Introduction
Shingles, also called herpes zoster, is an infectious disease caused by the varicella-zoster virus. Herpes zoster is the same virus that causes chickenpox. It occurs only in those individuals who have previously had chickenpox. When chickenpox is gone, the virus remains inactive in the body. This means that the person may not feel symptoms, but the virus still exists in the body. When the varicella-zoster virus becomes active again, it causes herpes zoster. Since the virus penetrating the sensitive nerve endings is embedded in the genetic apparatus of nerve cells. After that, a complete cure for the human from the virus is impossible. Shingles go into a latent (inactive) state in people who have had chickenpox.
Overview
Shingle is a viral infection that arouses a rash that causes pain and discomfort. Although the site of herpes zoster can be anywhere on the body, it usually appears as a single band of blisters around one part of the torso. Shingles are not life-threatening, but the virus may cause severe pain in the affected area (Huether & McCane, 2017). Vaccines only reduce the risk of shingles but do not guarantee complete protection. Timely treatment reduces the likelihood of many complications and infections in the body.
The virus can persist in nerve fibers for many years after chickenpox without causing any damage to human health. Activation of the virus usually occurs with a sharp weakening of local and general immunity. As a result, the patient develops rashes on those areas of the skin for which the affected nerve is responsible. Thus, due to the affected nerve, a person develops pain syndrome. A one-sided lesion characterizes shingles.
Disease process
The clinical picture of Herpes zoster consists of skin manifestations and neurological disorders. Along with this, most patients have general infectious symptoms: fever, an increase in hormonal lymph nodes, and a change (in the form of lymphocytosis and monocytosis) of the cerebrospinal fluid. Usually, erythematous spots of a round or irregular shape, raised, or swollen, are found on the skin. A specific shagreen appearance of the skin (tiny bumps) is felt when held with a finger. Then, groups of bubbles appear sequentially in these areas, often of different sizes. Vesicles can merge, but they are most often located in isolation, close to one another – the vesicular form of Herpes zoster. Sometimes they look like a tiny bubbles surrounded on the periphery with a red rim. Since the rash coincides, the rash elements are at the same stage in their development. However, the rash may appear in separate clusters within 1 to 2 weeks.
In typical cases, the bubbles are transparent, quickly turning cloudy and drying up into crusts. A deviation from the described type is the milder abortive form of the Herpes zoster. With this form, papules also develop in the foci of hyperemia, which, however, do not transform into vesicles; this is how this form differs from vesicular. Another variety is the hemorrhagic form of Herpes zoster, in which the cysts have a bloody content. The process extends deep into the dermis, and the crusts become dark brown. In severe cases, the bottom of the vesicles is necrotic – the gangrenous form of herpes zoster, after which cicatricial changes remain.
Causes
Herpes zoster can only appear in people who have previously been infected with the varicella-zoster virus, more often as a result of natural infection, and who have had chickenpox or, less commonly, as a result of the chickenpox vaccine. Age is one of the critical factors in the development of herpes zoster. The risk of herpes zoster increases rapidly after age 50. Similarly, with age, the risk of developing postherpetic neuralgia increases sharply. In this regard, elderly patients with herpes zoster may require hospitalization to treat complications of the disease, including neuralgia.
Risk factors for developing shingles can include diseases that reduce cellular immunity, such as disseminated tumors, including leukemia and lymphomas, human immunodeficiency virus (HIV) infection, and immunosuppressive therapy (glucocorticosteroids, drugs prescribed after organ transplantation). Patients after bone marrow transplantation and parenchymal organs (kidneys, heart, liver, and lungs) taking immunosuppressive therapy, including glucocorticosteroids, are especially prone to a severe course of herpes zoster. A risk factor is the treatment of cancer with radiotherapy or chemotherapy.
