Nursing Management of Shingles (Herpes Zoster) and Disease Process

Shingles or herpes zoster is believed to be due to a failure of the immune defense system to control the latent replication of the virus. Individuals who maintain a high level of immunity rarely develop shingles. Even after herpes zoster resolves, many clients continue to suffer from moderate to severe pain known as postherpetic neuralgia. The condition has no cure but can be prevented in most clients via vaccination. The role of nurses is to improve the client’s immune system, prevent the development of complications, and educate the clients about the importance of infection control and vaccination.

Overview

Shingles or herpes zoster is an acute, cutaneous viral infection that occurs with the reactivation of the varicella-zoster virus, a herpesvirus that is the cause of varicella (chickenpox). After an episode of varicella, the varicella-zoster virus (VZV) remains dormant in the nervous system. Reactivation of the virus that has remained dormant, often for decades after the client’s initial exposure to the virus in the form of chickenpox, results in shingles.

Incidence/Classification

The incidence of shingles appears to be inversely correlated with the host’s capacity to mount a cellular immune response. However, many clients with shingles apparently have normal immunity. In these clients, zoster is postulated to occur when VZV antibody titers and cellular immunity drop to levels that no longer are completely effective in preventing viral invasion.

Herpes zoster rates are increasing among adults, especially among younger adults. The increase has been gradual over a long period of time. Most people have only one episode of shingles in their lifetime, however, multiple episodes can occur. The precise incidence of recurrence is not known.

Treatment

Episodes of shingles are generally self-limiting and resolve without intervention; they tend to be more benign and milder in children than in adults. Conservative therapy includes:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Wet dressings with 5% aluminum acetate applied for 30 to 60 minutes, four to six times daily
• Lotions such as calamine

Antiviral therapy may decrease the length of time for new vesicle formation, the number of days to attain complete crusting, and the days of acute discomfort. The earlier antiviral medications are started, the more effective they are in shortening the duration of shingles and in preventing or decreasing the severity of postherpetic neuralgia. Oral treatment with the following has been found beneficial:

• Acyclovir
• Famciclovir
• Valacyclovir

Pathophysiology

VZV infection gives rise to two distinct syndromes. The primary infection, chickenpox, is a contagious and usually benign febrile illness. After this infection resolves, viral particles remain in the dorsal root ganglia, where they may lay dormant for years to decades. In this latent period, host immunologic mechanisms suppress replication of the virus, but VZV reactivates when the host mechanisms fail to contain the virus. Once the virus is activated at the spinal root or cranial nerve neurons, an inflammatory response occurs that also encompasses the leptomeninges; both plasma cells and lymphocytes are noted.

The dermatological involvement is centripetal and follows a dermatome. In most cases, it is the lumbar and cervical roots that are involved, whereas motor involvement is rare. The infection is contagious to individuals who have no prior immunity to varicella-zoster, however, the rates of transmission are low. The virus can be transmitted either via direct skin contact or by inhaling infected droplets.

Epidemiology of Herpes Zoster or Shingles

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 clients older than 65 years. There is no seasonal variation seen with herpes zoster. Recurrences are most common in immunosuppressed clients.

An estimated one million cases of shingles occur annually in the United States. Approximately 1 to 4% of clients with herpes zoster get hospitalized for complications. Older adults and clients with compromised or suppressed immune systems are more likely to get hospitalized. About 30% of all clients hospitalized with herpes zoster have compromised or suppressed immune systems.

One study estimated that 96 deaths occur each year in which shingles were the actual underlying cause (0.28 to 0.69 per 1 million population). Almost all the deaths occurred in older adult people or those with compromised or suppressed immune systems.

