28 Nursing made Incredibly Easy! July/August

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1 Shingles: 28 Nursing made Incredibly Easy! July/August

2 Chicken pox revisited Herpes zoster, or shingles, is often seen in older and immunocompromised patients. We help you identify the causes, symptoms, evaluation, treatment, and prevention of shingles. By Kathleen T. Ogle, PhD, RN, FNP-BC Graduate Program Director and Assistant Professor Towson University Towson, Md. 2.0 ANCC CONTACT HOURS Ms. J, 67, arrives at your clinic complaining of right upper quadrant abdominal pain. She rates this pain as a 3 on a scale of 0 to 10. She denies nausea, vomiting, diarrhea, constipation, or fever. The exam reveals normal bowel sounds, no abdominal tenderness, no masses, and no rebound tenderness. The pain isn t reproducible with palpation. The patient relates that she has recently changed her diet and thinks the pain may be related to that change. She s prescribed esomeprazole, 20 mg by mouth once a day, for 2 weeks and is advised to eat bland food for the next few days. Three days later, Ms. J returns to the clinic. Her pain level has increased to 6 out of 10 and remains in the right upper quadrant. She still states that there are no other symptoms. Her exam is identical to the one at her first visit. In view of her increasing symptoms, the patient is referred for a computed tomography (CT) scan of her abdomen to rule out gallstones or a possible liver mass. Two days after her second clinic visit, Ms. J is back. The abdominal CT scan is normal, with no sign of gallstones or abdominal masses. She reports the addition of another symptom to her increasing pain: a rash has appeared on her right flank area, radiating around to the right upper abdomen. The diagnosis is now clear the patient has shingles, also known as herpes zoster. Because active lesions shed virus, Ms. J is moved to a room away from the general patient population. VZV redux Shingles is a viral infection caused by the varicella-zoster virus (VZV) the same virus that causes chicken pox. It s thought that after an individual has chicken pox, viral particles are preserved within the posterior spinal or cranial sensory ganglia in a dormant state. Years later, these particles become active, resulting in a painful rash along the sensory dermatomes of the involved ganglia (see How it happens). It s also thought that during the normal aging process, immunity to VZV decreases, allowing the virus to reactivate. The virus may also be activated when the immune system is weakened by disease or medications. Individuals who are older than age 60, had chicken pox before the age of 1, are taking immunosuppressing drugs, or have a disease that affects the immune system, such as HIV, are considered at higher risk for developing shingles. Although there s no gender difference in shingles occurrences, research shows that White patients are affected more frequently than Black patients. Hallmark: Painful rash The first symptom experienced by patients is usually pain along the affected dermatome. The pain is described as a burning sensation and is usually present before the rash appears. Some patients state that the pain is more of an itching sensation before the rash. Red patches appear on the skin on July/August 2012 Nursing made Incredibly Easy! 29

3 How it happens An individual (usually a child) develops chicken pox through droplet transmission or inhalation of the varicella or chicken pox virus. The virus initially causes a silent infection of the nasopharynx. This infection progresses to viremia, seeding of fixed macrophages, and dissemination of VZV to the skin (the rash seen in chicken pox). After the initial infection, the virus lays dormant in the dorsal spinal ganglion, where it remains for many years. The virus is reactivated, probably because of decreased cellular immunity, and spreads from ganglia along the sensory nerves to the peripheral nerves of sensory dermatomes, causing shingles. 1 Varicella zoster virus (chicken pox) Dormant?! I can t believe there s anything dormant in this little guy. 2 Non-immune individual (usually a child) one side of the body, followed by vesicles filled with clear serum (see A closer look at shingles). These vesicles, or blisters, are clustered and may become purulent before they rupture and form a crust. The rash is confined to a narrow band on one side of the body or the face. Symptoms last from 1 to 3 weeks. Depending on what area of the body is affected, other symptoms may occur, such as abdominal pain, chills, headache, photophobia, or joint pain. Lymph nodes in the area of the rash may become enlarged and tender. A diagnosis is made based on the patient s history and symptoms. Although this can be difficult in the early stages, as seen in the 3 Virus in dorsal spinal ganglion (latent phase) case of Ms. J, after the rash is visible, the diagnosis is clear. Complication station A patient who presents with a shingles infection that involves the nerves around the eye is at risk for permanent damage and blindness in that eye. Herpes zoster ophthalmicus, or VZV of the trigeminal nerve, is an ophthalmologic emergency requiring immediate referral to an ophthalmologist for evaluation and treatment. Another complication of VZV is Ramsay Hunt syndrome, in which the virus infects the facial nerve near the inner ear. When the nerve becomes irritated, it swells, causing symptoms that include weakness to one side of the face and a rash on the eardrum, ear canal, tongue, and roof of the mouth on the same side as the weakness. The patient may experience hearing loss on the same side, drooping of the eyelid (ptosis) or face, and vertigo. Complications of Ramsay Hunt syndrome include permanent changes to the appearance of the face due to loss of movement, changes in taste, and nerves that may grow back to the wrong structures causing changes in movement of the face (for example, smiling causes the eye to close). Rarely, VZV infection may cause meningitis or encephalitis. The patient will present 30 Nursing made Incredibly Easy! July/August

