Diagnosis

When the presentation includes the typical dermatomal rash, additional studies are not
required. Studies to consider in specific situations include the following:

If the diagnosis is in doubt, a Tzanck smear or culture of vesicular fluid can be

performed

In cases of zoster sine herpete, DNA analysis via PCR can be used

In cases of acyclovir-resistant VZV, detections of mutations in thymidine kinase can

be determined by PCR and sequence analysis

MRI may be useful if myelitis or encephalitis is suspected

Lumbar puncture may be helpful if signs suggest myelitis or encephalitis

Laboratory Studies
When the presentation includes the typical dermatomal rash, additional studies are not
required.

If the diagnosis is in doubt, a Tzanck smear can be performed and has a sensitivity of about
60%. To obtain a Tzanck smear, remove the crust from a vesicle and scrape the underlying
moist skin with a No. 15 surgical blade. Smear the cells from the vesicle base onto a slide, fix
for 1 minute with absolute alcohol, and stain with Wright stain (other staining methods can
also be used).

The diagnosis can also be confirmed with a culture of vesicular fluid that is positive for
varicella-zoster virus (VZV).

In cases of zoster sine herpete, DNA analysis via polymerase chain reaction (PCR) can be
used for early diagnosis if laboratory turnaround time is reasonably short. If not, the decision
of whether to start empiric acyclovir must be based on clinical grounds alone.

In cases of acyclovir-resistant VZV, detections of mutations in thymidine kinase can be

determined by PCR and sequence analysis. Acyclovir-resistance may occur in stem cell
transplant recipients. [5]

Histologic Findings
The varicella zoster virus is a DNA virus with a genome that encodes 70 proteins.

The Tzanck preparation shows characteristic findings of giant cells with 2-15 nuclei.
Recently infected epithelial cells contain a single enlarged nucleus with a thick nuclear
membrane.
After reactivation, meningeal biopsy samples show a local inflammatory response, consisting
of plasma cells and lymphocytes, that encompasses the leptomeninges.

Evidence has shown that motor neuron involvement is demyelinating rather than axonal.

Management

Treatment options are based on the following:

Patient age

Patient immune state

Duration of symptoms

Presentation

Antiviral medications decrease the duration of symptoms and the likelihood of postherpetic
neuralgia, especially when initiated within 2 days of the onset of rash. Oral acyclovir may be
prescribed in otherwise healthy patients who have typical cases. Compared with oral
acyclovir, other medications (eg, valacyclovir, penciclovir, famciclovir) may decrease the
duration of the patient's pain.

Varicella zoster immune globulin (VariZIG) is indicated for administration to high-risk

individuals within 10 days (ideally within 4 days) of chickenpox (VZV) exposure. [2] High-
risk groups include the following:

Immunocompromised children and adults

Newborns of mothers with varicella shortly before or after delivery

Premature infants

Infants less than younger than 1 year of age

Adults without evidence of immunity

Pregnant women

Medical Care
Treatment options are based on the patient's age, immune state, duration of symptoms, and
presentation.

Several studies indicate that antiviral medications decrease the duration of symptoms and the
likelihood of postherpetic neuralgia, especially when initiated within 2 days of the onset of
rash. In typical cases that involve individuals who are otherwise healthy, oral acyclovir may
be prescribed. An important study by Kubeyinje (1997) suggested that the use of acyclovir in
healthy young adults with zoster is not clearly justified, especially in situations of limited
economic resources. [6]

Acyclovir has 2 limitationsbioavailability and the existence of some resistant strains of

varicella-zoster virus (VZV).

Other medications, including valacyclovir, penciclovir, and famciclovir, are also available.
They may have an increasing role in the treatment of typical zoster. Studies suggest that,
when compared with oral acyclovir, the new medications may decrease the duration of the
patient's pain.

Varicella zoster immune globulin (VariZIG) is indicated for administration to high-risk

individuals within 10 days (ideally within 4 days) of chickenpox (varicella zoster virus)
exposure. [2]

In July 2013, the CDC issued updated recommendations for the use of varicella-zoster
immune globulin (VariZIG) to reduce the severity of VZV infection, extending the window
for postexposure prophylaxis for those at high risk for severe varicella. [7, 8] The FDA's
original approval of VariZIG recommended use within 4 days, but subsequent studies have
shown that the treatment is effective for up to 10 days after exposure.

