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Experts will take you to grasp the 4 key points of diagnosis and apply effective antiviral therapy as early as possible~
Written by丨Thinker
Recently, the disease herpes zoster has become a hot topic due to the experience of two well-known singers. Na Ying wore a veil for herpes zoster in her eyes in "Singer 2024", while Cai Guoqing suffered severe pain from acute shingles during the recording of the show.
These two incidents not only attracted widespread public attention, but also provided us with an opportunity to learn more about shingles.
Figure 1. Image source Weibo
Herpes zoster (HZ), commonly known as "loincloth", is an acute infectious skin disease caused by varicella-zoster virus (VZV) characterized by clusters of blisters along the nerves and severe pain. Herpes zoster can affect all ages, but the incidence is always high in the elderly, who are often more severe, have longer pain and are at higher risk of complications!
So what is the reason why the elderly have become a high incidence of shingles, and how can we prevent and treat it? At this CSD conference, Professor Hao Fei from the Third Affiliated Hospital of Chongqing Medical University will introduce the current situation, treatment strategies and preventive measures of geriatric herpes zoster from the following three perspectives, so as to provide scientific reference for the diagnosis and treatment of elderly patients with herpes zoster.
The incidence of herpes zoster in the elderly is high and the disease burden is heavy
At present, herpes zoster in the elderly over 60 years old is usually called "senile shingles". Professor Hao Fei said that the lifetime risk of HZ also increases with age, ranging from 20%~30% in the general population to 50% at the age of 85. The incidence of shingles in the elderly not only increases significantly with age, but also increases significantly with age.
Figure 2: HZ age and incidence in North America, Europe, and Asia-Pacific[1]
Herpes zoster not only has a high incidence in the elderly population, but also causes a variety of serious complications, causing great distress to their quality of life. Professor Hao Fei pointed out that after being infected with herpes zoster, the elderly often face postherpetic neuralgia, in addition, a series of comorbidities or complications such as keratitis, scleritis, stroke, angina pectoris, etc. may occur.
Figure 3: Serious complications caused by shingles
There are many special manifestations of herpes zoster in the elderly, and the diagnosis is challenging
Professor Hao Fei said that the diagnosis of herpes zoster is not difficult at present, but there are still some problems in clinical diagnosis, mainly including the following conditions:
- There was no pain before the rash, but a lot of tests were done, and it was found to be shingles after being admitted to another department;
- Neglect of examination and discovery of underlying diseases after diagnosis of herpes zoster;
- After diagnosis, the same complex treatment is taken without detailed analysis of the condition;
- There are misdiagnoses or missed diagnoses for atypical presentations.
Therefore, the following elements should be focused on in diagnosis:
➤ Emphasis on early diagnosis
The challenge of pre-eruptive diagnosis is to recognize the pain caused by herpes zoster, which often precedes the lesion by one to several days and is characterized by the following:
- Pain level: Severe pain
- Nature of pain: Neuropathic pain (pins and needles, lightning, burning, etc.)
- Accompanying symptoms: only locally accompanied by numbness, tenderness (pain sensitivity), sensory sensitivity
- Location of pain: more consistent with nerve distribution
➤ Focus on the diagnosis of herpes zoster in specific areas
For senile herpes zoster or herpes zoster without rash in the early stage, it is necessary to distinguish it from migraine, trigeminal neuralgia, pulpitis, myocardial infarction, angina, cholecystitis, renal colic, appendicitis, lumbar disc herniation, or muscle strain, depending on the body part corresponding to the pain. Atherema herpes zoster auricular should be distinguished from idiopathic facial palsy and Meniere's disease.
Age-related herpes zoster lesions should be distinguished from incipient or localized bullous pemphigoid, herpes zoster on the head and face should be distinguished from erysipelas on the face, and herpes zoster around the mouth and nose and in the genital area should be distinguished from herpes simplex and genital herpes. Recurrent herpes simplex should be considered if herpes occurs repeatedly in the same area. When herpes zoster affects the internal organs and central nervous system, laboratory tests are needed to distinguish herpes zoster from other neurological and medical disorders.
➤ Discover the underlying disease that causes shingles
Professor Hao pointed out that if older patients with herpes zoster have the following more severe or widespread conditions, it is important to focus on screening for other underlying diseases.
