Romero, Dana

BSN-III

HERPES ZOSTER
Introduction

Herpes zoster is commonly known as shingles. It is a viral disease caused by reactivation of

varicella-zoster virus which remains dormant in the sensory ganglia of the cranial nerve or the
dorsal root ganglia after a previous varicella infection. Varicella is commonly known as
chickenpox; it occurs in children while herpes zoster occurs in adults or the elderly. It is believed
that zoster occurs due to the failure of the immune defense system to control the latent
replication of the virus. The incidence of herpes zoster is strongly correlated to the immune
status. Individuals who maintain a high level of immunity rarely develop shingles. The infection
is not benign and can present in many ways. Even after herpes zoster resolves, many patients
continue to suffer from moderate to severe pain known as postherpetic neuralgia

Epidemiology

The incidence of herpes zoster ranges from 1.2 to 3.4 per 1000 persons per year among
younger healthy individuals while incidence is 3.9 to 11.8 per 1000 persons per year among
patients older than 65 years. There is no seasonal variation seen with herpes zoster.

Recurrences are most common in patients who are immunosuppressed.

Causes

•Shingles is caused by the varicella-zoster virus ;,the same virus that causes chickenpox.
Anyone who's had chickenpox may develop shingles. After you recover from chickenpox, the
virus enters your nervous system and lies dormant for years.

•Eventually, it may reactivate and travel along nerve pathways to your skin — producing
shingles. But, not everyone who's had chickenpox will develop shingles.

•The reason for shingles is unclear. But it may be due to lowered immunity to infections as you
grow older. Shingles is more common in older adults and in people who have weakened
immune systems.
 •Varicella-zoster is part of a group of viruses called herpes viruses, which includes the viruses
that cause cold sores and genital herpes. Because of this, shingles is also known as herpes
zoster. But the virus that causes chickenpox and shingles is not the same virus responsible for
cold sores or genital herpes, a sexually transmitted infection

Symptoms

The symptoms of shingles usually affect only a small section of one side of your body. These
symptoms may include:

•Pain

•burning

•numbness or tingling

•Sensitivity to touch

•A red rash that begins a few days after the pain

•Fluid-filled blisters that break open and crust over

•Itching

Some people also experience:

•Fever

•Headache

•Sensitivity to light

•Fatigue
Risk Factors

•Anyone who has ever had chickenpox can develop shingles. Most adults in the United States
had chickenpox when they were children, before the advent of the routine childhood
vaccination that now protects against chickenpox.

Factors that may increase your risk of developing shingles include:

•Being older than 50. Shingles is most common in people older than 50. The risk increases with
age.

•Having certain diseases. Diseases that weaken your immune system, such as HIV/AIDS and
cancer, can increase your risk of shingles.

•Undergoing cancer treatments. Radiation or chemotherapy can lower your resistance to

diseases and may trigger shingles.

•Taking certain medications. Drugs designed to prevent rejection of transplanted organs can
increase your risk of shingles — as can prolonged use of steroids, such as prednisone.

Anatomy and Physiology

The skin is composed of 3 layers: the epidermis is the outermost layer and is composed of
keratinocytes or skin cells that form the “bricks” of our skin’s barrier. The functions of the
epidermis are protection from environmental insults (like ultraviolet light and toxins),
prevention of dryness, and immune surveillance. The base of the epidermis is called the basal
layer – it contains the cells that replicate in order to replace the epidermis every month. Mixed
in between keratinocytes of the epidermis are pigment cells, called melanocytes, that give skin
its characteristic color. These cells become activated with ultraviolet exposure found in
sunlight. The result of this activation is two-fold – 1) melanocytes produce more melanosomes,
envelopes that contain brown melanin pigment, and 2) the increased transfer of these
melanosomes to adjacent skin cells. The result is freckling or sun-spots that can significantly
impact appearance.

Beneath the epidermis is the dermis, composed mostly of collagen but also adjunctive
structures like hair follicles and sweat glands. Sebaceous glands are found next to hair follicles
and produce sebum, a combination of natural lipids that coat the skin’s surface and provide a
protective nourishing role. Sweat glands function to help regulate temperature through
evaporation and cooling. Their ducts pass through the dermis and epidermis to empty directly
onto the skin’s surface. The dermis also contains vital blood vessels and nerves which traverse
the collagen network there. Within the dermis also lies a protein, elastin, that provides
cutaneous elasticity and fibroblasts, the cells that produce more collagen. The function of the
dermis is temperature regulation though the secretion of sweat to the skin’s surface and the
regulation of blood flow to the area. The dermis also provides mechanical protection for the
adenexal structures discussed above.