People with the following conditions that compromise or suppress their immune system have an increased risk for herpes zoster:

• Cancer (leukemia and lymphoma)
• Human immunodeficiency virus (HIV)
• Bone marrow or solid organ transplant recipients
• Taking immunosuppressive medications, including steroids, chemotherapy, or transplant-related immunosuppressive medications

Other potential risk factors for herpes zoster have been identified, but findings are either inconsistent or unexplained, such as:

• More women than men develop shingles
• Shingles are less common in Blacks (by at least 50%) than in Whites

Signs and Symptoms

Shingles characteristically present with a prodrome of fever, malaise, and excruciating burning pain followed by the outbreak of vesicles that appear in one to three crops over three to five days. The clinical manifestations can be divided into three phases:

• Pre-eruptive phase
• Acute eruptive phase
• Chronic phase

The pre-eruptive phase is characterized by:

• Sensory phenomena along one or more skin dermatomes, lasting one to ten days
• Phenomena usually are noted as pain or, less commonly, itching or paresthesias
• Pain may simulate headache, iritis, pleurisy, brachial neuritis, cardiac pain, appendicitis, or other intra-abdominal diseases
• Other symptoms may occur such as malaise, myalgia, headache, photophobia, and fever (uncommon)

The acute eruptive phase is marked by:

• Patchy erythema accompanied by induration
• Regional lymphadenopathy
• Grouped herpetiform vesicles at the erythematous base: a classic finding
• Cutaneous findings that appear unilaterally, stopping at the midline of the involved dermatome
• Vesicles initially are clear but eventually cloud, rupture, crust, and involute
• Slow resolution of remaining erythematous plaques
• Scarring, if deeper epidermal and dermal layers were involved in excoriation, secondary infection, or complications
• Severe pain
• Severe pain without a vesicular eruption
• Symptoms tend to resolve over 10 to 15 days
• Complete healing of lesions may require up to a month

The chronic phase is characterized by:

• Persistent or recurring pain lasting 30 or more days after the acute infection or after all lesions have crusted
• Pain is usually confined to the area of the original dermatome
• Severe, incapacitating pain
• Pain can persist for weeks, months, or years
• Slow resolution of pain especially common among older adults

Prevention

Infection control measures depend on whether the client with shingles is immunocompetent or immunocompromised and whether the rash is localized or disseminated.

• Varicella-zoster virus vaccine
  The routine use of live attenuated varicella vaccine has led to a remarkable reduction in the incidence of primary varicella infection. Furthermore, vaccinated children have demonstrated lower rates of herpes zoster than those infected through natural exposure to VZV. Two doses of recombinant zoster vaccine (RZV) should be administered 2 to 6 months apart to adults aged 50 years or older regardless of past episodes of herpes zoster or receipt of the zoster vaccine live (ZVL). Two doses of RZV are also to be given 2 to 6 months apart to adults who previously received ZVL at least two months after ZVL. Lastly, for adults aged 60 years or older, either RZV or ZVL should be administered.

• Varicella-zoster immune globulin
  The CDC recommends the administration of VZIG to prevent or modify clinical illness in persons with exposure to varicella or herpes zoster who are susceptible or immunocompromised. VZIG provides maximum benefit when administered as soon as possible after the presumed exposure, but it may be effective if administered as late as 96 hours after exposure. Protection lasts for an average of approximately 3 weeks.
• Cover the rashes or lesions and avoid scratching or touching them.
  Direct contact with the fluid from the rash blisters can spread VZZ to people who have never had chickenpox or never received the chickenpox vaccine. The risk of spreading the virus to others is low if the rash is covered. People with shingles cannot spread the virus before their rash blisters appear or after the rash crusts.
• Avoid contact with immunosuppressed people or people who may develop severe complications when infected with shingles.
  Avoid contact with the following people until the rash crusts: pregnant women who have never had chickenpox or the chickenpox vaccine; premature or low birth weight infants; and people with the weakened immune system, such as people receiving immunosuppressive medications or undergoing chemotherapy, organ transplant recipients, and people with HIV.

