Herpes Zoster: A Brief Definitive Review

Herpes zoster in older adults: Impact on carbon footprint in the United States

We provide estimates for (I) annual herpes zoster (HZ) cases, (II) carbon costs related to healthcare utilization, and (III) annual carbon emissions due to HZ among ≥50 years of age (YOA) United States (US) population. We estimated the annual number of HZ cases in the US based on available incidence data and demographic data of individuals ≥50 YOA. Both the healthcare resource utilization (HCRU) associated with HZ cases and the unit carbon dioxide equivalent (i.e. CO2e) costs associated with each type of HCRU in the US were estimated based on literature and studies available online. The carbon footprint associated with HZ annually among US adults ≥50 YOA was estimated by multiplying the unit carbon estimates by the HCRU. In the US population aged ≥50 YOA in 2020 (i.e. approximately 118 million), approximately 1.1 million cases of HZ occur annually assuming no vaccination. Based on 2 sources of HCRU the average kgCO2e per HZ patient ranged from 61.0 to 97.6 kgCO2e, with values by age group ranging from 40.9 kgCO2e in patients aged 50-59 to 195.9 kgCO2e in patients ≥80 YOA. The total annual HZ associated carbon ranged between 67,000 and 107,000 tons of CO2e in the US population aged ≥50 YOA. The impact of HZ on carbon footprint in the US results in considerable greenhouse gas (GHG)emissions. Assuming no vaccination, the burden of HZ is projected to rise over the coming years with the aging populations consequently worsening its impact on GHG emissions. (Figure 1).

Herpes zoster ophthalmicus temporally after COVID-19 vaccination: a systematic review of uncontrolled case reports and case series

Purpose

Herpes zoster ophthalmicus (HZO) following COVID-19 vaccination has been reported previously but the clinical characteristics, onset, treatment, and outcomes of these cases have not been previously systematically reviewed.

Methods

A systematic review, guided by PRISMA guidelines, surveyed PubMed and Embase databases from April 2021 to June 2023 for case reports and series detailing HZO following COVID-19 vaccination. Studies excluded were abstracts, reviews, and clinical trials. A subsequent descriptive analysis was performed, focusing on patient demographics, clinical characteristics, and outcomes.

Results

Sixteen publications involving 27 participants who developed HZO post-COVID-19 vaccination met the inclusion criteria. The onset of HZO averaged 13 days (SD 12) postvaccination, predominantly after the first dose (n = 20/27 HZO cases, 74%). Most patients (70%) had preexisting medical conditions. Antiherpetic antiviral therapy was utilized in all cases, with the majority achieving resolution of cutaneous and ocular symptoms. Long-term sequelae included postherpetic neuralgia in 7.4% of patients.

Conclusion

Cases of HZO following COVID-19 vaccination generally mirror the clinical trajectory of HZO in general. This review focused on case reports describing HZO occurring in an interval postvaccination; neither association nor causation can be addressed methodologically.

Clinical Features of Varicella-Zoster Virus-Associated Anterior Uveitis with or without Ophthalmic Herpes Zoster

PURPOSE

This study aimed to investigate the clinical characteristics, diagnostic markers, and treatment outcomes of varicella-zoster virus-associated anterior uveitis (VZV-AU) with and without ophthalmic herpes zoster (herpes zoster ophthalmicus (HZO) and zoster sine herpete (ZSH), respectively).

METHODS

Clinical records of 47 VZV-AU patients (21 ZSH, 26 hZO) were retrospectively reviewed for clinical findings, medication use, and PCR using aqueous humor (AH) results.

RESULTS

There was no significant difference in age, gender, visual acuity (VA), or intraocular pressure (IOP) between the two groups. At the initial visit, small-to-medium white keratic precipitates (KPs) were significantly more observed in ZSH group than in HZO group, although there was no significant difference in the frequencies of other ocular findings between the two groups. Early antiviral medication use was significantly higher in HZO group (96.2%) than in ZSH group (19.1%). PCR was performed in 85.7% of ZSH and 53.8% of HZO patients. VZV-DNA positivity and viral load were similar between groups. Multivariate analysis revealed a positive correlation between white KPs and VZV viral load in AH. Although the ultimate use of antiviral medication was still less in ZSH group (71.4%), there were no significant differences in VA and IOP at the last visit between the two groups.

