HERPES

ZOSTER
SHINGLES; ACUTE POSTERIOR
GANGLIONITIS

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 VARICELLA-ZOSTER VIRUS (VZV)

 Human alpha-herpesvirus
 Causes 2 major diseases
 Varicella (chicken pox): Primary VZV infection usually in childhood
 Zoster (shingles): reactivation at a later time of VZV

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 VARICELLA: CHICKEN POX

 Mild, highly contagious disease (mainly affecting children)

 Mode of transmission
 Airborne droplets, direct contact from varicella pts
 Vesicular fluid of Zoster pts can be source of Varicella in
susceptible children

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HISTORY OF
CHICKEN POX
The name chicken pox
existed because the
blisters that appeared
from varicella zoster
infection seemed like
the skin has been
PECKED by the chicken.

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 HERPES ZOSTER: SHINGLES
 From the Greek word for a ‘circingle’ or girdle, because it spreads in a
zone-like manner along the intercostal nerves around half the chest
 Following initial infection (varicella), VZV establishes permanent latent
infection in dorsal root and cranial nerva ganglia
 Years to decade later VZV reactivates and spread to skin through
peripheral nerves causing pain and unilateral vesicular rash in a
dermatomal distribution.

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DERMATOMAL
DISTRIBUTION

A band or region
of skin supplied
by a single
sensory nerve.

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 CLINICAL FEATURES
 Prodrome: headache, photophobia, malaise, fever, abnormal skin sensations
and pain
 Rash:
 Unilateral, involving 1-3 adjacent dermatomes
 Thoracic, cervical, ophthalmic involvement most common
 Initially erythematous, maculopapular
 Vesicles form over several days, then crust over
 Full resolution in 2-4 weeks
 Occasionally, rash never develops (zoster sine herpete)

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HERPES
ZOSTER
INVOLVING
A NERVE
SEGMENT
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 COMPLICATIONS
 Postherpetic Neuralgia (PHN)
 Herpes Zoster Ophthalmicus
 Neurologic complications
 VZV viremia
 Dermatologic complications

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 VZV TRANSMISSION FROM ZOSTER
 VZV can be transmitted from persons with zoster to persons with no
history of varicella disease or vaccine and cause varicella
 Risk of VZV transmission from zoster is much lower than from varicella
 Transmission is mainly through direct contact with zoster lesions, although
airborne transmission has been reported in healthcare settings
 Localized zoster is only contagious after the rash erupts and until the
lesions crust
 Transmission from localized zoster can be decreased by covering the lesions

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 RISK FACTORS
 Increasing age
 Immunosuppression
 Bone marrow and solid organ
transplantation
 Patients with hematological
malignancies and solid tumors
 HIV
 Immunosuppressive medications
 Gender: increased risk in females
 Race: Risk in black less than half
that in whites
 Trauma or surgery in affected
dermatome
 Early varicella (in utero, infancy);
increased risk of pediatric zoster
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 DIAGNOSIS
 HZ: suspected in patients with the characteristic rash and sometimes in patients with
typical pain in a dermatomal distribution.
 Diagnosis is usually based on the virtually pathognomonic rash. If the diagnosis is
equivocal, detecting multinucleate giant cells with a Tzanck test can confirm infection,
but the Tzanck test is positive with herpes zoster or herpes simplex.
 Herpes simplex virus (HSV) may cause nearly identical lesions,
 but unlike herpes zoster, HSV tends to recur and is not dermatomal.
 Viruses can be differentiated by culture. Antigen detection from a biopsy sample can
be useful.

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TZANCK TEST
- mainly used in an acute
setting to rapidly detect a
herpes infection
- or to distinguish
Stevens- Johnson
syndrome / toxic
epidermal necrolysis
(SJS/TEN) from
staphylococcal scalded
skin syndrome.
- However, it can be used
to diagnose a variety
cutaneous infections
and blistering diseases.

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 MEDICAL MANAGEMENT
 Oral antiviral agents
 acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir)
are given within 24 hours of the initial eruption.

 IV acyclovir may be indicated in patients who are

immunocompromised (Janniger et al., 2016).

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 MEDICAL MANAGEMENT

 Goals of herpes zoster management:

 to relieve the pain
 reduce or avoid complications, which include infection, scarring, and
PHN and eye complications.

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 MEDICAL MANAGEMENT
 Analgesic agents: Pain
 adequate pain control during the acute phase helps prevent persistent
pain patterns.
 Systemic corticosteroids: may be prescribed to reduce the
incidence and duration of PHN.
 Healing usually occurs more quickly in those who have been
treated with corticosteroids.

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 MEDICAL MANAGEMENT

 Triamcinolone (Aristocort, Kenalog): SQ under painful areas is

effective as an anti-inflammatory agent.
 Patients with HZO require emergent treatment by an
ophthalmologist (Janniger et al., 2016).

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 MEDICAL MANAGEMENT
 People who have been exposed to varicella by primary infection
or by vaccination are not at risk for infection with VZV after
exposure to patients with herpes zoster.
 Since 1995, the widespread vaccination of children with the VZV
vaccine (Varivax) has led to a marked reduction in the incidence
of primary varicella, which presumably will result in marked
decrease in 4779 rates of herpes zoster eventually.

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 MEDICAL MANAGEMENT
 The VZV vaccine (Zostavax) was developed to boost VZV
cellular immunity in adults older than 50 years.
 This vaccination is now recommended as part of prevention
strategies in adults who are not immunocompromised,
including those with a history of herpes zoster, because it
may recur (Janniger et al., 2016

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 NURSING MANAGEMENT

 The patient and family members are instructed about the importance
of taking antiviral agents as prescribed and in keeping follow-up
appointments with the primary provider.
 The nurse assesses the patient’s discomfort and response to
medication and collaborates with the primary provider to make
necessary adjustments to the treatment regimen.

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 NURSING MANAGEMENT
 The patient is educated about how to apply dressings or medication to the
lesions and to follow proper hand hygiene techniques to avoid spreading the
virus.
 Diversionary activities and relaxation techniques are encouraged to ensure
restful sleep and to alleviate discomfort.
 A caregiver may be required to assist with dressings, particularly if the
patient is an older adult and unable to apply them. Food preparation for
patients who cannot care for themselves or prepare nourishing meals must
be arranged.

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 PREVENTION

 Prevention involves preventing primary infection (chickenpox) by giving

the varicella vaccine to children and susceptible adults.
 Adults ≥ 60 yr should have a single dose of zoster vaccine (a more
potent
preparation of varicella vaccine) whether they have had herpes
zoster or not. This vaccine has been shown to decrease the
incidence of zoster.

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 THANK YOU!
BY: HANNAH CLARISSE M. IGNI
(STUDENT, BSN 3B-G1)

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