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• What causes herpes zoster (shingles)?
• Who is at risk for herpes zoster?
• What are the symptoms of herpes zoster/shingles?
• How is herpes zoster treated?
• Is the myth “if the herpes zoster wraps around the body, you will die” true?
• What are the preventions for herpes zoster/shingles?
• Herpes zoster vaccine
• FAQ

Herpes Zoster (Shingles)

Herpes zoster, or shingles, is a viral infection caused by the reactivation of a dormant VZV quiescent in the sensory ganglia of people who have had chickenpox. When a person recovers from chickenpox, the VZV remains dormant in the nerve ganglia. However, when body immunity weakens, the latent VZV reactivates, resulting in herpes zoster symptoms including itching, burning pain, and a flare-up stripe of red rashes along the sensory nerve ganglia, followed by eruption of clear blisters that may be associated with a fever. If left untreated, herpes zoster can cause complications such as herpes zoster ophthalmicus, postherpetic neuralgia (PHN), and neurological problems. Those who suspect they have herpes zoster should seek medical attention as soon as possible for appropriate treatment and antiviral drugs.

What causes herpes zoster (shingles)?

Herpes zoster, or shingles, is caused by the reactivation of the varicella-zoster virus (VZV), which causes chickenpox when first infected. Once recovered, the VZV remains dormant in the sensory ganglia for decades without causing symptoms. As the body's immunity deteriorates, the latent VZV reactivates by dividing, multiplying, and spreading along the nerve distribution of a sensory ganglion, resulting in nerve inflammation, pain along the sensory nerve, and a stripe of red rash on the skin, followed by clear fluid-filled blisters distributed in band-like distribution along the length of the sensory nerves, causing itching, burning pain, sharp neuropathic pain, headaches, and may be associated with fever. Everyone who has ever had chickenpox is at risk of developing herpes zoster.

Who is at risk for herpes zoster?

•    Those aged 50 years and up
•    Those with low body immunity
•    Those who take immune-suppressing medications.
•    HIV-infected individuals
•    Those who have cancer.
•    Bedridden patients
•    Those under stress
•    Those who do not get enough sleep.
•    Those who have suffered multiple traumas.
•    Those who have received an organ transplant.
•    Those who are undergoing chemotherapy.
•    Those who have used steroids for a prolonged period.
•    Those suffering from chronic diseases such as diabetes, autoimmune diseases, SLE, heart disease, or kidney disease.

What are the symptoms of herpes zoster/shingles?

Herpes zoster/shingles symptoms are classified into 3 stages:

1. Pre-eruptive phase
   The pre-eruptive phase (or preherpetic neuralgia stage) occurs when the latent VZV spreads through the sensory ganglion through the sensory nerves, resulting in nerve inflammation, peripheral neuropathy, numbness, acute pain, and burning pain on one side (unilateral) of the skin along the sensory nerve distribution of the ganglion, as well as itching, body aches, and headache. In some cases, there may be associated symptoms such as fever, fatigue, diarrhea, or light sensitivity (photophobia). During the pre-eruptive phase, symptoms typically last 1-3 days. However, there will be no skin lesions.
2. Acute eruptive phase
   The acute eruptive phase occurs when red skin rashes appear along the sensory nerve distribution of a sensory ganglion, followed by eruptions of clear fluid-filled blisters (vesicles), typically on the left or right half of the body as well as the back or legs, or on one side of the face, eyes, or neck. Unlike the chickenpox rash, the herpes zoster rash typically does not disperse as widely throughout the body and will fully develop within 3-5 days. Those with a herpes zoster infection rash will experience a headache, fever, fatigue, and exquisite pain along the skin innervated by the sensory nerves with light contact or simply touching by the clothing. Over 10–15 days, the rashes will break and become sores, then gradually dry, scab over, and eventually fall off the skin. In those with normal body immunity, herpes zoster rash typically appears on one side of the body (unilateral). Conversely, rashes are more likely to be severe, formed on both sides of the body in those with low immunity, cancer, AIDS, or those receiving chemotherapy.
   