Symptoms
A few days before the onset of the disease, the patient begins to worry about weakness, headache, fatigue, chilling, and body temperature rises to subfebrile numbers. Sometimes dyspeptic disorders are added to the above symptoms. In parallel, discomfort occurs and then burning, itching, and pain in the area of future rashes – along the nerve trunks. The period of pronounced clinical manifestations is characterized by an acute onset with increased body temperature to febrile figures and other signs of general intoxication. At the same time, characteristic rashes appear in the area of the affected nerve projection.
First, pink spots appear 2–5 mm in diameter; after 1–2 days, against the background of redness, groups of bubbles with colorless contents are formed. Rarely “do people report that their skin tingles or feels numb” (Nazarko, 2019, p. 21). Usually, skin manifestations are located unilaterally; more often, they are localized on the face along the branches of the trigeminal nerve in the intercostal space. Some cases are located along the upper and lower extremities’ nerves and in the genital area. The rash is usually accompanied by an increase in regional lymph nodes and their soreness.
A few days after the appearance of the rash, the background on which they are located turns pale, and the bubbles dry up, crusts form in their place, which disappear after 3-4 weeks. Symptoms of intoxication disappear with a decrease in body temperature. The above clinic is usual for a typical form of the disease, but sometimes the rash can be different. Abortive condition – after forming an abscess, the rash sharply regresses, bypassing the vesicular stage. Bullous form – vesicles merge, forming large bubbles with hemorrhagic contents. Generalized form – after the appearance of local rashes, new cysts spread over the entire surface of the skin and mucous membranes (a similar structure is often found in immunodeficiencies).
Risk factors
As a weakened immune system is a common trigger for latent varicella-zoster virus activation, many factors associated with a weakened immunity can increase the risk of developing herpes zoster. Shingles can develop in anyone who has ever had chickenpox. Many people in the United States had chickenpox before the usual childhood vaccination, which now protects against chickenpox. Factors that can increase the risk of appearing and developing shingles include: being over 50 years old.
Shingles are most common in people of old age, and the risk increases with age. Moreover, having certain medical conditions is also an enormous risk. Some diseases that weaken the immune system can increase the risk of developing shingles. In some cases, chemotherapy or radiation can lower your resistance to disease and cause shingles (Nazarko, L., 2019). The shingles can start from taking certain medications. Medications designed to prevent organ transplant rejection can increase the risk of shingles, as can long-term use of steroids such as prednisone. Many of these risk factors can be applied to both young people and older children.
Contagiousness
A person with shingles can transmit the chickenpox virus to anyone who is not immune to chickenpox. Generally, the virus occurs through direct contact with open shingles and sores. Herpes zoster can spread by touching an infected person’s blisters. Disseminated herpes zoster can spread through contact with an infected person’s droplets of liquid from the nose and throat. Droplets containing the virus of herpes zoster are released into the air when an infected person coughs or sneezes. They are easy to breathe in and get infected; after infection, the person will develop chickenpox, but not shingles. Chickenpox can be dangerous for some people. Until shingles blisters go away, a person is infectious and should avoid physical contact with anyone who has not yet had chickenpox or chickenpox vaccine, especially people with weakened immune systems, pregnant women, and newborns.
Treatment
Treatment should be started within 72 hours before crusting on the lesions for better recovery. Treatment with antiviral drugs helps with rash healing, reduces viral shedding, and may or may not prevent PHN. During phase 1, “aspirin and nonsteroidal anti-inflammatories are of limited value, except with mild pain” (Fritz et al., 2020, p. 282). First-line treatment with gabapentin and pregabalin has moderate-quality evidence for moderate to severe pain, but people with renal failure should use this treatment with caution. Amitriptyline has some efficacy and may be used if first-line drugs are not tolerated; however, it can confuse older people. In addition, topical application of capsaicin and lidocaine for mild to moderate local pain may be helpful.
The most commonly used medication for herpes zoster is acyclovir, famciclovir, and valacyclovir. They prevent the virus from multiplying and limit the attack of shingles. Antiviral treatment reduces rashes, pain, and complications such as postherpetic neuralgia (PHN). Treatment should be started immediately because antiviral drugs are most effective when given within 72 hours of the onset of the rash. If there are delays in diagnosis, antiviral drugs should be prescribed if the person is in severe pain or the inflammation continues progressing, as the person will still benefit from treatment.