CONCLUSION

Patients with ZSH had more white KPs and received less early antiviral medication than those with HZO. However, visual outcomes were similar between the two groups. Small-to-medium white KPs were significantly associated with the viral load of VZV in AH, suggesting that they could be an active marker.

Single-cell immune profiling and validation of PBMCs in the onset of and recovery from herpes zoster

To gain deeper insights into pathogenesis of herpes zoster, the peripheral blood mononuclear cells (PBMCs) from male patients mostly were subjected to single-cell RNA-seq (scRNA-seq) and ATAC-seq analysis. Here we show a detailed immune cell profile in the onset of and recovery from herpes zoster, revealing proportion alterations of the subpopulations, which were validated by flow cytometric analysis and comparison of blood routine data. The integrative analysis of the transcriptomes and epigenomes provided a comprehensive description and validation of the key changes in peripheral blood. This study may provide deep insight into the immune profile during herpes zoster progression and holds potential clinical significance.

The Role of Moist Dressings in the Management of Herpes Zoster With Scalp Involvement: A Case Report

Comprehensive management, including antivirals and pain control, is crucial for mitigating complications and improving patient outcomes in herpes zoster. Moist wound dressings, specifically hydrocoll, effectively reduce pain, and promote healing in herpes zoster with scalp involvement, as demonstrated in the case of a 76-year-old male.

Risk of incident gout following exposure to recombinant zoster vaccine in US adults aged ≥50 years

OBJECTIVE

To assess whether recombinant zoster vaccine (RZV) is associated with an increased risk of new-onset gout among US adults aged ≥50 years.

METHODS

We conducted a real-world, retrospective safety study with a self-controlled risk interval (SCRI) design using administrative claims data. We included health plan members aged ≥50 years with RZV exposure, followed by incident gout within 60 days. Days 1-30 following RZV exposure were considered the risk window (RW), and days 31-60 were considered the control window (CW). We estimated the risk ratio (RR) of gout in the RW versus CW, using a conditional Poisson model. The primary analysis estimated the risk of incident gout following any RZV dose. Sensitivity analyses evaluated dose 1- and dose 2-specific risks, risk among patients compliant with recommended dose spacing of 60-183 days, adjustment for seasonality, and restriction to the pre-COVID-19 era (before December 1, 2019).

RESULTS

A total of 461,323 individuals received ≥1 RZV dose; we included 302 individuals (mean age 72.5 years; 66 % male) with evidence of new-onset gout within 60 days in SCRI analyses. A total of 153 (50.7 %) individuals had gout events in the RW and 149 (49.3 %) in the CW (RR 1.03; 95 % confidence interval 0.81, 1.29). All sensitivity analyses had consistent results, with no association of RZV with incident gout.

CONCLUSION

In a population of US adults aged ≥50 years, there was no statistically significant increase in the risk of gout during the 30 days immediately after RZV exposure, compared with a subsequent 30-day CW.

Viral Anterior Uveitis: A Practical and Comprehensive Review of Diagnosis and Treatment

Anterior uveitis is the most common type of uveitis worldwide. The etiologies of anterior uveitis can be divided into infectious and non-infectious (idiopathic, autoimmune, autoinflammatory, trauma, and others). The viral pathogens most commonly associated with infectious anterior uveitis include Herpes Simplex Virus, Varicella-Zoster Virus, Cytomegalovirus, and Rubella Virus. Other emerging causes of viral anterior uveitis are West Nile Virus, Human-Immunodeficiency Virus, Epstein-Barr Virus, Parechovirus, Dengue Virus, Chikungunya Virus, and Human Herpesvirus type 6,7, and 8. Early recognition allows prompt management and mitigates its potential ocular complications. This article provides an updated literature review of the epidemiology, clinical manifestations, diagnostic tools, and treatment options for viral anterior uveitis.

