PCR) test can be done to confirm cases where no lesions are visible.1 PCR tests are rapid and easy to perform using blood or a sample from the individual's skin with only a slight risk of a false positive.2

Treating patients with Herpes Zoster

HZ is treated with antiviral medications, which are more effective the earlier they are administered. The most common are acyclovir, valacyclovir, and famciclovir, typically prescribed in a five-day course. A topical antibiotic cream is also recommended to prevent a second bacterial infection.2

Pain management is essential. An oral painkiller such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen can be prescribed. However, opioid painkillers and tramadol have been proven much more effective. Additional treatment options include, nerve blockers and topical capsaicin.5
​
Individuals who suspect they have HZ should try to remain isolated for 10 to 21 days, depending on the severity of the illness. They are contagious from 4 days before the lesions appear until after they have dissipated and dried up.1

Long-term complications

Chronic cases of HZ also exist, with pain and shock-like sensations lasting more than 4 weeks and up to several months.

Postherpetic neuralgia (PHN), a chronic pain disease, is one of the most common lingering complications.1 PHN occurs in up to 10% of HZ patients.3 Tricyclic antidepressants, selective serotonin reuptake inhibitors, gabapentin, or pregabalin are the first line of treatment.1

HZ ophthalmicus is a very serious form of HZ that involves the optic nerve and can lead to permanent vision loss. If suspected, advise the patient to seek emergency ophthalmological care immediately.1
​
While HZ is very rarely linked with death, HZ vasculitis, for instance, is associated with morbidity, and renal and gastrointestinal problems.1
Other complications include:

• scarring
• bacterial infections
• nerve palsy or paralysis
• hepatitis
• encephalitis

​Updated Vaccination Recommendations

The CDC recommends Shingrix (a recombinant zoster vaccine or RZV) for all adults over the age of 50. Other immunocompromised patients or those directed to by their doctor should also receive Shingrix. It is administered in two shots given between 2 to 6 months apart and has been shown to be 90% effective in preventing HZ reactivation.6
Patients should receive this new vaccine even if they have been administered prior doses of Zostavax in the past. Zostavax’s effectiveness dramatically decreases as the patient ages, dropping to efficacy rates as low as 18%.6 As of November 2020, Zostavax is no longer available in the US.7
​
It is not necessary to screen patients for prior incidences of varicella in the past, since Shingrix is an inactive vaccine and safe for all patients.6

​COVID-19 and Herpes Zoster

Matters have become more complicated due to COVID-19 and its vaccines. Most vaccines cause a temporary lowering in the patient’s immune system, potentially triggering the reactivation of HZ, and COVID-19 appears to be no exception.4

Since the COVID-19 vaccine is essential to control the spread of the disease and VZV is so common, researchers have tried to clarify the relationship between them. Two recent studies took a cumulative look at previously published data to find causation.4,5
Both studies revealed that there is a slight increase in HZ reactivation in patients within 18 days of receiving the COVID-19 vaccine. However, the cases were rarely severe and sometimes the causation was barely statistically significant.5 Individuals with COVID-19 also had an increased risk.8

Staying up-to-date on vaccinations is the best way to prevent life-threatening illness.8 Individuals with a history of receiving HZ and other common vaccines appear to be hospitalized less frequently for COVID-19.9
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People with a high risk of HZ reactivation should be monitored closely. A follow-up visit is required within 2 to 3 weeks from receiving any vaccine, including the COVID-19 vaccine.5 Clinical awareness of signs and symptoms of HZ and identifying at-risk patients is important to prevent and curtail any serious complications.4

References

1. Patil A, Goldust M, Wollina U. Herpes zoster: A review of clinical manifestations and management. Viruses. 2022;14(2):192. Published 2022 Jan 19. doi:10.3390/v14020192
2. Nair PA, Patel BC. Herpes Zoster. In: StatPearls. Treasure Island (FL): StatPearls Publishing; April 3, 2023.
3. Menéndez R, González-Jiménez P, Méndez R. Herpes zoster virus: Should patients with chronic respiratory diseases be vaccinated? [published online ahead of print, 2023 Jul 14]. Arch Bronconeumol. 2023;S0300-2896(23)00227-2. doi:10.1016/j.arbres.2023.07.012
4. Shafiee A, Amini MJ, Arabzadeh Bahri R, et al. Herpesviruses reactivation following COVID-19 vaccination: a systematic review and meta-analysis. Eur J Med Res. 2023;28(1):278. Published 2023 Aug 10. doi:10.1186/s40001-023-01238-9
5. Jeon YH. Herpes Zoster and Postherpetic Neuralgia: Practical Consideration for Prevention and Treatment. Korean J Pain. 2015;28(3):177-184. doi:10.3344/kjp.2015.28.3.177
6. Centers for Disease Control and Prevention. Shingles (Herpes Zoster) Vaccination Information for Healthcare Providers. Updated January 24, 2022. Accessed October 19, 2023.
7. Centers for Disease Control and Prevention. Shingles Zostavax vaccination. October 5, 2020. Accessed October 24, 2023.
8. Yoon JG, Kim YE, Choi MJ, et al. Herpes zoster reactivation after mRNA and adenovirus-vectored coronavirus disease 2019 vaccination: Analysis of National Health Insurance Database [published online ahead of print, 2023 Aug 7]. J Infect Dis. 2023;jiad297. doi:10.1093/infdis/jiad297
9. Chen YC, Ho CH, Liu TH, et al. Long-term risk of herpes zoster following COVID-19: A retrospective cohort study of 2 442 686 patients [published correction appears in J Med Virol. 2023 Jul;95(7):e28944]. J Med Virol. 2023;95(4):e28745. doi:10.1002/jmv.28745
10. Salas J, Morley JE, Hoft DF, Scherrer JF. Lower risk for COVID-19 hospitalization among patients in the United States with past vaccinations for herpes zoster and tetanus, diphtheria and pertussis. Prev Med Rep. 2023;35:102302. Published 2023 Jun 25. doi:10.1016/j.pmedr.2023.102302