4 4 Reactivation of virus 5 To peripheral nerves of dermatome 6 Herpes zoster (shingles) with the usual symptoms of these diseases (headache, fever, change in mentation or seizures), but a spinal tap reveals VZV as the causative organism. The most common complication of shingles is postherpetic neuralgia, in which pain in the area where the rash occurred lasts for months or years. It s thought that this prolonged pain is caused by the destruction of the basal ganglia by the replication process of VZV. Research reveals that patients most at risk for postherpetic neuralgia include those over age 80, women, patients who suffered from severe pain during the outbreak, and those who had severe prodromal pain before the rash appeared. Treatments on deck In most cases, the healthcare provider will prescribe an antiviral to reduce pain and shorten the course of the outbreak. Acyclovir, famciclovir, and valacyclovir are the most commonly prescribed antivirals for shingles. These medications should be started within 72 hours of symptom onset, making early diagnosis paramount. Adverse reactions to acyclovir include leukopenia, renal impairment, nausea, vomiting, dizziness, and photosensitivity. Adverse reactions to famciclovir may include neutropenia, hallucinations, headache, abnormal liver function tests (caused by the drug being metabolized in the liver by the cytochrome P450 enzymes), and fatigue. Adverse reactions to valacyclovir include thrombocytopenia, delirium, abdominal pain, and elevated alkaline phosphatase. It should be emphasized to patients taking antiviral drugs that they aren t in the same category as antibiotics; they aren t a cure for shingles. Rather, these drugs shorten the vesicle (blister) life and decrease the incidence of viral shedding. Of the antiviral drugs, acyclovir is the least expensive should the patient have to pay out of pocket. In weakened patients who are unable to swallow, the medications may have to be given by I.V. infusion. In addition to medications to shorten the duration of the vesicles, medications to help control pain, such as opioid combinations (acetaminophen with codeine, hydrocodone with acetaminophen, or oxycodone with acetaminophen), are usually prescribed. All opioid medications may cause lightheadedness, sedation, nausea, vomiting, constipation, or rash. It s important to note that most of the commonly used pain medications contain acetaminophen, which is metabolized in the liver by the same cytochrome P450 enzymes as the antiviral medications. Patients should be advised not to take did you know? There s a higher incidence of shingles in White patients than Black patients, but it equally affects men and women. Patients who are immunocompromised are particularly at risk for developing shingles. July/August 2012 Nursing made Incredibly Easy! 31