- It is difficult to explain the association between lesion severity and age and constitution
- Severe skin lesions such as hemorrhagic and gangrenous that are difficult to explain
- The course of the disease is longer and the lesions heal poorly
- Hard-to-explain lesions are widespread and even disseminated
- Recurrence of the condition that is difficult to explain
➤ Predict the occurrence of postherpetic neuralgia
Postherpetic neuralgia (PHN) is the most common type of pain in older adults, and its incidence increases with age. PHN is more common in the upper body than in the lower body, especially in the trigeminal nerve. The more severe the disease in the early stages, the more likely the patient is to develop PHN.
In addition, patients with longer time for the rash to resolve, a higher number of blisters, and a larger area of infected skin are more likely to develop PHN. Early treatment reduces the incidence of PHN, and antiviral therapy is more important than corticosteroid therapy.
Antiviral therapy for herpes zoster in the elderly is essential
The goals of the treatment of herpes zoster in the elderly are to rapidly control the disease, reduce the inflammation and edema of the affected nerves, relieve pain in the acute phase, shorten the duration of skin lesions, reduce the occurrence of PHN, and promote recovery.
However, at present, it is also facing some problems, such as severe clinical symptoms, many complications, large treatment needs, many complications of geriatric herpes zoster, common drug interactions, and low drug treatment index of geriatric herpes zoster.
At present, the commonly used treatment methods are antiviral drugs and hormone therapy, so how should they be chosen?
Professor Hao Fei said that it is traditionally believed that early administration of hormones in herpes zoster can effectively reduce inflammation and reduce the occurrence of postherpetic neuralgia, so it has become a routine treatment method in clinical practice. However, with rigorous clinical research, especially the application of evidence-based medicine, it has been found that the value of hormones in the treatment of herpes zoster is exaggerated and even abused. Therefore, corticosteroids should be used with caution.
In terms of antiviral drug treatment, the early application of highly effective antiviral therapy in elderly patients with herpes zoster is very important, and the early standard and systematic application of antiviral therapy within 72 hours of the appearance of rash can help improve the prognosis. Standardized and systematic antiviral therapy should also be considered for elderly patients who have not received antiviral therapy for more than 72 hours or in the acute phase. First-line antiviral drugs for the treatment of herpes zoster in the elderly include brovudine, valacyclovir, famciclovir and acyclovir. One of the most effective is bromovudine.
Figure 4: Main antiviral treatment regimens for herpes zoster in the elderly[2]
As an antiviral drug, bromovudine tablets are essentially a nucleoside analogue with high efficiency and high selectivity against VZV, and their antiviral activity is significantly better than that of acyclovir and its derivatives. Bromvudine 125 mg once a day for a 7-day course of treatment for herpes zoster is as effective and safe as acyclovir and famciclovir, with high patient compliance and few drug interactions, making it one of the best options for the treatment of herpes zoster.
brief summary
In summary, the diagnosis and treatment of herpes zoster in the elderly needs to consider many factors. On the basis of early and accurate diagnosis, timely antiviral therapy and symptomatic treatment, it is particularly important to pay attention to the assessment and management of patients' underlying diseases. Through standardized treatment plans and individualized care measures, the incidence of postherpetic neuralgia (PHN) can be effectively reduced and the quality of life of patients can be improved.
Expert Profile
Prof. Fei Hao
- Professor, Chief Physician, Doctoral Supervisor
- Director of the Dermatology Center of the Third Affiliated Hospital of Chongqing Medical University
- Expert who enjoys the special government allowance of the State Council
- Famous teachers and famous teachers in Chongqing
- Chongqing academic and technical leader
- The 11th-14th Standing Committee Member and the 14th Secretary-General of the Chinese Society of Dermatology and Venereology
- The 1st-3rd Vice President of the Dermatology Branch of the Chinese Medical Doctor Association
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Bibliography:
[1] Kawai, K.; Gebremeskel, B. G.; Acosta, C. J. (2014). Systematic review of incidence and complications of herpes zoster: towards a global perspective. BMJ Open, 4(6), e004833–e004833.
[2] Chinese Society of Dermatology and Venereology, Chinese Association of Rehabilitation Medicine, Chinese Association of Rehabilitation Medicine, Chinese Association of Integrative Medicine, Dermatology and Venereology Branch, et al. Expert consensus on the diagnosis and treatment of herpes zoster in the elderly[J]. Chinese Journal of Dermatology,2023,56(02):97-104.
Review of this article: Professor Hao Fei
Editor in charge: Liu Sisi
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