A Case of Psoriasis and Pseudohernia of the Abdominal Wall at the Site of Herpes Zoster-Wolf's Isotopic Response

The patient, a 77-year-old Asian male presented with herpes zoster in the left lumbar and abdominal regions 9 weeks before presentation. The infection dried up after 2 weeks but was followed by an erythematous scaly rash in the same region with left-sided abdominal elevation. Pathological examination revealed continuous parakeratosis and Munro microabscesses. Abdominal computer tomography revealed no abnormalities, suggesting psoriasis with herpes zoster and Wolf's isotopic response to the pseudohernia of the abdominal wall.

A comprehensive, updated systematic review and meta-analysis of epidemiologic evidence on the connection between herpes zoster infection and the risk of stroke

Stroke is a common worldwide cause of death and disability, resulting from an obstruction or reduction in blood flow to the brain. Research has demonstrated that systemic infection such as herpes zoster (HZ) / ophthalmicus herpes zoster (HZO) can potentially trigger stroke. This study includes an updated systematic review and meta-analysis of the epidemiologic data on the connection between HZ/HZO infection and the risk of stroke. A meticulous search of different database yielded 905 studies. Furthermore, an additional 14 studies from a previous meta-analysis were incorporated. Eligible studies underwent rigorous screening, resulting in 18 papers. Statistical analyses, including random/fixed effects models and subgroup analyses, were conducted to assess pooled relative risk (RR) and heterogeneity. The meta-analysis consisted of 5,505,885 participants and found a statistically significant association between HZ infection and the risk of stroke (pooled RR = 1.22, 95% confidence interval [CI] 1.12-1.34). The HZO infection showed a significantly higher overall pooled RR of 1.71 (95% CI 1.06-2.75), indicating a strong connection with the risk of stroke. Subgroup analysis revealed that the odds ratio might play a significant role in causing heterogeneity. Time since infection emerged as a crucial factor, with heightened stroke risk in the initial year post-HZ/HZO exposure, followed by a decline after the first year. Asian/Non-Asian studies demonstrated varied results in HZ/HZO patients. Meta-analysis reveals a significant HZ/HZO-stroke link. Subgroups highlight varied risks and warrant extended Asian/non-Asian patient investigation.

Herpes Zoster Ophthalmicus: Presentation, Complications, Treatment, and Prevention

Herpes zoster (HZ) is caused by reactivation of latent infection of varicella zoster virus (VZV) in sensory (cranial, dorsal root) ganglia. Major risk factors for HZ are increasing age and immunosuppression. HZ ophthalmicus (HZO) is a subset of HZ with involvement of the ophthalmic division of the fifth cranial trigeminal nerve. Approximately 4-20% of patients with HZ develop HZO. Approximately 50% of patients with HZO develop ocular disease, among whom up to 25% develop chronic or recurrent disease. Common manifestations of ocular disease include conjunctivitis, keratitis, and uveitis, whereas optic neuropathy and retinitis are uncommon. Due to the potential for vision impairment, ocular involvement requires urgent ophthalmic consultation. Early recognition and timely treatment with antivirals may prevent ocular complications. HZO is preventable by vaccination against HZ. Vaccine efficacy/effectiveness studies have been largely conducted for HZ with few studies assessing HZO. Both the recombinant adjuvanted vaccine (RZV) and live-attenuated vaccine (ZVL) significantly reduce the incidence of HZ and HZO in older adults. RZV is more effective than ZVL. Data on the effectiveness of vaccines for prevention of recurrent disease in patients with HZO are limited; however, vaccination is recommended. Despite recommendations to vaccinate individuals likely to benefit from an HZ vaccine, coverage for adults remains suboptimal. Barriers to vaccination include patient beliefs about HZ or HZ vaccines, and factors related to healthcare providers. In particular, the lack of a recommendation from their primary care physician is often cited by patients as a reason for remaining unvaccinated. By encouraging vaccination against HZ, physicians not only prevent HZ and HZO but also potential vision loss due to HZO.Graphical abstract available for this article.

Herpes zoster ophthalmicus: frequency and risk factors for developing uncommon ocular manifestations

OBJECTIVE

To determine the frequency of herpes zoster ophthalmicus (HZO) and assess risk factors for developing uncommon ocular manifestations of laboratory-verified HZO.