5 Assessing for shingles cheat Be alert for the following signs and symptoms: tingling or itching on one side of the body rash along a dermatome that doesn t cross the midline painful rash fever chills abdominal pain headache joint pain lymphadenopathy sheet additional acetaminophen or drink alcohol, and their liver enzymes should be evaluated after antiviral treatment. The healthcare provider should also consider other medications that the patient may be taking, such as a statin for elevated cholesterol, which is also metabolized by the cytochrome P450 enzymes. There has been some research into the use of systemic corticosteroids as a treatment for shingles. This treatment is controversial because it may lead to increased complications and hasn t been shown to reduce the risk of postherpetic neuralgia. It may, however, reduce some of the pain associated with shingles and increase the speed of healing. When pain persists Patients who develop postherpetic neuralgia may experience pain at the site of the rash for months or years. There are several treatments that can help with the pain of postherpetic neuralgia, including topical (lidocaine or capsaicin) and systemic medications. Common adverse reactions of topical medications include reactions at the application site, localized edema, urticaria, and erythema. In addition to topical treatment, oral medications can be prescribed to control postherpetic pain. The opioid combination medications that were used for pain during the acute episode may be continued, although this isn t ideal due to dependency issues and adverse reactions. Tricyclic antidepressants are also indicated for the control of postherpetic neuralgia pain. These are better tolerated than opioids and are usually as effective. Medications in the tricyclic category that are indicated for treatment of postherpetic neuralgia are amitriptyline (the most commonly prescribed), nortriptyline, imipramine, and desipramine. Amitriptyline and the other tricyclic antidepressants have a high cardiac adverse reaction profile, including syncope, ventricular arrhythmias, QT prolongation, stroke, and myocardial infarction. Common adverse reactions include drowsiness, blurred vision, palpitations, and confusion. A closer look at shingles What to look for Fever Malaise Severe, deep pain Eruption of small, red, nodular skin lesions in painful areas Pruritus Paresthesia or hyperesthesia Erythematous base Umbilicated vesicles 32 Nursing made Incredibly Easy! July/August

6 Recent research has revealed that the serotonin norepinephrine reuptake inhibitors (SNRIs) duloxetine and venlafaxine are effective in reducing the severity of postherpetic pain. Adverse reactions of this class of medications include depression, serotonin syndrome, nausea, dizziness, dry mouth, and insomnia. The antiepileptic drugs pregabalin and gabapentin have also been used to treat postherpetic pain. Adverse reactions include thrombocytopenia, dizziness, weight gain, dry mouth, and tremor. Research shows that medications in the tricyclic category are more effective in controlling pain than the antiepileptic medications. However, the adverse reaction profile is higher in the tricyclic medications, so SNRIs and antiepileptic drugs are more commonly used. For prolonged periods of postherpetic pain, nonpharmacologic interventions may be utilized. Patients may be referred to pain management specialists for nerve blocks, instruction in biofeedback methods, acupuncture, and transcutaneous electric nerve stimulation units. Prevention mention To prevent shingles, instruct your older patients and those with compromised immune systems to stay away from individuals with active chicken pox or shingles because VZV sheds during the acute phase. Children should be immunized against VZV with chicken pox vaccination a series of two vaccines given at least 3 months apart. Although some children may still develop chicken pox, the severity of the illness is reduced with the vaccine. However, because the vaccine was recommended as part of routine childhood vaccination in 1995, there are no vaccinated individuals who are older than age 60. In 2006, the FDA approved the use of a vaccine to reduce the risk of developing shingles in individuals age 60 and older. Zoster vaccine live is given as a one-time subcutaneous injection. The most common adverse reaction is irritation at the injection Nursing interventions site. Early research shows that immunity appears to last at least 4 years. Although the recommended age for vaccination was reduced to 50 in 2011, the emphasis on vaccinating adults over age 60 remains. There are several contraindications to receiving the vaccine, including anyone who has had a severe reaction to the antibiotic neomycin, patients with severely compromised immune systems, patients who are on or who have recently been treated with steroids, patients undergoing cancer treatment with radiation or chemotherapy, and those with a history of cancers that affect the bone marrow or lymphatic system. After patients receive the vaccine, it s safe to be around infants, pregnant women, and those with compromised immune systems because there s no evidence of viral shedding after immunization. In addition to reducing the incidence of shingles by 50%, the vaccine reduces postherpetic neuralgia by 66%. Patients who ve had shingles can receive the vaccine after the rash has resolved. Single out shingles After the proper diagnosis is made, Ms. J is treated with an antiviral and pain medication. She develops pain at the outbreak site after the rash is healed and is treated with topical lidocaine patches and pregabalin, which control her pain. After 8 weeks, she returns to the clinic pain free and is given the zoster vaccine to help reduce the severity of any future outbreaks. Shingles, or herpes zoster, presents as a painful rash along a dermatome years after the initial infection with chicken pox. The patient may initially present with different cheat Keep patients with open lesions isolated because they re shedding virus. Reassess pain levels frequently. If the rash affects the patient s face, perform a baseline vision check. Antivirals should be started within 72 hours of symptoms, so patients shouldn t delay filling a prescription. Do a complete medication assessment to evaluate for drug interactions with antivirals and pain medications. sheet July/August 2012 Nursing made Incredibly Easy! 33