Below the dermis, lies the subcutis which holds fat and larger blood vessels. Fat is arranged
into lobules that are several millimeters wide. These lobules are divided by thin wisps of tissue
that contain blood vessels and nerves. The subcutis acts as a heat insulator and also provides
protection from mechanical trauma

Pathophysiology
Laboratory Test

Polymerase chain reaction (PCR)

• PCR is the most useful test for confirming cases of suspected zoster sine herpete (herpes
zoster-type pain that occurs without a rash).

•PCR can be used to detect VZV DNA rapidly and sensitively, and is
now widely available. The ideal samples are swabs of unroofed
vesicular lesions and scabs from crusted lesions; you may also detect
viral DNA in saliva during acute disease, but salvia samples are less
reliable for herpes zoster than they are for varicella.

Direct Fluorescent Antibody Test

•Direct fluorescent antibody staining of VZV-infected cells in a

scraping of cells from the base of a lesion is rapid, specific, and
sensitive, but it is substantially less sensitive than polymerase
chain reaction (PCR). This method can also be used on biopsy
material and on eosinophilic nuclear inclusions

Tzanck Smear

•If the rash has appeared, identifying this disease (making

a differential diagnosis) only requires a visual
examination, since very few diseases produce a rash in a
dermatomal pattern. The Tzanck smear is helpful for
diagnosing acute infection with a herpes virus, but does
not distinguish between HSV and VZV.
When the rash is absent (early or late in the disease, or in the case of zoster sine herpete),
herpes zoster can be difficult to diagnose.[5] Apart from the rash, most symptoms can occur
also in other conditions

MRI

•MRI may be used to provide clues for the diagnosis of

herpes zoster infection and its complications. However, it is
not routinely done in the diagnosis of the infection

PET/CT

•A PET/CT scan can present with focal skin lesions and/or reactive lymph node enlargement,
with increased FDG (2-deoxy-2[18F]fluro-D-glucose) uptake. Local reactive adenopathy is an
important finding on PET/CT scan in patients with herpes zoster infection, but must be
correlated with the pertinent skin findings.

Medications

•Antiviral Agents ( Famciclovir,valacyclovir)

✓The antiviral medications are most effective when started within 72 hours after the onset
of the rash.

• Anti-inflammatory Drug ( Corticosteroids)

 ✓An orally administered corticosteroid can provide modest benefits in reducing the pain of
herpes zoster.

• Analgesics

✓Analgesics are medications that relieve pain. Unlike medications used for anesthesia during
surgery, analgesics don't turn off nerves, change the ability to sense your surroundings or alter
consciousness. They are sometimes called painkillers or pain relievers

Medical Management

•Admission to an isolation room is advised

•Pharmacologic intervention involves the following: analgesics, corticosteroids, acetic acid or

white petrolatum, and antiviral agents such as Acyclovir, famciclovir, and valacyclovir.

•Cold baths and lotions must be started.

•Pregnant women should not go near the person with shingles as it may be infectious.

•Give antihistamines in order to prevent itching

Nursing Management

•Monitor the vital signs.

•Observe proper measures in containing the infectious agent.

•Observe proper personal protective gear as well as routine hand washing before and after the
procedures.

•Encourage complete compliance with the medications being ordered.Teach the patient as well
as the folks about the proper disposal of materials that are in contact with the patient.

•Listen to the ideas and perception of the patient about being isolated, the prognosis as well as
recovery from the present status.
•Teach the patient about the possibility of having post-herpetic neuralgia or pain on the sites of
shingles which may be present for months or even years. Proper medications can be given in
order to lessen the pain

Discharge Plan

•Call your local emergency number if:

You have trouble moving your arms, legs, or face.

You become confused, or have difficulty speaking.

You have a seizure.

•Return to the emergency department if:

You have weakness in an arm or leg.

You have dizziness, a severe headache, or hearing or vision loss.

You have painful, red, warm skin around the blisters, or the blisters drain pus.

Your neck is stiff or you have trouble moving it.

•Call your doctor if:

You feel weak or have a headache.

You have a cough, chills, or a fever.

You have abdominal pain or nausea, or you are vomiting.

Your rash becomes more itchy or painful.

Your rash spreads to other parts of your body.

Your pain worsens and does not go away even after you take medicine.

You have questions or concerns about your condition or care

•Self-care:

Keep your rash clean and dry. Cover your rash with a bandage or clothing. Do not use bandages
that stick to your skin. The sticky part may irritate your skin and make your rash last longer