Standards of practice
Early prescription of antiviral drugs is necessary in treating Herpes zoster of various localization and severity. It is known that the virus contains proteins that form its envelope and carry an enzymatic function and nucleic acid – the carrier of its genetic properties. Penetrating cells, viruses are freed from the protein protective envelope. It was shown that it is possible to inhibit their reproduction with the help of nucleases. These enzymes hydrolyze viral nucleic acids without damaging the cell’s nucleic acids.
In recent years, antiviral chemotherapy drugs from synthetic acyclic nucleosides have been used to treat Herpes zoster. Acyclovir is currently the most well-studied. The mechanism of acyclovir actions is based on the interaction of synthetic nucleosides with replication enzymes of herpesviruses (Engler et al., 2017, p. 134). Herpesvirus thymidine kinase binds to acyclovir thousands of times faster than cellular, so the drug accumulates almost only in infected cells. This explains the complete absence of cytotoxic, teratogenic, and mutagenic properties in acyclovir.
Clinical Guidelines
The diagnosis is established based on a characteristic clinical picture; if necessary, it is confirmed by detecting the Varicella-Zoster virus in the clinical material under study. If needed to clarify and verify the diagnosis, using test systems is recommended to use molecular biological methods to identify the Varicella-Zoster virus contained in the material from herpes zoster lesions on the skin and mucous membranes.
It can be a physical examination of vesicular fluid, scrapings from rashes on the virus, or determination of the DNA of the varicella-zoster virus in the vesicular fluid, or scrapings from rashes by the PCR method. To test blood from a vein for the virus, a healthcare professional takes a blood sample from a vein. After this, a user collects a small amount of blood in a test tube or vial. The doctor will gently press a cotton swab on the blister to take a fluid sample for analysis.
Also, in connection with the current epidemiological situation, whether it is possible to make a vaccine against coronavirus with shingles. If the disease is not in the acute stage and the patient does not have a rash, he can be vaccinated (Machingaidze & Wiysonge, 2021). According to global practice, the drug of choice in the treatment of OL is famciclovir at a dose of 500 mg 3 times daily. Tricyclic antidepressants (in elderly patients), and glucocorticosteroids (can be considered by the attending physician as a therapeutic option in the presence of a pronounced inflammatory component in the acute period in the absence of contraindications and taking into account the risks associated with undesirable effects), sympathetic blockade are also used as pathogenetic therapy.
The addition of an oral corticosteroid may provide moderate benefits in reducing herpes zoster pain and the incidence of postherpetic neuralgia. Herpes zoster eye involvement can lead to rare but severe complications and usually requires a referral to an ophthalmologist. Patients with postherpetic neuralgia may require drugs for adequate pain relief. Tricyclic antidepressants or anticonvulsants, often given in low doses, can help control neuropathic pain. Some patients may also use capsaicin, lidocaine patches, and nerve blocks.
Management
Patients who develop shingles may be seen by different healthcare professionals depending on the healthcare organization in which they live and the development of the herpes zoster episode, especially complications. Although general practitioners do not usually see many HZ patients, this often affects their most vulnerable patients, with severe risks of serious complications. These patients are at increased iatrogenic risk because they usually take multiple drugs for chronic diseases and have a high risk of decompensation and functional decline. The recommendations are important for general practitioners as they may have little personal experience due to the low incidence of disease among their patients.
The mildest form, is characterized by a rapid course of the disease. Erythematous-papular rash lasts for several days, vesicles are absent – abortive herpes zoster. In case of contact with a patient with chickenpox, patients with reduced immunity are recommended to inject human immunoglobulin or immune plasma. The drugs reduce the risk of developing shingles, but they are most effective when used in the first 96 hours after exposure.
