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3. Shingles and Shingles Vaccination
Shingles and Shingles Vaccination
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Epidemiology
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Variations
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PatientPlus articles are written by UK doctors and are based on research evidence, UK and
European Guidelines. They are designed for health professionals to use, so you may find the
language more technical than the condition leaflets.
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Synonyms: herpes zoster and varicella zoster
Shingles is caused by the human herpesvirus-3 (HHV-3). Primary infection usually occurs in
childhood, producing chickenpox (varicella) although it can be subclinical. After this the virus
lies dormant in the sensory nervous system in the geniculate, trigeminal or dorsal root ganglia. It
may lie dormant for many years or many decades, kept in check by the immune system before
flaring up in a single dermatome segment.[1]
When this happens, the virus travels down the affected nerve over a period of 3 to 4 days,
causing perineural and intraneural inflammation along the way. There is not always a clear
reason for a flare-up but associations include ageing (most patients are over 50 years old),
immunosuppressive illness, or psychological or physical trauma.
In immunocompetent patients, the most frequent site of reactivation is the thoracic nerves
followed by the ophthalmic division of the trigeminal nerve (herpes zoster ophthalmicus (HZO)),
which can progress to involve all structures of the eye. If the mucocutaneous division of the VII
cranial nerve is involved, the lesions in the ear, facial paralysis, and associated hearing and
vestibulary symptoms are known as Ramsay Hunt syndrome. [2] Shingles may also affect cervical,
lumbar and sacral nerve roots.
Epidemiology
At least 90% of children have been exposed to chickenpox before they are aged 16. Shingles is
seen as a disease of older people but it can affect all ages, including children. The incidence and
severity increase with age. This may be due to a decline in cellular rather than humoral
immunity.
Chickenpox can rarely be acquired from a patient with active shingles, as the lesions shed virus
(transmission is by direct contact or droplet spread) but shingles is not caught from contact with
a person with chickenpox.
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Risk factors
Increasing age increases the incidence and morbidity of shingles.
Incidence and risk are increased in the immunocompromised patient.
Diseases such as HIV, Hodgkin's lymphoma and bone marrow transplants all have a high
risk.
Consider underlying immunodeficiency If anyone presents with shingles affecting more
than one dermatome or if the patient is aged under 50 years.
Presentation
The disease can be divided into the pre-eruptive phase, acute eruptive phase and chronic phase postherpetic neuralgia (PHN).
Pre-eruptive phase
In the pre-eruptive phase there is no skin lesion to see but 80% of patients complain of
burning, itching or paraesthesia in one dermatome.
This usually lasts for a day or two but it can be over a week before the characteristic
eruption appears.
The patient may feel unwell with malaise, myalgia, headache and fever but these
symptoms may abate as the eruption appears.
In the pre-eruptive phase the skin may be tender but there are no lesions to see. There
may be lymphadenopathy.
Diagnosis is difficult before the characteristic rash appears.
Eruptive phase
The eruptive phase is when the skin lesions appear. Most, but not all, adults have acute,
neuritic pain in this phase. A few have severe pain without any eruption, called zoster
sine herpete. Young adults and children are most likely to be free of pain.
Crust formation and drying occurs over 7 to 10 days and is followed by resolution at 14
to 21 days.
Patients are infectious (resulting infection is chickenpox) until lesions are dried.
In the eruptive phase the rash first appears as a patch of erythematous, swollen plaques
with clusters of small vesicles. This eruption is virtually diagnostic of shingles. It may not
affect the whole dermatome but it will not extend outside it. Hence any rash that crosses
the midline is not shingles.
More vesicles may erupt over the next 5 to 7 days. They form crusts that fall off inside 3
weeks.
In elderly and immunocompromised patients, the eruptive phase is longer and more
extensive. It occasionally results in haemorrhagic blisters, skin necrosis, and secondary
bacterial infections.
The typical pattern of an abdominal dermatome (left T12) - the more crusted and deeper
lesions look more likely to result in PHN
Chronic phase
Chronic phase, or PHN, is persistent or recurring pain lasting 30 days or more after the
acute infection or after all lesions have crusted.
Variations
Ophthalmic shingles
Synonyms: herpes zoster ophthalmicus (HZO), ophthalmic herpes zoster