3. Chronic phase:
   The chronic phase (or postherpetic neuralgia: PHN) occurs after the herpes zoster rash has subsided and the skin lesions along the sensory nerve distribution have faded. However, most people with herpes zoster will continue to experience some symptoms, such as burning pain, tingling sensations, or acute pain along the nerve that ranges from moderate to severe. Pain may be constant or come and go. In some cases, pain may persist for decades. 
4. Zoster Sine Herpete (ZSH):
   Some people with herpes zoster may experience zoster sine herpete (ZSH) or herpetic neuralgia without a rash. There may be numbness, itching, and burning pain along the nerves, but no rash appears on the skin. Anyone who suspects they have zoster sine herpes should seek medical attention promptly for further diagnosis. 

How is herpes zoster diagnosed?

Doctors will diagnose herpes zoster by taking a history and performing a physical examination to look for herpes zoster lesions by examining for the skin rashes or blisters to see if they are dispersed widely or appear in clusters along one side of the body with symptoms of itching, burning pain, or fever. In cases where no lesions are visible or there is a suspicion of zoster sine herpete (ZSH), the doctor will employ the following methods to perform additional diagnostic tests for herpes zoster:

• Tzanck smear: The Tzanck smear involves puncturing the blisters, scraping off a sample of tissue for cells from their bases, placing the sample on a glass slide, leaving it dry, and sending it to the laboratory for Wright-Giemsa staining to examine cell characteristics under a microscope. The Tzanck smear is considered a quick and simple test, but it may be unable to distinguish between herpes simplex and herpes zoster rash. 
• Viral culture entails taking a sample of vesicle cells and culturing them in a VZV viral growth media. The accuracy of the test ranges between 60 and 90%.
• Polymerase chain reaction (PCR) is an immunological test that looks for specific genetic elements of the suspected herpes zoster virus. The PCR test has high sensitivity and specificity, 2-3 times more accurate than the viral culture method.

How is herpes zoster treated?

The doctor will treat herpes zoster to decrease the disease severity and the burning pain, prevent complications, and assist the patient in recovering from the disease as quickly as possible. The doctor will consider herpes zoster treatment and medications based on the duration of the disease and detected symptoms. However, the most effective treatment for herpes zoster is to begin treatment within 48-72 hours after the rash appears. Herpes zoster treatments include the following:

• Antiviral drugs: Doctors may prescribe antiviral drugs such as Acyclovir, Famciclovir, or Valaciclovir to reduce the severity of the disease, inflammation, and virus spread in the skin, as well as reduce burning pain, accelerate blister subsidence, minimize the risk of recurrence, promote a quick recovery, and reduce the risk of complications associated with herpes zoster.
• Antibacterial drugs: The doctor may consider anti-inflammatory agent prednisolone and antibiotics, both oral and topical, for people with herpes zoster who have secondary bacterial infections to reduce inflammation, pain, and hasten herpes zoster rash clearance, particularly those with zoster sine herpete or herpes zoster rash flare up on any part of the face.
• Pain reliever: In cases of severe pain, the doctor may opt to combine antiviral drugs with pain medications like paracetamol or NSAIDs such as ibuprofen to expedite pain relief

What is the complication of herpes zoster (shingles)?

• Postherpetic neuralgia (PHN) 5-30% of herpes zoster patients aged 50 and older will experience persistent neuropathic pain for more than three months after the disappearance of skin rashes. The severity of the symptoms correlates with age. Seniors will experience more severe and prolonged symptoms than younger people. In some instances, pain can persist for a lifetime, leading to issues such as insomnia, limited mobility, nerve-related pain, weakness, or being able to move an affected limb only slightly.
• Herpes zoster ophthalmicus/Ocular shingles, is a herpes zoster complication in which the herpes zoster rash flares up in the eyes, causing eye irritation, inflammation, corneal ulcers, or retinal inflammation, blurred vision, sensitivity to light (photophobia), or cataracts. In severe cases, ocular shingles can result in blindness, Ramsay-Hunt syndrome, or facial hemiplegia. Those experiencing ocular shingles should seek medical attention promptly to avoid further complications.
• Neurological problems: Herpes zoster can cause neurological issues such as facial paralysis, hearing loss, and balance problems.
• Bacterial skin infections: If not kept clean, a bacterial skin infection can complicate an episode of herpes zoster, causing delayed healing, persistence of rash, redness, and scarring.
• Severe pain: For those with low body immunity, HIV, or cancer patients receiving chemotherapy, when they have herpes zoster, the pain is likely to be more severe and can transmit the disease to others more easily.
• Stroke: Cerebral artery occlusion, and cerebral hemorrhage (found in those suffering from severe chronic pain).
• Pneumonia and encephalitis are rare complications of herpes zoster.

