Herpes Zoster (HZ), fire pox, is the reactivation of latent varicella-zoster virus (VZV) in the sensory ganglia, which previously caused varicella (chickenpox). Fire pox reactivation usually occurs in elderly individuals or with reduced immunity.
Epidemiology of Fire Pox
- The incidence of fire pox increases with age >50 years.
- About 20-30% of the population will experience fire pox at least once in life.
- Risk is higher in patients with HIV, cancer, or immunosuppressant users.
Clinical Manifestations
- Prodromal: neuropathic pain (burning, stabbing), accompanied by malaise and low-grade fever. Rash: appears within 1-5 days, as unilateral papules along the dermatome, usually thoracal, ophthalmic, cranial sacral. Duration: 2-4 weeks. Lesions scab over in 7-10 days.
- Acute phase: papules → vesicles → pustules → crusts.
Clinical variants:
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt Syndrome)
- Zoster sine herpete
Diagnosis
Clinical diagnosis of fire pox is based on dermatomal distribution and lesion characteristics.
Supportive examination (if required):
- PCR of VZV from vesicle fluid (gold standard).
- Tzanck smear (non-specific).
- Serology for confirmation in atypical cases.
Herpes Zoster Management
1. Antivirals
- Acyclovir 800 mg 5x/day for 7 days – 10 days.
- Valacyclovir 1000 mg 3x/day for 7 days.
- Famciclovir 500 mg 3x/day for 7 days.
Antiviral efficacy is maximized if given <72 hours from lesion onset, may reduce duration of rash and risk of Postherpetic Neuralgia if given early.
2. Analgesics
- Acute pain: paracetamol, NSAIDs
- Severe pain/Postherpetic Neuralgia: gabapentin, pregabalin, amitriptyline
- Topical: lidocaine patch 5%, capsaicin
- Intervention: nerve block, TENS (Transcutaneous Electrical Nerve Stimulation)
3. Oral corticosteroids
- Methylprednisolone: only for severe cases, together with antivirals
Aim: reduce inflammation and the risk of Postherpetic Neuralgia
- Antibiotics
If there is secondary infection (cellulitis, impetigo)
Prevention
- Balanced nutritional intake
- Regular exercise at least 150 minutes a week
- Get enough sleep 7-8 hours a day
- No smoking
- Regular medical check-ups for early detection of risk factors
- Fire Pox Vaccination, can be given one – two doses depending on the type of vaccine.
Indications for vaccination
- All individuals ≥50 years old, especially with a history of Herpes Zoster or comorbidities
- Immunocompromised patients (with consideration of vaccine type)
Complications
- Postherpetic Neuralgia (PHN): persistent pain for > 90 days, especially in elderly patients.
- Bacterial secondary infection.
- Ophthalmic herpes zoster (in the trigeminal nerve branch 1), risk of keratitis/permanent vision loss.
- Ramsay Hunt Syndrome (in the geniculate ganglion) causing fascial paralysis and auricular vesicles.
Algorithm
Conclusion
The clinical management of Herpes Zoster demands a holistic approach—beginning with early diagnosis through careful clinical assessment and appropriate adjunctive testing, prompt initiation of antiviral therapy to shorten lesion duration and reduce the risk of postherpetic neuralgia, and tailored pain control using systemic and topical analgesics as well as nerve-targeted interventions, with corticosteroids reserved for severe presentations.
Primary prevention via active vaccination, reinforced by healthy lifestyle measures and routine screening in high-risk groups, remains the cornerstone of lowering HZ incidence and its complications. Ultimately, interdisciplinary collaboration and thorough patient education on the value of early recognition and timely treatment are key to optimizing outcomes and enhancing patients’ quality of life.
References:
- Gagliardi AMZ et al. Vaccines for preventing herpes zoster in older adults. Cochrane Database. 2019.
- CDC. Shingrix recommendations. 2024 Update.
- Indonesian Dermatology Association – HZ Clinical Practice Guidelines 2023.
- Strezova A, et al. Open Forum Infect Dis. 2022;9(10);ofac485; 5. CDC. Shingles vaccine Recommendations. 2024;
- Patil A, Goldust M, Wollina U. Viruses. 2022;14(2):192.
- Cunningham AL, et al. New Engl J Med.2016;375(11):1019-32.
- PAPDI. Adult Immunization Schedule; 2025
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