Usually, the herpes zoster vaccine can be given to people over 60 years of age. It is performed once and reduces the risk of developing a Herpes zoster and also reduces the intensity of pain and the likelihood of postherpetic neuralgia. Thus, patients who do well with herpes zoster can have the same lifespan as people without the virus. To contribute to the treatment of the disease, the patient must 1) be vaccinated, 2) be regularly observed by a doctor, and 3) take all the necessary medications to prevent the intensification of the disease.
Care Disparities
Herpes zoster is a common disease, with one million cases reported annually in the United States, so it is said that 30% of the population will contract the disease during their lifetime (Nazarko, 2019). The likelihood of contracting this disease increases with age and ranges from about five cases per 1000 people to ten patients per 1000 people in a group of at least 80 people (Engler et al., 2017). The continued failure to achieve health equity between different social groups with herpes zoster vaccination is likely to have severe economic and public health implications, especially with the growing elderly population in the United States.
Despite the long-standing inequality between blacks and whites in obtaining ZVL, no studies have been conducted to help quantify this inequality’s joint public health and state economic impact on herpes zoster. Thus, the chosen disease affects society: the gap between certain population strata is widening. Difficulties also arise for patients and their families: when the disease intensifies, the patient cannot see some of his family members, leading to depression. Shingles and their complications can result in direct medical costs and productivity losses of more than $ 2.4 billion annually in the United States.
Health promotion
Preventive measures (vaccination, long-term use of antiherpetic drugs) are advisable for patients with recurrent herpes. People with viral diseases are advised to lead a healthy lifestyle, to observe the proper sleep, work, and rest regimen. Observance of special days is not required, but the patient needs to be provided with adequate nutrition; the diet should be rich in fresh vegetables and fruits. Prevention of recurrence of herpes includes treatment of concomitant diseases. The patient should pay attention to the factors provoking relapses (stress, hypothermia, alcohol consumption, diet, etc.). The patient should avoid trauma to the blisters; erosion should be kept dry and clean, clothing should be soft, and personal hygiene items should be used and stored separately from others.
Conclusion
Treatment for shingles should be started as early as possible. In the later stages, specific therapy is ineffective. Thanks to a timely set of therapeutic and anti-relapse measures, it is possible to achieve a favorable prognosis. The disease should be differentiated from chickenpox, streptococcal impetigo, contact vesicular manifestations of allergic dermatitis, drug taxidermy, and Dühring’s dermatitis. After the resolution of skin rashes, neuropathologists carry out treatment until the neurological symptoms disappear. The prognosis for herpes zoster is favorable, except for gangrenous forms and forms complicated by meningoencephalitis.
The diagnosis is not difficult with a detailed clinical picture of the ganglionic forms of herpes zoster. Errors often occur in the initial period of the disease, when there are symptoms of intoxication, fever, and sharp pain. These cases mistakenly diagnose angina pectoris, pleurisy, pulmonary infarction, renal colic, acute appendicitis, etc. Differentiate from herpes simplex, erysipelas, acute eczema; the generalized form of herpes zoster – from chickenpox. For laboratory confirmation of the diagnosis, the virus is detected by microscopy or immunofluorescence, the virus is isolated on tissue cultures, and serological methods are used.
References
Engler, D., Sibanda M., Motubatse, H. J. (2017). Shingles. Pharmaceutical Journal, 84(6), 132-138.
Fritz, D. J., Curtis, M. P., Kratzer, A. (2020). Shingles. Home Healthcare Now, 38(5), 282-283.
Huether, S.E. & McCance, K.L. (2017). Understanding Pathophysiology (6th ed.). St. Louis, MO: Elsevier.
Machingaidze, S., Wiysonge, C.S. (2021). Understanding COVID-19 vaccine hesitancy. Nature Medicine, 27, 1338–1339.
Nazarko, L. (2019). Diagnosis, treatment and prevention of shingles: the role of the healthcare assistant. British Journal of Healthcare Assistants, 13(1), 20-25.