30 | Nursing in Practice | Autumn 2023
IMMUNISATION
Understanding shingles and the extended vaccination campaign
September saw the start of an NHS vaccination campaign targeting almost a million people with the Shingrix vaccine . Here , nurse consultant Linda Nazarko explains the background to the programme , and advises on diagnosing and treating shingles and its associated complications
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What is shingles ? Shingles is a painful blistering rash caused by reactivation of varicella zoster virus , the chickenpox virus . It is correctly known as herpes zoster . 1
Almost everyone is infected with the chickenpox virus during childhood . 2 On recovery , the virus remains dormant in the spinal nerves for life . It can reactivate when the immune system is compromised , so ageing increases the risk of developing shingles , because the immune system becomes less effective with age . 3 Each year around 50,000 people over 70 in England and Wales are affected⁴ , and more than half of adults who have had chickenpox will develop shingles by the age of 85 . ⁵
Diseases like HIV and lymphoma , and medications such as steroids depress the immune system and increase the risk of shingles , as do statins . 6 , 7 , 8 Older people with severe depression are more likely to develop shingles as depression also affects the immune system . 9
The prevalence of shingles has prompted NHS England to extend the vaccination programme to cover almost a million people over the next decade .
Clinical features of shingles The person may feel unwell , with a headache , generalised aching and a mild temperature before the rash is seen . The rash normally appears along a single dermatome – an area of skin supplied by a single spinal nerve . At first , the rash is red with tiny blisters or vesicles that can be intensely itchy . In the next 72 hours , it extends along the dermatome and the vesicles become larger as they fill with fluid . After three to five days , these burst and begin to dry and crust , normally healing within 10-14 days .
However , the rash can leave pigmentation – this varies but is noticeably different to the person ’ s normal skin colour . 10 It often settles quickly , but can persist for 12 months or longer . It can be treated topically with vitamin C , retinoids , azelaic acid or short-term topical steroids .
Treatment Shingles is painful and distressing . Treatment aims to reduce the severity of the attack , ease pain and discomfort , accelerate healing and protect others from potential infection . Treatment is normally with oral antivirals such as acyclovir , famciclovir and valaciclovir . If infection is very severe or the person is especially vulnerable , these may be given intravenously .
Antiviral treatment reduces rash , pain and complications such as postherpetic neuralgia ( PHN ). 11 It prevents the virus multiplying and may limit the extent of the attack . Treatment should begin at diagnosis , as antivirals work best within 72 hours of rash onset . 12
If there are delays in diagnosis , antivirals will still be beneficial if the person has severe pain or the rash is
13 , 14
continuing to progress . Corticosteroids such as prednisolone may be prescribed in severe infections to reduce pain and inflammation and increase the rate of healing . Evidence supports their ability to reduce acute pain but there is little evidence that they improve wound healing or
15 , 16 prevent PHN .
NICE recommends consideration of oral corticosteroids in combination with antiviral medication if pain is severe , in the first two weeks after rash onset in immunocompetent adults with localised shingles . 17
Table 1
Complications of shingles 18
Type of complication
Details
Neurological Neuropathic pain . Cranial and peripheral nerve palsies ( excluding Ramsay Hunt syndrome ), encephalitis , transverse myelitis , meningitis , Guillain-Barré syndrome , stroke
Ophthalmic Keratitis , conjunctivitis , iritis , blepharitis , retinitis , optic neuritis , orbital myositis , scleritis , glaucoma , vision loss or blindness , nonspecific eye infections
Cutaneous Secondary bacterial skin infection ( cellulitis , necrotising fasciitis and erysipelas )
Visceral and systemic Pneumonia , hepatitis , pancreatitis , sepsis , pulmonary embolism , osteomyelitis , pleuritis , peritonitis , myocardial infarction , myositis , myocarditis , pericarditis and endocarditis
Zoster-specific complications
Ramsay Hunt syndrome , varicella zoster virus dissemination