Is the myth “if the herpes zoster wraps around the body, you will die” true?

The myth “if the herpes zoster wraps around the body, you will die” is untrue. In some cases, herpes zoster rash can develop simultaneously on the left and right sides of the body, eventually giving the appearance that it is wrapping around your body and seeming to constrict you to die. In fact, most people who die from herpes zoster are secondary to their low body immunity, leading to complications associated with herpes zoster infection, which later weaken their bodies and eventually cause death. Therefore, patients 50 or older and those with low immunity are more likely to contract it.

How to manage herpes zoster at home?

• See a doctor right away to receive an antiviral drug within 48–72 hours of the onset of sharp pain or burning pain associated with fever.
• Take oral and apply tropical medicine strictly as prescribed by the doctor to help reduce the severity of the disease, lesions, and complications.
• Apply a cold compress with gel and cover the rash loosely.
• Avoid using herbal medicines, inhalers, or other medications obtained without a doctor's prescription for the herpes zoster rash or itchy rash, as they may cause complications from a bacterial infection, slowing wound healing and possibly leaving a scar.
• Avoid scratching a herpes zoster or itchy rash. If your nails are long, trim them short to reduce bacteria buildup, which can lead to complications and recurrent bacterial infections.
•  Cover an open wound to prevent bacterial infection.
• Always wash your hands thoroughly and keep your hands clean regularly.
• Wear loose, clothing to prevent skin from rubbing against clothing.

What are the preventions for herpes zoster/shingles?

1. Herpes zoster vaccine: Those who have or have not previously had chickenpox as a child, those aged 50 years and older, those with low body immunity, and all those at high risk of herpes zoster can prevent herpes zoster by receiving vaccination against the disease.  
2. Avoid direct contact with high-risk people: Those with herpes zoster should avoid direct contact with high-risk people to prevent the virus from spreading to others, such as the elderly, those who have never had chickenpox, those with weakened immune systems, young children, or pregnant women. Furthermore, personal belongings including bedding, clothes, and clothing of individuals with herpes zoster should be kept separate from others.
3. Maintain a healthy body: Eating all five food groups, exercising regularly, keeping your mind stress-free and relaxed, and getting enough rest will help your immune system remain strong and keep you away from herpes zoster.
   

Herpes zoster vaccine

With current medical advancements, the Herpes Zoster Vaccine was developed and designed to be more effective in preventing and reducing herpes zoster complications. There are 2 types of herpes zoster vaccines available in Thailand.

1. Zoster vaccine live (ZVL) is a live attenuated vaccine. The recommended dosage is 1 dose. ZVL is a vaccine that is 69.8% effective in preventing herpes zoster in people aged 50–59 years.
2. Shingrix vaccine, a recombinant subunit zoster vaccine (RZV), is a new type of herpes zoster vaccine requiring a series of 2 shots. Shingrix is a protein sub-unit vaccine made of glycoprotein E, a VZV component providing effective prevention for herpes zoster.

Instructions for administering the new Herpes Zoster Vaccine: Shingrix vaccine.

• Adults over 50: Give 2 RZV injections, space 2–6 months apart.
• Anyone 18 with a weakened immune system due to disease or treatment: Give 2 RZV injections 1-2 months apart.

Shingrix vaccine is 97% effective in preventing herpes zoster in people over 50. It is 68-91% effective in preventing herpes zoster in immunocompromised people aged 18 and older, up to 91.2% effective in preventing postherpetic neuralgia (PHN), and up to 89% effective in preventing herpes zoster as long as 10 years after vaccination.