Other recommendations include the use of VariZIG in the following patients:

Immunocompromised patients without evidence of immunity

Newborn infants whose mothers have varicella symptoms between 5 days

before and 2 days after delivery

Hospitalized premature infants born at 28 weeks of gestation or later

whose mothers do not have evidence of immunity to varicella

Hospitalized premature infants born at less than 28 weeks of gestation or

who weigh less than 1000 g at birth, regardless of their mothers' evidence
of immunity to varicella

Pregnant women without evidence of immunity

Dworkin et al (2009) conducted a randomized, placebo-controlled trial of oral oxycodone and

oral gabapentin as potential treatments for acute pain in patients with herpes zoster. They
found that controlled-release oxycodone was superior to placebo in the early period of pain
(1-14 d). Gabapentin was not shown to yield a significantly greater relief of pain than
placebo, although it conferred modest pain relief during the first week. [9]
Medication Summary
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Current
research is considering whether the varicella vaccine may also prove efficacious as treatment
for active varicella-zoster virus (VZV) infection.

Antiviral agents
Class Summary

Three medications may help reduce pain and symptoms and the incidence of postherpetic
neuralgia. All need to be used with caution in patients with renal compromise. Hemolytic
uremic syndrome is rare but has been reported. All 3 agents may be used for 7-10 d,
depending on response. Only acyclovir is available in an intravenous form.

Acyclovir (Zovirax)

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Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h
from rash onset. May prevent recurrent outbreaks.

Valacyclovir (Valtrex)

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Prodrug rapidly converted to the active drug acyclovir. More expensive but has a more
convenient dosing regimen than acyclovir.

Famciclovir (Famvir)

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Prodrug that, when biotransformed into active metabolite penciclovir, may inhibit viral DNA
synthesis/replication.

Vaccine, Live Virus

Class Summary

These agents are used to induce active immunity.

The combined MMRV vaccine (ProQuad) has been shown to be associated with an increased
risk of febrile seizure occurring 5-12 days following vaccination at a rate of 1 in 2300-2600
in children aged 12-23 months compared with separate MMR vaccine and varicella vaccine
administered simultaneously. [10, 11] As a result, the CDC Advisory Committee on
Immunization Practices (ACIP) recommends that separate MMR and varicella vaccines be
used for the first dose, although providers or parents may opt to use the combined MMRV for
the first dose after counseling regarding this risk. [12] MMRV is preferred for the second dose
(at any age) or the first dose if given at age 48 months or older.

Data from postlicensure studies do not suggest that children aged 4-6 years who received the
second dose of MMRV vaccine had an increased risk for febrile seizures after vaccination
compared with children the same age who received MMR vaccine and varicella vaccine
administered as separate injections at the same visit. [12]

Varicella virus vaccine (Varivax)

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A live attenuated varicella virus prepared from the Oka/Merck strain. It is propagated in
human diploid cell cultures (MRC-5). Each 0.5-mL dose (when reconstituted) contains 1350
PFU of varicella, sucrose, and gelatin; residual components of MRC-5 DNA and protein; and
trace quantities of neomycin and fetal bovine serum. Indicated for vaccination against
varicella in individuals >1 y.

Varicella zoster vaccine (Zostavax)

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This is a lyophilized preparation of the Oka/Merck strain of live, attenuated varicella-zoster

virus (VZV). It has been shown to boost immunity against herpes zoster virus (shingles) in
older patients. It reduces the occurrence of shingles in individuals older than 60 years by
about 50%. For individuals aged 60-69 years, it reduces the occurrence by 64%. In the ZEST
trial, the vaccine significantly reduced the risk by 70% in subjects aged 50-59 years. It also
slightly reduces pain compared with no vaccination in those who develop shingles. It is
indicated for the prevention of herpes zoster in patients who have no contraindications.

Topical Analgesics
Class Summary

Topical analgesics that contain capsaicin are effective in decreasing neuropathic pain caused
by postherpetic neuralgia.

Capsaicin transdermal patch (Qutenza)

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Transient receptor potential vanilloid-1 (TRPV1) agonist indicated for neuropathic pain
associated with postherpetic neuralgia. TRPV1 is an ion channelreceptor complex expressed
on nociceptive skin nerve fibers. Topical capsaicin causes initial TRPV1 stimulation that may
cause pain, followed by pain relief by reduction in TRPV1-expressing nociceptive nerve
endings. Neuropathic pain may gradually recur over several months (thought to be caused by
TRPV1 nerve fiber reinnervation of treated area).

Immune Globulins
Class Summary

The specific immune globulin with IgG varicella zoster antibodies provides passive
immunization for susceptible individuals when administered within 10 days (ideally within
96 hours) of exposure.

Varicella zoster immune globulin, human (VariZIG)

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Varicella zoster immune globulin (VZIG) contains immunoglobulin G (IgG) varicella-zoster

antibodies. It provides passive immunization to exposed individuals at high risk of
complications from varicella. High- risk groups include immunocompromised children and
adults, newborns of mothers with varicella shortly before or after delivery, premature infants,
infants < 1 year, adults without evidence of immunity, and pregnant women. Administer by
deep IM injection, preferably in deltoid muscle. For neonates or infants, administer IM in
anterolateral aspect of thigh.

Link : http://emedicine.medscape.com/article/231927-medication