DESIGN

Retrospective cohort study.

METHODS

The frequency of HZO out of all herpes zoster cases was calculated using International Classification of Diseases codes for patients seen at the University of Pittsburgh Medical Center from January 1, 2004 to October 31, 2021. We also collected demographic and clinical data of patients with HZO identified by polymerase chain reaction (PCR) detection of varicella zoster virus from January 1, 2011 to December 31, 2020.

RESULTS

The frequency of HZO from 2004 to 2021 in all ages was 4.2% and ranged from 2.7% to 6.7% annually, with a consistent increase of 2.9% from 2012 to 2021. After the live zoster vaccine became available in 2008, the frequency of HZO decreased by 5.1% from 2008 to 2012 in patients aged 60 and older. Among 50 cases of PCR-verified HZO, 62% represented clinically-common ocular manifestations, mostly comprised of 13 cases of keratitis and 10 cases of anterior uveitis. Fifteen cases of acute retinal necrosis (ARN) represented the majority of uncommon HZO manifestations (38%), which were significantly more likely to occur in immunosuppressed patients (unadjusted odds ratio 4.55, 95% confidence interval 1.29-13.83).

CONCLUSIONS

The overall frequency of HZO from 2004 to 2021 was 4.2% and has increased annually since 2012. Uncommon ocular manifestations of PCR-verified HZO, mostly comprised of ARN, were more likely to occur in immunosuppressed patients.

Herpes zoster in Belgium: a new solution to an old problem

Herpes zoster (HZ) is caused by reactivation of the varicella-zoster virus. The life-time risk of developing HZ is ~ 30%. Management of HZ can be challenging due to limited efficacy of oral antivirals on pain control, and neuropathic pain that may require aggressive management. Post-herpetic neuralgia (PHN) can cause substantial pain and occurs in up to one-quarter of patients with HZ. Up to 48,000 HZ cases are estimated to occur annually in Belgium, estimated to cost almost 7 million euros in treatment. The recombinant zoster vaccine (RZV, Shingrix, GSK) was approved in Europe in 2017. In 2022, the Belgian Superior Health Council recommended vaccination with RZV for immunocompetent adults aged ≥ 60 years, and immunocompromised patients aged ≥ 16 years, including those receiving immunosuppressive therapy, in particular Janus kinase inhibitors. RZV showed high age-independent efficacy in preventing HZ infection and in clinical trials that has since been confirmed in real-world effectiveness studies. In clinical trials, protection was sustained for at least 10 years after vaccination. As of 1 November 2023, RZV is reimbursed for three immunocompromised patient groups aged ≥ 18 years: malignancy treated in the past 5 years, HIV infection, and organ or haematological stem cell transplantation or are a transplant candidate. HZ is vaccine-preventable and RZV provides a highly effective tool for HZ prevention. While reimbursement for some at-risk groups is welcomed, reimbursement currently falls well short of Superior Health Council recommendations. Adult immunisation strategies should be promoted to achieve high vaccination coverage against HZ, contributing to healthy aging in Belgium.

Public Perception in Saudi Arabia Toward Herpes Zoster and Its Vaccination: A Cross-Sectional Study

Background Herpes zoster (HZ) or shingles, arises from the reactivation of the varicella zoster virus (VZV), mainly affecting older and immunocompromised individuals. Despite the efficacy of vaccines, vaccination rates in Saudi Arabia are low. Thus, this study aimed to assess the knowledge, attitude, and practice of the Saudi Arabian population toward HZ and its vaccination. Methods An observational cross-sectional study was carried out to evaluate the public perception in Saudi Arabia toward HZ and its vaccination, during the period from January to March 2024. Participants were selected using a non-probability, convenience sampling method, with recruitment facilitated through WhatsApp, a messaging app. Data has been analyzed using the statistical software Statistical Package for Social Sciences (SPSS), version 26.0 (IBM Corp., Armonk, NY). A p-value of <0.05 has been used to report the statistical significance. Results The study's demographic profile included 1237 participants, predominantly younger than 30 years (65.5%), with a female majority (65.7%). Public knowledge about HZ was limited, only 29.6% of participants recognized the risk of HZ post-chickenpox. More than half of the participants were not aware that the vaccine is provided by the Saudi Ministry of Health (MOH) for certain groups. However, over 75% are willing to receive the HZ vaccine upon physician recommendation. Conclusion This study shows a general lack of awareness about HZ and its vaccination in Saudi Arabia, including misconceptions about vaccination availability, recommendations, and the disease's complications. Gender differences in attitude and interest highlight the potential for tailored educational campaigns. Addressing these issues is essential for improving vaccination rates and mitigating HZ's impact.