7 More CE? Here you go! symptoms, so you should be alert for any complaints of tingling or painful skin. Although there s no cure for the viral condition, treatment is aimed at controlling the symptoms of a painful rash and malaise. Patients over age 50 should be given information regarding the herpes zoster vaccine, which may prevent or lessen the severity of an outbreak. Learn more about it Bloch KC, Johnson JG. Varicella zoster virus transmission in the vaccine era: unmasking the role of herpes zoster. J Infect Dis. 2012;205(9): CDC. Shingles vaccination: what you need to know. vacc-need-know.htm. Family Practice Notebook. Herpes zoster. fpnotebook.com/id/virus/hrpszstr.htm. Family Practice Notebook. Postherpetic neuralgia. Javed S, Javed SA, Tyring SK. Varicella vaccines. Curr Opin Infect Dis. 2012;25(2): Larhammar D. Acupuncture for herpes zoster pain. Focus on Alternative and Complementary Therapies. 2012;17(1): Li HT, Lu S, Liu JM. Herpes zoster vaccination in people aged years. Clin Infect Dis. 2012;54(7): MedlinePlus. Ramsay Hunt syndrome. nih.gov/medlineplus/ency/article/ htm. MedlinePlus. Shingles. plus/ency/article/ htm. O Malley P. Just say no to shingles! The zoster vaccine: update for the clinical nurse specialist. Clin Nurse Spec. 2011;25(6): Smeltzer S, Bare B, Hinkle J, Cheever K. Brunner & Suddarth s Textbook of Medical-Surgical Nursing. 12th ed. Philadelphia, PA: Lippincott Williams & Wilkins; Yawn BP. Post-shingles neuralgia by any definition is painful, but is it PHN? Mayo Clin Proc. 2011;86(12): The author and planners have disclosed that they have no financial relationships related to this article. DOI /01.NME c2 For more than 21 additional continuing education articles related to infection topics, go to Nursingcenter.com/CE. Earn CE credit online: Go to and receive a certificate within minutes. TEST INSTRUCTIONS To take the test online, go to our secure Web site at CE/nmie. On the print form, record your answers in the test answer section of the CE enrollment form on page 55. Each question has only one correct answer. You may make copies of these forms. Complete the registration information and course evaluation. Mail the completed form and registration fee of $21.95 to: Lippincott Williams & Wilkins, CE Group, 74 Brick Blvd., Bldg. 4, Suite 206, Brick, NJ We will mail your certificate in 4 to 6 weeks. For faster service, include a fax number and we will fax your certificate within 2 business days of receiving your enrollment form. You will receive your CE certificate of earned contact hours and an answer key to review your results.there is no minimum passing grade. Registration deadline is August 31, INSTRUCTIONS Shingles: Chicken pox revisited DISCOUNTS and CUSTOMER SERVICE Send two or more tests in any nursing journal published by Lippincott Williams & Wilkins together by mail and deduct $0.95 from the price of each test. We also offer CE accounts for hospitals and other health care facilities on nursingcenter. com. Call for details. PROVIDER ACCREDITATION Lippincott Williams & Wilkins, publisher of Nursing made Incredibly Easy!, will award 2.0 contact hours for this continuing nursing education activity. Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP for 2.0 contact hours. Lippincott Williams & Wilkins is also an approved provider of continuing nursing education by the District of Columbia and Florida #FBN2454. Your certificate is valid in all states. The ANCC s accreditation status of Lippincott Williams & Wilkins Department of Continuing Education refers only to its continuing nursing educational activities and does not imply Commission on Accreditation approval or endorsement of any commercial product. 34 Nursing made Incredibly Easy! July/August