Herpes Zoster (Shingles)

What is the most important risk factor for zoster?

Age is the most important risk factor for zoster.1

  • ~99.5% of adults aged ≥40 years are at risk for zoster because they have had chickenpox.1
  • Nearly all adults over the age of 50 are at risk for zoster. Risk increases with age.1,2

RISK OF ZOSTER BY AGE GROUP2

Risk of Herpes Zoster by Age Group Chart

RISK OF ZOSTER BY AGE GROUP2

After age 50, risk and severity of zoster increase markedly due to age-related decline in immunity.3

US Census Bureau projections show a substantial, steady increase in the US population aged ≥60 years—a 60% increase is projected between 2010 and 2030.4

PROJECTED US POPULATION AGED ≥60 YEARS4

Increasing Older Population Impacts the Number of Zoster Cases You'll See

PROJECTED US POPULATION AGED ≥60 YEARS4

The increasing older population impacts the number of zoster cases you’ll see.2,4

How do you know which patients will be affected by zoster?

You can’t know which patients will be affected by zoster.5

  • There is no way to predict when the varicella-zoster virus (VZV) will reactivate, who will develop zoster, or how severe any individual case may be.1,3,6,7,8

Dermatomal zoster rashes.

Dermatomal zoster rashes.

According to the CDC, approximately 1 in 3 people will experience zoster in their lifetime.1

  • Nearly 1 million new cases of zoster are diagnosed in the United States each year.1,2
  • An estimated 70% of the annual cases occur in people aged ≥50 years.9

How do patients describe zoster?

Almost all patients experience more than a rash.

  • Even though zoster generally presents as a rash, typically patients also experience pain.6
  • Pain can occur daily and be potentially severe.8

In a 2004 study designed to describe the acute pain of zoster and assess its impact on patients (n=110)8:

  • 96% of patients in this study experienced acute pain.
  • 45% reported that they experienced pain every day.
  • 42% reported that their worst zoster-associated pain was “horrible” or “excruciating.”
Are zoster complications common, and what are they?

Even before the rash appears, the damage may already be done.10

  • A severe hemorrhagic inflammation occurs in the dorsal root ganglia as VZV reactivates and replicates.
  • VZV causes scarring and loss of nerve cells and fibers, which can lead to neuropathic pain.
Depiction of Dorsal Root Ganglia

Postherpetic neuralgia (PHN) is the most common complication of zoster.3

  • PHN is chronic neuropathic pain lasting for at least 3 months after rash onset and can last months or even years.3
  • Not everyone who experiences zoster suffers from PHN.3
  • The incidence of PHN increases with age.3
  • Patients have described PHN as: burning, throbbing, stabbing, shooting, and/or sharp pain.6,11

In addition to PHN, other complications of zoster can vary in degree of severity.7

  • 10% to 25% of zoster patients suffer from ophthalmic zoster.1
  • 50% to 72% of patients who develop ophthalmic zoster will suffer chronic, recurring ocular disease and visual loss.7
Ophthalmic Herpes Zoster Rash
Ophthalmic zoster rash. NOT TYPICAL.

1 in 4 zoster patients will experience 1 or more complications, some of which may be severe, including11,12:

  • Scarring
  • Bacterial superinfection
  • Pneumonia
  • Cranial and motor neuron palsies
  • Visual impairment, when eye area is involved
  • Hearing loss, when ear area is involved

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ref1

Reference

  1. Centers for Disease Control and Prevention (CDC). Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;57(RR-5):1–30.
ref2

Reference

  1. Insinga RP, Itzler RF, Pellissier JM, et al. The incidence of herpes zoster in a United States administrative database. J Gen Intern Med. 2005;20(8):748–753.
ref3

Reference

  1. Johnson RW, Bouhassira D, Kassianos G, et al. The impact of herpes zoster and post-herpetic neuralgia on quality-of-life. BMC Med. 2010;8(37). doi:10.1186/1741–7015–8–37.
ref4

Reference

  1. Centers for Disease Control and Prevention (CDC). Population projections, United States, 2004-2030. http://wonder.cdc.gov/population-projections.html. Published September 2005. Accessed November 7, 2019.
ref5

Reference

  1. Chickenpox and Herpes Zoster (Varicella-Zoster Virus). In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases; vol 2. 9th ed. Philadelphia, PA: Elsevier Saunders; 2019:1849-1856.
ref6

Reference

  1. Schmader KE, Dworkin RH. Natural history and treatment of herpes zoster. J Pain. 2008;9(1)(suppl 1):S3–S9.
ref7

Reference

  1. Pavan-Langston D. Ophthalmic zoster. In: Arvin AM, Gershon AA, eds. Varicella-Zoster Virus: Virology and Clinical Management. Cambridge, UK: Cambridge University Press; 2000:276–298.
ref8

Reference

  1. Katz J, Cooper EM, Walther RR, et al. Acute pain in herpes zoster and its impact on health-related quality of life. Clin Infect Dis. 2004;39(3):342–348.

ref9

Reference

  1. Pappagallo M, Haldey EJ. Pharmacological management of postherpetic neuralgia. CNS Drugs. 2003;17(11):771–780.
ref10

Reference

  1. Schmader K, Gnann JW Jr, Watson CP. The epidemiological, clinical, and pathological rationale for the herpes zoster vaccine. J Infect Dis. 2008;197(suppl 2):S207–S215.
ref11

Reference

  1. Oxman MN. Clinical manifestations of herpes zoster. In: Arvin AM, Gershon AA, eds. Varicella-Zoster Virus: Virology and Clinical Management. Cambridge, UK: Cambridge University Press; 2000:246–275.
ref12

Reference

  1. Yawn BP, Saddier P, Wollan PC, et al. A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc. 2007;82(11):1341–1349.

US-CIN-00012 12/19