Medical Management

Therapeutic management choices generally depend on the host’s immune state and on the presentation of shingles. Treatment is of greatest benefit in those client populations at risk for prolonged or severe symptoms, specifically, immunocompromised people and persons older than 50 years. Uncomplicated zoster does not require inpatient care.

Topical therapy

There are a variety of topical treatments, including topical acyclovir 5% cream, lidocaine, and capsaicin.

• Capsaicin. This is applied at least 5 times a day. It depletes neurotransmitters at involved nerve endings.
• Topical lidocaine. This can be used to treat clients with postherpetic neuralgia.
• Burow solution. For acute herpes zoster ophthalmicus, a good approach is wet-to-dry dressings with sterile saline solution or Burow solution (a pharmacologic preparation made of 5& aluminum acetate dissolved in water), which should be applied to the affected skin for 30 to 60 minutes 4 to 6 times daily. A modified form of Burow solution is commercially sold as Domeboro powder packets, which need to be dissolved in water.
• Topical acyclovir. The acyclovir cream is often applied five times a day for four days.
• Calamine lotion. Calamine lotion, a mixture of zinc oxide with about 0.5% iron oxide, may be used as an antipruritic agent. It is also used as a mild antiseptic to prevent infections that can be caused by scratching the affected area, as well as an astringent for weeping or oozing blisters.

Pharmacologic Therapy

The goals of pharmacologic therapy are to shorten the clinical course, provide analgesia, prevent complications, and decrease the incidence of postherpetic neuralgia.

• Corticosteroids. Many practitioners have long used oral prednisone and similar medications to reduce acute pain. Some have also hoped to decrease the incidence of PHN, presumably by reducing inflammation in the dorsal root ganglia and involved sensory nerves. A substantial dose of 40 to 60 mg every morning is typically administered as early as possible in the course of the disease and is continued for one week, followed by a rapid taper over one to two weeks.
• Pain control. The majority of clients with acute herpes zoster experience pain, and this pain is usually the most debilitating symptom of the disease. Primary medications for acute zoster-associated pain include narcotic and non-narcotic analgesics, neuroactive agents, and anti-convulsant agents. The oral narcotic oxycodone and the oral anticonvulsant gabapentin, as well as the topical analgesics aspirin and lidocaine, proved capable of reducing acute zoster-associated pain.
• Antiviral agents. Many studies have found acyclovir and its derivatives (valacyclovir, famciclovir, penciclovir, and desciclovir) to be safe and effective in treating active disease and preventing PHN. Their mechanism of action involves preventing VZV replication through the inhibition of viral DNA polymerase. The duration of antiviral treatment in studies has ranged from 7 to 21 days. For immunocompetent clients, a 7 to 10-day course of acyclovir or a 7-day course of one of the newer agents is probably appropriate.

Assessment and Diagnosis

Herpes zoster is clinically diagnosed with burning pain, characteristic morphology, and typical distribution. These can be elicited through thorough history taking and physical examination.

Physical Assessment

Physical examination of the client with shingles mostly involves observation or inspection of cutaneous findings. The ocular examination may also reveal herpes zoster ophthalmicus, which results from viral invasion of the Gasserian ganglion. An oral examination may also show intraoral herpes zoster. The cranial nerve examination may show involvement of CN V. Herpes zoster may also affect the ears, termed as geniculate zoster or zoster auris. This condition is considered rare and more rarely recognized.

Findings

Findings during the physical examination of the client diagnosed with shingles include:

• Painful, grouped herpetiform vesicles on an erythematous base confined to the cutaneous surface
• Rashes occurring as a single stripe around either the left or the right side of the body, or on one side of the face
• Erythematous macules and papules, progressing to vesicles within one day
• Cloudy, ruptured, crusted, and involuted vesicles
• Sensory loss or paresthesias in the distribution of the rash
• Lumbar and cervical motor weakness
• Manifestations of HZO include conjunctivitis, scleritis, episcleritis, keratitis iridocyclitis, glaucoma, retinitis, choroiditis, optic neuritis, optic atrophy, exophthalmos, lid retraction, ptosis, and extraocular palsies
• Headaches
• Fever and chills
• Nausea and vomiting
• Prodromal lymphadenopathy
• Meningeal irritation
• Vesicles or erosions over the mucous membrane of the upper jaw (palate, gums of the upper teeth) or the lower jaw (tongue or gums of the lower teeth)

