Shingles: Treatment Options and Vaccine Considerations

Shingles

A patient experienced right chest pain on December 29, 2021, and visited a local orthopedic clinic on January 1, 2022, where they were diagnosed with herpes zoster and subsequently referred to a dermatology clinic.
The dermatologist confirmed the diagnosis of herpes zoster and prescribed a low dose of the antiviral medication Acyclovir, 400 mg four times a day for a total of 1,600 mg, which is below the standard dosage of 4,000 mg per day.
After six days of treatment, the patient reported no significant improvement and increasing pain that prevented them from sleeping at night.
They then sought care at another dermatology clinic, where they were prescribed the self-paid antiviral medication Valaciclovir at the standard dosage of 3,000 mg per day (two tablets three times daily) and a corticosteroid, Dexamethasone, at 0.5 mg three times daily.
After two days of taking Valaciclovir and Dexamethasone, the patient was able to sleep at night, and the herpes vesicles appeared to have stabilized without further increase for four to five days.
However, the right anterior chest and posterior back developed red rashes that became thicker and slightly purplish, with some areas turning dark purple.
The patient was also taking 1,000 mcg of methylcobalamin (Vitamin B12) daily.

Questions:
1.
After completing nine days of antiviral treatment and three days of corticosteroid therapy, should the patient continue taking the medications?
2.
Additionally, a publication from the Taiwan Dermatological Association mentions that receiving the COVID-19 vaccine may potentially trigger herpes zoster or exacerbate its severity, and this patient has not yet received the first dose of any COVID-19 vaccine.
Is it advisable for them to get vaccinated, and when would be the appropriate time to do so? Thank you for your assistance.

Lin Likun, 70~79 year old female. Ask Date: 2022/01/10

Dr. Wu Yuxin reply Dermatology

1.
In principle, it is sufficient.
2.
Currently, there seems to be a higher statistical correlation, but the actual relationship is still unclear.
Whether to receive the vaccine should be assessed by the individual.

Reply Date: 2022/01/10

More Info

Understanding shingles and its treatment options, particularly in the context of vaccination, is crucial for managing this painful condition effectively. Shingles, or herpes zoster, is caused by the reactivation of the varicella-zoster virus (VZV), the same virus that causes chickenpox. After a person recovers from chickenpox, the virus remains dormant in the nerve tissues and can reactivate later in life, leading to shingles.
In the case presented, the patient experienced significant pain and discomfort associated with shingles, which is not uncommon, especially in older adults. The initial treatment with Acyclovir was at a lower than standard dose, which might have contributed to the lack of improvement. The subsequent treatment with Valaciclovir and Dexamethasone appears to have been more effective, as the patient reported better sleep and a reduction in the progression of the rash.
1. Continuation of Medication: After completing a course of antiviral medication like Valaciclovir and a short course of corticosteroids like Dexamethasone, it is essential to evaluate the patient's current condition. If the rash has stabilized and the pain has decreased significantly, the continuation of antiviral therapy may not be necessary. However, if there are lingering symptoms or if the patient is still experiencing significant pain, it may be prudent to consult with a healthcare provider about the potential for extending antiviral therapy or considering other pain management strategies. In some cases, postherpetic neuralgia (PHN), a common complication of shingles, may require additional treatment even after the rash has resolved.

2. COVID-19 Vaccination Considerations: Regarding the concerns about the COVID-19 vaccine potentially exacerbating shingles or triggering a new outbreak, it is important to note that while some studies have suggested a possible association, the overall risk remains low. The benefits of vaccination against COVID-19, especially for individuals who are older or have underlying health conditions, generally outweigh the risks.
For this patient, who has not yet received any doses of the COVID-19 vaccine, it is advisable to wait until the shingles outbreak has fully resolved before getting vaccinated. This typically means waiting until the rash has healed completely and any associated pain has subsided. The Centers for Disease Control and Prevention (CDC) recommends that individuals wait until they have fully recovered from shingles before receiving the COVID-19 vaccine, which can help ensure a better immune response and minimize any potential complications.

In summary, the management of shingles involves timely antiviral treatment and pain management, with careful consideration of the patient's overall health status. Vaccination against COVID-19 should be approached with caution, ensuring that the patient is fully recovered from shingles before proceeding. It is always best to consult with a healthcare provider for personalized advice based on the patient's specific medical history and current condition.

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