This paper will describe the disease process of Herpes Zoster. Herpes Zoster more commonly referred to as Shingles is an acute, unilateral, and segmental inflammation of sensory nerve roots. Herpes Zoster will be referred to as Shingles hereafter in this paper. The first section of this paper will explain the epidemiology of Shingles. This will include prevalence, mortality, and morbidity using the latest statistics available. The second section will list the predisposing factors of Shingles. Rationales for all risk factors explaining why each one predisposes the individual for that particular disease will be covered. In the third section the pathophysiology will explained. A brief description of the normal anatomy and physiological mechanism will precede the actual pathophysiology. In the fourth section all clinical manifestations will be listed. Including complaints from patients, and abnormalities found in physical exams. In the fifth section an explanation of all tests used to diagnose the disease and a description of these tests. The subsequent section will list the management of this disease from a medical stand point. This will include a description and rationale for all types of interventions such as invasive, non-invasive procedures, and pharmacological measures used to treat this disease. In the seventh section, nursing management of this condition will be explained. This will include nursing diagnoses, nursing goals, interventions (pharmacological, dietary, and patient education). The eighth and final section will describe research trends for this disorder. Including any new treatments, pharmacological, immunizations, invasive/non-invasive therapies, and, diagnostic testing, that are currently under investigation.
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Epidemiology
Shingles is the resurgence of latent Varicella Zoster Virus (Chickenpox), so statistics from this disorder will be included. Humans are the only known reservoir for Chickenpox. Chickenpox has an attack rate of 90% in susceptible individuals. The virus is endemic in the population but becomes epidemic among susceptible individuals during late winter and early spring. Children between the ages of 5-9 are most commonly affected and account for 50% of all cases. Most other cases involve children 1-4 and 10-14. Roughly 10% of the population in the United States over age 15 is susceptible to the virus. The incubation period of chickenpox is 10 to 21 days however is more likely 14 to 17 days. Patients are contagious 48 hours prior to the formation of vesicular rash and until all vesicles have crusted. Attack rates in susceptible siblings in the same household are 70-90%. About 1 million cases of shingles occur in the United States every year. More than half of the people who develop shingles are over 60, and nearly 50% of complications from shingles are in older adults. Shingles occurs at all ages but is more likely to affect those in the sixth decade of life. Except for immunocompromised, and AIDS patients recurrent attacks are rare. The total duration of the disease is usually 7-10 days however it may be as long as 2-4 weeks until the skin is back to normal.
Predisposing Risk Factors
Anyone who has recovered from chickenpox may develop shingles, including children. It is not clear what reactivates the virus. Anyone who has had chickenpox has a 10-30% lifetime risk of developing shingles. At 85 years of age, this risk increases to 50%. This increased risk may be linked to a weakening of the immune system. As people get older, their bodies become more vulnerable to many diseases. Having certain diseases such as cancer, leukemia, lymphoma, and, HIV/AIDS, can severely compromise the immune system. Also, treatments for cancer, such as chemotherapy; and other drugs such as steroids, and, medication taken to prevent rejection after an organ transplant can reduce immune function. In summary, having had chickenpox is the number one risk factor for contracting shingles. Among those that have had chickenpox advancing age is the number one risk factor. With immunosuppression being the only other risk factor for shingles.
Pathophysiology
Shingles is a viral disease. The initial infection with Varicella Zoster Virus causes the acute illness chickenpox, which usually occurs in young people and children. Once chickenpox has resolved, the body does not eliminate the virus. The virus lies dormant until the immune system is compromised. At which time it can cause shingles, an illness with different signs and symptoms, often years after the initial infection. The symptoms of shingles follow a series of three stages, prodromal or onset, active or erruptive, and chronic. However it is common for people not to experience all three stages. The onset phase is the most commonly experienced. During this phase, continuous or intermittent burning, tingling, itching, or various types of pain frequently precede rash by a few hours or days. While the onset phase and the presence of cutaneous nerve fibrils indicate that shingles infection is present in the sensory ganglia, a loss of sensation can also occur. The acute phase is considered the active phase and follows the onset phase, which involves the development of the distinguishing skin lesions. Development of a rash in elderly patients may be accompanied by malaise, headache, low-grade fever, and nausea. Encephalopathy and severe pain may also go along with these symptoms. The active phase is initially characterized by erythematous papules and edema. Papules progress to vesicles in 12 to 24 hours and to pustules within one to seven days. The pustules eventually dry and fall off within 14-21 days, leaving behind erythematous lesions. The chronic phase is unlike any of the other phases and occurs mostly in the elderly. Many patients develop PHN, which is most likely to result during the chronic stage. PHN is Postherpetic Neuralgia is a chronic pain that persist after the shingles have resolved.