Diagnostic Testing

In most clients, confirming the diagnosis via laboratory testing usually has no utility, because most tests are time-consuming, lack specificity, or are unavailable outside of research facilities. In select client populations, however, the presentation can be atypical and may require additional testing. Tests for the varicella-zoster virus include the following:

• Tzanck smear. The Tzanck smear of vesicular fluid shows multinucleated giant cells. It has lower sensitivity and specificity than direct fluorescent antibody (DFA) or polymerase chain reaction (PCR).
• VZV-specific IgM antibody. Varicella-zoster virus-specific IgM antibody in the blood is detected during the active infection of chickenpox or shingles but not when the virus is dormant.
• Polymerase chain reaction testing. PCR testing of vesicular fluid, a corneal lesion, or blood in a case with eye involvement or disseminated infection may be performed. The latest real-time PCR tests are rapid, easy to perform, as sensitive as nested PCR, have a lower risk of contamination, and also have more sensitivity than viral cultures.

Diagnosis

Diagnosis of shingles is based primarily on the history and physical findings, specifically, the characteristic location and appearance of the skin eruption in association with localized pain. Systemic manifestations are uncommon and usually are confined to clients in whom the immune system has been compromised by other disease processes or chemotherapy.

Complications

Complications of shingles include secondary bacterial infection, post-herpetic neuralgia (PHN), scarring, nerve palsy, and encephalitis in the case of disseminated zoster.

• Post-herpetic neuralgia (PHN). the most common complication of shingles is long-term nerve pain called post-herpetic neuralgia. PHN occurs in the areas where the shingles rash was, even after the rash clears up. It can last for months or years after the rash goes away. The pain from PHN can be so severe and debilitating that it interferes with daily life.
• Disseminated zoster. This is defined as more than twenty skin lesions developing outside the primarily affected area or dermatomes directly adjacent to it. Besides the skin, other organs may also be affected, causing hepatitis or encephalitis making this condition potentially lethal.
• Other complications. Complications like cranial neuropathies, polyneuritis,  myelitis, aseptic meningitis, or partial facial paralysis occur due to the involvement of the nervous system.

Nursing Management

Nursing management of clients diagnosed with shingles or herpes zoster involves infection control measures and symptomatic treatment. Since herpes zoster is a virus, they are generally self-limiting and may resolve without interventions. Existing therapies focus on reducing the extent and duration of symptoms, and possibly the risk of chronic sequelae as well.

Nursing Assessment

Nursing assessment of shingles is especially important because this infectious disease is diagnosed through clinical findings. A thorough and efficient assessment may help arrive at an accurate diagnosis of herpes zoster infection. The nursing assessment must include the client’s history, subjective and objective cues, and presenting clinical manifestations.

Subjective Cues

• Severe pain at the affected site
• Sensory loss along skin areas with rashes
• Motor weakness
• Headaches
• Nausea and vomiting
• Hearing loss
• Toothache
• Neck stiffness

Objective Cues

• Maculopapular rash at one side of the body or face
• Erythematous macules and papules
• Vesicles
• Crusts
• Lymphadenopathy
• Vesicles at the tip of the nose
• Eye lesions
• Intraoral or otic vesicles

Nursing Diagnosis

Nursing diagnosis for herpes zoster or shingles focuses on the classical manifestations assessed by the clinical eye. These include:

• Acute pain related to inflammation/local lesions along sensory nerves
• Deficient knowledge related to learning needs regarding pathophysiology, therapy, and potential complications
• Risk for infection related to immunosuppression, immunosuppressive therapy, or the status of the host’s immune defense
• Impaired skin integrity related to open lesions and rashes
• Risk for impaired oral mucous membrane integrity related to oral cavity involvement with vesicles

Nursing Care Planning and Goals

The nurse creates goals and outcomes for the client diagnosed with shingles, taking into consideration the assessment findings and diagnosis formulated.