Practice Patterns in the Initial Management of Herpes Zoster Ophthalmicus in the United States

PURPOSE

The aims of this study were to examine the trends in the initial management of herpes zoster ophthalmicus (HZO) in the United States from 2010 to 2018 and compare them with the treatment preferences of corneal specialists.

METHODS

A retrospective, observational deidentified cohort study was conducted on individuals enrolled in the OptumLabs Data Warehouse who had a new diagnosis of HZO from 1/1/2010 to 12/31/2018. An online survey ascertaining HZO management perspectives was distributed to The Cornea Society listserv. The main outcome assessed was proportion of cases with systemic antiviral prescriptions, eye care provider involvement, and follow-up visits after the initial HZO diagnosis.

RESULTS

Approximately 50% of patients received systemic antivirals the day of initial HZO diagnosis or within 7 days (45.6% and 53.7%, respectively). Most initial diagnoses were made by ophthalmologists (45.0%), followed by optometrists (19.2%). Referral rate to ophthalmology within a year of initial diagnosis was 38.6%. 48.7% cases had at least 1 follow-up visit with any type of provider within 30 days. Our survey of corneal specialists found 97% would prescribe systemic antivirals to those with ocular involvement, but 66% would prescribe antivirals to those without ocular or eyelid involvement. Seventy percent supported all patients having follow-up with an eye care provider within a month.

CONCLUSIONS

HZO antiviral therapies seem to be underprescribed in the United States, referral rates to ophthalmology are low, and follow-up is suboptimal, which are not aligned with recommendations from corneal specialists. More research is needed to establish standardized guidelines for treatment, referral, and follow-up with ophthalmology for HZO.

Herpes Zoster after COVID-19 Infection or Vaccination: A Prospective Cohort Study in a Tertiary Dermatology Clinic

Background

Herpes zoster (HZ) has been observed to occur after COVID-19 infection and vaccination; however, knowledge regarding the demographic data, clinical presentations, and treatment outcomes of HZ is limited.

Objective

To compare the demographic data, clinical manifestations, treatments, and outcomes of patients with and without HZ within 14 days of COVID-19 infection or vaccination.

Methods

This prospective cohort study involving patients diagnosed with cutaneous HZ was conducted at a dermatology clinic from October 2021 to January 2023.

Results

Among a total of 232 patients with HZ, the median age was 62.0 years and 59.1% were female. HZ developed in 23 (9.9%) and four (1.7%) patients after COVID-19 vaccination and infection, respectively. The mean duration from vaccination and the median duration from infection to HZ onset were 5.7 and 8.5 days, respectively. The proportion of female patients was significantly higher in the group of patients with COVID-19 vaccination or infection than in those without such a history (P = 0.035). Patients who developed HZ following the recent COVID-19 infection had a median age of 42.5 years, which was lower than that of the other groups. Dissemination occurred in 8.7% of the patients after COVID-19 vaccination. HZ recurrence was reported in five cases, of which 80% had been vaccinated or infected with COVID-19 during the previous 21 days. All patients had similar durations of antiviral treatment, crust-off time, and duration of neuralgia.

Conclusions

HZ after COVID-19 vaccination is more frequently observed in females, while HZ after COVID-19 infection tends to occur in younger patients. Disseminated HZ is more common in patients recently vaccinated against COVID-19. COVID-19 vaccination or infection may trigger recurrent HZ infection.

