Q: A 63-year-old female patient showed persistent corneal lesions following herpes zoster. Now, three months after she was cleared, her primary care physician wants to give her Zostavax (Merck), the shingles vaccine. Is it wise to vaccinate a patient when an immune-mediated aggravation may occur?

A: Herpes zoster, commonly known as shingles, is a viral disease that stems from the reactivation of the varicella-zoster virus (VZV).1 Herpes zoster affects 10% to 20% of the population.2 About 10% to 25% of all cases of shingles affect the ophthalmic division of the trigeminal nerve; this is called herpes zoster ophthalmicus (HZO).3-7 The sequelae of HZO can include chronic ocular inflammation, visual loss and debilitating pain.

“Herpes zoster causes an acute infection that deposits in the cornea; however, it is not the acute infection that results in these severe complications. It is rare for acute infections alone to be vision threatening,” says Eric Donnenfeld, M.D., of Rockville Centre, N.Y.

The serious consequences of HZO are due to an immune mediated disease stemming from the deposition of antigens. When the viral antigen—deposited in the cornea or in the uveal tract—is not cleared by the body’s immune system, it can be sequestered in the ocular tissue and ultimately lead to prolonged inflammation, scarring, glaucoma, iritis and even cystoid macular edema, Dr. Donnenfeld says.

Treating the Infection
The primary therapy for herpes zoster is to treat the infection acutely. Dr. Donnenfeld recommends antiviral therapy with oral acyclovir. In the past, there was no effective topical antiviral therapy. Viroptic (trifluridine, Monarch Pharmaceuticals) was often prescribed, but was not effective. However, Dr. Donnenfeld says the new topical Zirgan (gangciclovir, Bausch + Lomb), used off-label, has shown good activity against herpes zoster and is now his starting point when facing acute corneal dendrites.

Active treatment for infectious herpes zoster is a seven to 10-day course of oral anti-virals—such as acyclovir, famciclovir or valacyclovir. For the immune mediated inflammation, years of anti-inflammatory therapy may be necessary. Dr. Donnenfeld recommends starting with the strongest steroid possible, such as topical Durezol (difluprednate, Alcon) and then taper down to a lower-strength steroid, such as Lotemax (loteprednol 0.5%, Bausch + Lomb) depending on the amount of inflammation.

“The management of the inflammation in herpes zoster can be more important than the management of the infection itself. Both the infection and the inflammation need to be treated aggressively—as early as possible with as strong a medication as possible,” Dr. Donnenfeld says.

Christopher J. Rapuano, M.D., of Philadelphia, agrees. “Patients with zoster often need long-term higher potency—Durezol or Pred Forte (prednisolone acetate 1%, Allergan) or lower potency Lotemax, FML (fluorometholone alcohol 1%, Allergan) or Alrex (loteprednol 0.2%, Bausch + Lomb)—topical steroids for years. Doctors make a mistake when they try and stop the steroids too soon for zoster patients.”

Considering Vaccination
Dr. Rapuano follows the guidelines set out by the CDC, which recommend the shingles vaccine to help reduce the risk of shingles and the associated pain in people 60 years or older.8 The vaccine is recommended for all people, even those who have previously had zoster. The vaccine should not reactivate herpes.

“We have looked at all of our patients with zoster for a certain number of years now. Many patients have zoster below age 60 and may benefit from receiving the zoster vaccine earlier, which is not currently FDA indicated,” he says.

If there is extra concern, doctors should watch the patient closely for any redness or pain, he says.

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8. CDC. Shingles (Herpes Zoster) Vaccination. 2010 August. Available at: www.cdc.gov/vaccines/vpd-vac/shingles/default.htm (Accessed October 2010).