Some patients may benefit from specialized treatment.
The majority of patients diagnosed with shingles (herpes zoster; HZ) by primary healthcare providers do very well when treated with antivirals and analgesics for the blistering rash and accompanying pain. However, a consultation with a medical specialist may be necessary to help ensure the best outcome for some patients. This includes cases where complications develop, or when the patient is compromised by age or pre-existing medical conditions.
“The main issue with shingles is in patients that are elderly and have more severe cases,” Lindsay C. Strowd, MD, FAAD, associate professor in the Department of Dermatology at Wake Forest School of Medicine told Drug Topics®.
Other high-risk individuals include those receiving chemotherapy or other types of immunosuppressive medications that impair their ability to fight off infections. “They can get a more widespread rash that may not be confined to a local part of the skin,” explains Strowd. “They can get shingles that actually go into their bloodstream or into their cerebral spinal fluid and cause meningitis or other types of more serious infections. It’s one of the reasons that we want to diagnose it quickly and treat it quickly.”
Shingles on the face is 1 category of shingles that is more prone to complications. This includes herpes zoster ophthalmicus (HZO), or ocular shingles; Ramsay Hunt Syndrome, which occurs when the varicella zoster virus that causes shingles reactivates in a facial nerve near the ear; and oral shingles, which erupts in the mouth. All can cause serious permanent damage, including blindness, hearing loss, and facial paralysis. Patients are often referred to specialists for treatment, including ophthalmologists and oral facial pain specialists.
Postherpetic neuralgia (PHN), a chronic pain syndrome that lasts weeks to months after an acute outbreak of shingles, is a serious complication that affects up to 20% of patients. Age and immunocompetence appear to be factors for developing PHN.
“In immunosuppressed individuals—for example, people who are on immunosuppressant drugs, people with HIV, people who have an underlying malignancy—shingles can be more severe, and the incidence of postherpetic neuralgia can have a higher frequency,” explains Justin C. McArthur, MBBS, MPH, professor and director of the Department of Neurology, the Johns Hopkins University School of Medicine and past-president of the American Neurological Association.
According to McArthur, prompt treatment of shingles seems to reduce the incidence of PHN and the risk of transmitting the varicella zoster virus to susceptible individuals. Treatments include modifying anticonvulsants and narcotics, as well as interventional treatments like transcutaneous electrical nerve stimulation, onabotulinumtoxinA injections (Botox), acupuncture, and injections into the intercostal nerve.
“A primary healthcare provider would typically refer the patient to a pain treatment specialist, who might be a neurologist or anesthesiologist. Because these are interventional procedures, they’re usually done in a specialized pain treatment center,” McArthur said.
Both McArthur and Strowd recommend vaccination against shingles with Shingrix, which is administered as a 2-dose series to adults 50 years and older. It can be given to individuals whether they’ve already had shingles or not.
“Even if you do happen to get it again, if you’ve been vaccinated it usually makes the disease course a lot milder and helps mitigate against some of the long-term complications,” Strowd concluded.