• Reducing/decreasing pain
  Pain caused by herpes zoster can be debilitating and affect the client’s quality of life, therefore, pain management must be instituted as early as possible.
• Educating about the disease process, treatment regimen, and possible complications
  The client and caregiver’s understanding of herpes zoster is important to increase their adherence to the therapy, resulting in positive outcomes.
• Preventing infection and developing complications
  A client who develops shingles has a weakened immune system. Other secondary bacterial infections may occur, such as encephalitis and meningitis. Prevention of these infections would decrease the mortality against herpes zoster.
• Preventing the progression of lesions to other parts of the body
  When lesions spread to other parts of the body, such as the oral cavity, eyes, and ears, the client’s overall well-being suffers, creating intense pain and the inability to function in their everyday life. Prevention of these complications enables the client to live optimally.

Nursing Interventions for Shingles

• Identify the client’s level of pain and pain characteristics.
• Instruct the client to avoid scratching or touching the lesions.
• Provide cool compresses and topical treatment for the rashes.
• Administer pain relievers as prescribed.
• Provide health teachings about the risk factors, pathophysiology, and medical treatment of herpes zoster.
• Provide essential written information before discharge.
• Educate the client about the importance of herpes zoster vaccines.
• Promote strict hand hygiene among the client, caregivers, and hospital staff.
• Ensure appropriate use of personal protective equipment when caring for the client.
• Cover open lesions with gauze bandages as indicated.
• Apply topical antibiotic treatments or administer oral antiviral therapy as indicated.
• Administer corticosteroids as ordered.

Nursing Evaluation

After the implementation of nursing interventions, the nurse evaluates if the desired goals and outcomes were achieved. The nurse needs to ensure that:

• The client’s level of pain is reduced or diminished.
• The client and caregiver attain an understanding of the disease process, the treatment, management, and how to identify and manage complications.
• The client does not develop any preventable complications such as secondary bacterial infections and postherpetic neuralgia.
• The lesions do not spread to other parts of the body and be contained in specific areas of the body only.

Discharge and Home Care Guidelines

Discharge planning starts upon the admission of the client. The participation and involvement of all necessary individuals, especially the client and family members, are needed to ensure that appropriate care can still be rendered even at home.

• Monitoring the client and remaining alert for complications and for sequelae.
• Providing emotional support, as well as medical therapy, to clients who develop postherpetic neuralgia.
• Returning for regular screening and laboratory testing for clients at increased risk of developing multiple myeloma, leukemia, and lymphoma.
• Acquiring vaccines that help prevent the recurrence of shingles and associated infectious diseases.

Nursing Documentation

The focus of documentation in a client diagnosed with herpes zoster should include the following:

• Individual assessment findings
• Pain medication use or substance use
• Plan of care and who is involved in planning
• Teaching plan
• Response to interventions, teachings, and actions performed
• Attainment or progress toward desired outcomes
• Modifications to the plan of care
• Long-term needs
• Specific referrals made

References

1. Centers for Disease Control and Prevention. (2020). Clinical Overview of Herpes Zoster (Shingles) | CDC. Centers for Disease Control and Prevention. Retrieved April 2, 2023, from https://www.cdc.gov/shingles/hcp/clinical-overview.html
2. Janniger, C. K., & Elston, D. M. (2021, July 21). Herpes Zoster: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved April 2, 2023, from https://emedicine.medscape.com/article/1132465-overview#a1
3. Munakomi, S. (2022). Herpes Zoster – StatPearls. NCBI. Retrieved April 2, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK441824/