Clinical manifestations
The most common symptom of shingles is pain that can be severe and unrelenting. In the prodromal stage, which is usually 48-72 hours prior to the presence of a rash, symptoms will include:
Numbness
Tingling
Burning
Shooting pain
Itching
Fever
Headache
Chills
Nausea
Shingles usually begins with parasthesias, which are itching, burning, or tingling of skin on one side of the body. Patient may develop a fever, a feeling of being sick, or a headache. Within 1-2 days a rash appears on either side of the body in a band like pattern. The chest or back is typically affected by the shingles rash. The rash may also occur on the face, if it appears near the eye it can permanently affect vision .The pain of shingles can be mild to severe, and generally has a sharp, stabbing, or burning quality. Usually the pain is localized to the skin affected by the rash. It can be severe enough to affect ADL’s. Older adults compared to younger people generally experience more pain. Within three to four days, shingles blisters can become open sores. These sores may become infected with bacteria. If the patient’s immune system is not compromised the sores crust over by day 7-10. The rash generally goes away within three to four weeks. Scarring and skin color changes may be permanent. Most people recover from shingles without any lasting problems. Postherpetic Neuralgia (PHN) is a complication of shingles. PHN is a condition in which damage to sensory nerves, causes severe neuropathic pain. This pain can be continuous or intermittent. The pain can occur without external stimuli. However it may also be caused by external stimuli, light touch, the brush of clothing, and even wind can cause extreme pain. The amount of pain from PHN greatly increases with age. PHN is defined as pain that last at least 3 months after all shingles lesions have went away.PHN is treated with:
Analgesics
Antidepressants
Anticonvulsants
Corticosteroids
These medications may all be used concurrently. However they should be added to the patient’s regimen one at a time in case there is any adverse reaction, so that the med that caused the reaction can be promptly stopped.
Diagnosis
Shingles can be diagnosed in the prodromal stage, before lesions appear but this is difficult as the symptoms in this stage can mimic many other illnesses. Virology of skin scrapings once the lesions have appeared is usually the only way to achieve a proper diagnosis. This is done by isolating the Varicella Zoster Virus (Chickenpox) in tissue culture cell lines. The two tests used most are the fluorescent antibody to membrane antigen test (FAMA), immune adherence hemagglutination and enzyme-linked immunosorbent assay (ELISA). These two tests are also the most sensitive. Also contact dermatitis is pruritic and shingles is painful. If lesions of herpes simplex are not differentiated from shingles, doses of antibiotics appropriate for shingles should be used. However herpes simplex and shingles are differentiated by the staining of antibodies from vesicular fluid and identified under fluorescent light. Usually the lesions of these two disorders occur in different places. If the CNS is involved, LP results show increased pressure, and protein levels.
Medical Management
Shingles is usually treated with prescription oral antiviral drugs to significantly reduce the healing time of the infection. Anti inflammatory drugs are used to reduce inflammation, these may be prescription or OTC. Analgesic medication is also used to lower pain level; these may also be prescription or OTC. Antivirals used to treat shingles are:
Acyclovir- is administered at a dose of 800mg five times a day for 7-10 days.
Famciclovir- is administered at a dose of 500mg three times a day for seven days.
Valacyclovir- is administered at a dose of 1g three times a day for 5-7 days.
Immunocompromised patients should be treated with IV Acyclovir at a dose of 10-12.5mg/kg q8hrs for seven days. Glucocorticoids such as prednisone administered at a dose of 60mg/d for the first 7 days, 30mg/d for day 8-14 and, 15mg/d for days 15-21. Glucocorticoid treatment should not be used unless there is concomitant antiviral therapy. Analgesics usually used for shingles include: gabapentin, amitriptyline hydrochloride, lidocane patches, codeine, aspirin, acetaminophen, and, fluphenazine hydrochloride. Topical antipruritics such as calamine lotion can be used to reduce pruritis.
Nursing Management
Nursing diagnoses for shingles include:
Acute Pain
Disturbed body image
Impaired skin integrity
Impaired social interaction
Risk for infection
Outcomes for patients with shingles include:
Patient will verbalize that an acceptable level has been achieved.
Patient will acknowledge a change in body image.
Patient will exhibit healed lesions.
Patient will demonstrate effective social interaction skills.
Patient will have no further signs of infection.
The following nursing interventions should be applied to patients with shingles. Apply calamine lotion as liberally as directed by physician. Apply silver sulfadiazine to soften and debride lesions that are infected. Administer pain medication as prescribed. Patients with severe pain should be referred to a pain specialist. Maintain hygiene to prevent the infection from spreading to other parts of the body. If the patient has open lesions follow contact isolation to avoid spreading the infection to immunocompromised patients. Patient should be reassured that the pain will eventually subside. Also cool wet compresses can be applied to the lesions for 20 minutes several times a day. Domeboro and Betadine soaks may be utilized to reduce crusting. The patient should be encouraged to wear loose fitting clothing to reduce irritation caused from clothing rubbing the lesions.
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Research Trends
New research regarding shingles has been in the area of prevention. Researchers have developed a preventive vaccine, Zostavax, marketed by Merck. Zostavax is a stronger version of the vaccine given to children to prevent chickenpox. The vaccine is 50% effective and is recommended for individuals over the age of 60. Even though an individual may still get shingles after vaccination, the vaccination reduces the risk of complications of shingles. The vaccine has not been utilized by many people because shingles is not a life threatening disease and there have not been many new vaccines for adults, so many people are not aware of this vaccination. Also the vaccine is not covered by insurance so many older adults that are on fixed incomes cannot afford it. Public education about shingles and the extremely painful complications associated with it are presumed to increase the use of this groundbreaking new vaccine.
In conclusion shingles is a disease that can affect people that have had chickenpox at any age. However it affects mainly the elderly population. Shingles usually presents with pain, numbness, tingling, burning, shooting pain, itching, fever, headache, chills, and, nausea. Shingles is treated with antivirals, analgesics, and antiinflammatories. Usually a person can only have shingles but there have been rare occasions of people having it more than once. From a nursing stand point relieving pain and starting antiviral therapy are the highest priority interventions. Lastly with patient education about vaccines now available to prevent shingles. The incidence of people getting shingles, or having painful complications if they do get shingles is greatly reduced.
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