Varicella-Zoster Virus Reactivation and Increased Vascular Risk in People Living with HIV: Data from a Retrospective Cohort Study

BACKGROUND

The increased vascular risk associated with varicella-zoster virus (VZV) reactivation is extensively established in the general population. This retrospective cohort study investigates whether this observation holds for People Living with HIV (PLWH), a group already confronting heightened cardiovascular risk.

METHODS

Among PLWH who initiated antiretroviral therapy (ART) at our center and have been under our care for >24 months since 1st January 2005, individuals with a history of herpes zoster (HZ) were identified, and their features were compared with those of PLWH with no history of HZ. The prevalence of ischemic events (deep venous thrombosis, stroke, and acute myocardial infarction) was calculated and compared using the chi-square test. An odds ratio (O.R.) and a 95% confidence interval (C.I.) for ischemic events following HZ were evaluated through univariate and multivariate logistic regression.

RESULTS

Overall, 45/581 PLWH reported HZ. Ischemic events followed HZ significantly more often than not (13% vs. 5%, p = 0.01). Positive serology for both VZV and HZ correlated with increased ischemic risk (O.R. 4.01, 95% C.I. 1.38-11.6, p = 0.01 and O.R. 3.14, 95% C.I. 1.12-7.68, p = 0.02, respectively), though chronic heart disease demonstrated stronger predictive value in multivariate analysis(O.R. 8.68, 95% C.I. 2.49-29.50, p = 0.001).

CONCLUSIONS

VZV potentially exacerbates vascular risk in PLWH, particularly in the presence of other predisposing factors. Further research is needed to confirm our data.

Herpes Zoster virus infection and the risk of developing dementia: A systematic review and meta-analysis

BACKGROUND

Herpes Zoster, commonly known as shingles, is a viral infection that affects a significant portion of the adult population; however, its potential role in the onset or progression of neurodegenerative disorders like dementia remains unclear.

METHODS

We searched the following databases: PubMed, Scopus, Cochrane library, and Web of Science. We included any randomized control trials and controlled observational studies as Cross-sectional, prospective, or retrospective cohort and case-control studies that investigated the prevalence of dementia in Herpes Zoster Virus (HZV)-infected patients and HZV-free control group or if the study investigated the prevalence of HZV in demented patients. Also, if the studies measured the levels of dementia biomarkers in patients with HZV compared with a healthy control group.

RESULTS

After the complete screening, 9 studies were included in the meta-analysis. In the outcome of the incidence of HZV, the pooled analysis showed no statistically significant difference between the dementia group and the No dementia group (RR = 1.04% CI = 0.86-1.25, P = .70). In the outcome of incidences of dementia and Alzheimer's disease, the pooled analysis showed no statistically significant difference between the HZV group and the incidence of dementia (RR = 0.99, 95% CI = 0.92-1.08, P = .89), (RR = 3.74, 95% CI = 0.22-62.70, P = .36) respectively. In the outcome of incidences of Herpes Zoster ophthalmicus (HZO), the generic inverse variance showed a statistically significant association between patients who have HZO and increased incidence of dementia (RR = 6.26, 95% CI = 1.30-30.19, P = .02).

CONCLUSION

Our study showed no significant association between HZV and the incidence of dementia or Alzheimer's disease, but it shows a significant association between HZO and the incidence of dementia. More multicenter studies are needed to establish the actual association between the HZV and dementia.

Investigation of Altered Spontaneous Brain Activity Patterns in Herpes Zoster Keratitis Using the Percent Amplitude of Fluctuation Method: A Resting-State Functional Magnetic Resonance Imaging Study

Purpose

The purpose of this study was to use the percent amplitude of fluctuation (PerAF) to study the changes in brain activity and nerve function of herpes zoster keratitis (HZK) patients.

Methods

We recruited 20 HZK patients and 20 healthy controls (HCs). Each of these groups included ten males and ten females and were matched in weight and age. All participants underwent resting-state functional magnetic resonance imaging (rs-fMRI). The percent amplitude of fluctuation (PerAF) method was used for analysis and detected differences between the two groups in the neurological function of brain areas. We also applied the receiver operating characteristic (ROC) curve to analyze the two groups and did a correlation analysis between the PerAF value, anxiety and depression score, and visual acuity.