How long does herpes zoster last?

Typically, from the pre-eruptive phase to the chronic phase, herpes zoster resolves within 3-5 weeks. However, individuals who have received antiviral medication within 72 hours of the onset of symptoms may recover from herpes zoster within 2 weeks.

Herpes Zoster, a Vaccine-Preventable Viral Infection

Individuals who have previously contracted chickenpox are susceptible to herpes zoster, particularly as they age, experience declining health, or a reduction in natural immunity. Herpes zoster can lead to severe pain, complications, and detrimental effects on quality of life. Those encountering symptoms of herpes zoster should promptly seek medical assistance to obtain suitable treatment for a speedy recovery.

Herpes zoster is preventable with vaccination, adequate rest, eating nutritious foods, and exercising regularly to keep the body strong and maintain robust natural immunity. Individuals over 50, those with weakened immune systems, and individuals at high risk for herpes zoster are advisable to receive the herpes zoster vaccine at a hospital. Prompt herpes zoster vaccination can help prevent herpes zoster and its complications in the long run, as well as promote long-term good health.

FAQ

1. What are the initial symptoms of herpes zoster/shingles?
   The first symptoms of herpes zoster/shingles encompass itching, sharp pain, tingling, and a burning sensation within 1-3 days before the appearance of clusters of red rashes in the skin innervated by sensory nerves of a ganglion, followed by the appearance of clear fluid-filled blisters that gradually break off and subside within 10-15 days. In addition, some people may experience fever, chills, and headaches, while others may later experience neuropathic pain.  
2. What is the difference between herpes zoster and herpes simplex?
   Both herpes zoster and herpes simplex are caused by infection with the human herpesvirus (HHV), which belongs to the same herpesvirus family but differs in the type of virus and the nature of the lesions. Herpes zoster is due to the VZV virus, which causes clear, fluid-filled blisters along the skin innervated by sensory nerves, whereas herpes simplex is due to HSV-1 or HSV-2 virus, which causes clear, fluid-filled blisters on the mouth or genital areas
3. Is herpes zoster/shingles contagious?
   Herpes zoster/shingles can be transmitted from person to person who has never had chickenpox by inhaling droplets containing viruses generated by coughing, sneezing, or direct contact with blisters or lymph from sores on the skin in those with acute herpes zoster. Therefore, herpes zoster patients should be isolated from high-risk groups such as those with weakened immune systems, the elderly, young children, or pregnant women to reduce the risk of possible cross-infection.
4. Which foods should be avoided during herpes zoster?
   Patients with herpes zoster should refrain from eating the following foods
   • High glycemic carbohydrate foods, e.g., white flour, bakery goods, cakes, desserts, candies, and syrups.
   • Foods high in saturated fat, such as fast food and fatty meat.
   • Foods high in arginine such as red meat, poultry, dried beans, and chocolate.
   • Ultra-processed foods, such as processed meats, butter, margarine, and ice cream
   • Alcoholic beverages such as liquor, beer, and wine
5. Can herpes zoster go away on its own?
   Herpes zoster may heal and go away on its own in those with strong immunity. However, if not treated properly by a doctor, untreated herpes zoster can lead to complications such as postherpetic neuralgia (PHN), neurological problems, etc.
6. What is the difference between herpes zoster and chickenpox?
   Herpes zoster and chickenpox differ in the appearance of the rash. Herpes zoster rash typically clusters in a band and does not spread throughout the body as does chickenpox rash. Typically, the rash of herpes zoster appears only along the skin distribution of sensory nerves of a ganglion, in which the varicella-zoster virus lies dormant previously. It starts out as a red rash and progresses to a swollen, clear, fluid-filled blister that eventually breaks off and scabs over. Herpes zoster rashes are prevalent on the waistline or ribcage, back, legs, and either side of the face, eyes, or neck. Herpes zoster symptoms are frequently more severe than chickenpox and can lead to complications if left untreated.

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