Results

The PerAF signal at the right putamen and right precentral gyrus was significantly higher in patients than in HCs. However, the PerAF value of the left inferior temporal was lower in patients than in HCs. In addition, the HZK patients' anxiety and depression score (HADS) and visual acuity (V.A.) Log MAR negatively correlated with the PerAF value at the left inferior temporal gyrus.

Conclusion

HZK patients had some changes in brain regions, and the changes were also related to their mood and visual acuity. These findings might contribute to other studies on the potential pathological mechanism, disease development, prognosis, and brain function in HZK patients.

Herpes Zoster Ophthalmicus Discovered During Pain Consult Possibly Complicated With Dural Sinus Thrombosis and Refractory Headache Managed With Ketamine: A Case Report

Pain is a common symptom associated with shingles and may precede the onset of the characteristic rash. In the context of herpes zoster ophthalmicus, pain can manifest with severe headaches, posing challenges due to other potentially life-threatening conditions such as stroke and intracranial hypertension. In this report, we present the case of a 51-year-old male with severe headache and imaging findings of dural sinus thrombosis. He was later diagnosed with herpes zoster ophthalmicus and required aggressive inpatient management of neuropathic pain. Despite appropriate treatment, acute herpes zoster can progress to post-herpetic neuralgia, requiring long-term pain management.

Current scenario and future applicability of antivirals against herpes zoster

Herpes zoster (HZ) is a common disease in the aging population and immunocompromised individuals, with a lifetime risk of 20%-30% that increases with age. HZ is caused by reactivation of the varicella-zoster virus (VZV), which remains latent in the spinal dorsal root ganglia and cranial sensory ganglia after resolution of the primary VZV infection. The main focus of HZ management is rapid recovery from VZV infection as well as the reduction and prevention of zoster-associated pain (ZAP) and postherpetic neuralgia (PHN). The use of antivirals against VZV is essential in the treatment of HZ. However, limited antivirals are only licensed clinically for the treatment of HZ, including acyclovir, valacyclovir, famciclovir, brivudine, and amenamevir. Fortunately, some new antivirals against different types of Herpesviridae have been investigated and suggested as novel drugs against VZV. Therefore, this review focuses on discussing the difference in efficacy and safety in the currently licensed antivirals for the treatment of HZ, the applicability of future novel antivirals against VZV, and the preventive or therapeutic effects of these antivirals on ZAP or PHN.

Herpes zoster: A Review of Clinical Manifestations and Management

The Varicella-zoster virus (VZV) or human herpes virus 3 is a neurotropic human alpha herpes virus responsible for chickenpox/varicella and shingles/Herpes zoster (HZ). This review will focus on HZ. Since HZ is secondary to varicella, its incidence increases with age. In children and youngsters, HZ is rare and associated to metabolic and neoplastic disorders. In adults, advanced age, distress, other infections (such as AIDS or COVID-19), and immunosuppression are the most common risk factors. HZ reactivation has recently been observed after COVID-19 vaccination. The disease shows different clinical stages of variable clinical manifestations. Some of the manifestations bear a higher risk of complications. Among the possible complications, postherpetic neuralgia, a chronic pain disease, is one of the most frequent. HZ vasculitis is associated with morbidity and mortality. Renal and gastrointestinal complications have been reported. The cornerstone of treatment is early intervention with acyclovir or brivudine. Second-line treatments are available. Pain management is essential. For (secondary) prophylaxis, currently two HZV vaccines are available for healthy older adults, a live attenuated VZV vaccine and a recombinant adjuvanted VZV glycoprotein E subunit vaccine. The latter allows vaccination also in severely immunosuppressed patients. This review focuses on manifestations of HZ and its management. Although several articles have been published on HZ, the literature continues to evolve, especially in regard to patients with comorbidities and immunocompromised patients. VZV reactivation has also emerged as an important point of discussion during the COVID-19 pandemic, especially after vaccination. The objective of this review is to discuss current updates related to clinical presentations, complications, and management of HZ.