Varicella-Zoster (Shingles) Organism-Specific Therapy 

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The Centers for Disease Control and Prevention (CDC) estimate that one-third of people in the United States will develop shingles, also known as herpes zoster, in their lifetime. There are an estimated 1 million cases of shingles each year in the United States. The risk for herpes zoster increases sharply after age 50 years. ^[1]

Herpes varicella zoster therapeutic regimens are provided below, including those for antivirals and zoster vaccines.

Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started generally within 72h of the onset of zoster rash.

Zoster confined to dermatome (normal or immunocompromised patients):

Acyclovir 800 mg PO 5 times daily for 7-10d or famciclovir 500 mg PO TID for 7d or valacyclovir 1000 mg PO TID for 7d

Visceral, central nervous system, or disseminated VZV infections, and zoster in severely immunocompromised patients:

Acyclovir 10 mg/kg (500 mg/m² in children <12 y) IV q8h for 7-10d

Despite longstanding recommendations for use of many vaccines, vaccination coverage among US adults is low. In 2015, among adults aged 60 years or older, 30.6% reported receiving herpes zoster vaccination to prevent shingles, a 2.7% increase from 2014. Whites aged 65 years or older had higher herpes zoster vaccination coverage (38.3%) compared with blacks (14.1%), Hispanics (19.2%), and Asians (30.6%). ^[4]

The immunization recommendations from the CDC include the following: ^{[2, 7]}

Zoster vaccine recombinant, adjuvanted (Shingrix)

Approval was based on a multicenter trial, Zoster Efficacy Study in Adults 50 Years of Age or Older (ZOE-50). The trial was conducted in 18 countries in 13,900 people aged 70 years or older. Participants were randomized in a 1:1 ratio to receive either Shingrix or placebo. Mean follow-up period was 3.7 years. The efficacy for the prevention of herpes zoster was 96.6% in persons aged 50-59 years, 97.4% in persons aged 60-69 years, and 91.3% in persons aged 70 years or older. ^{[5, 6]}

Zoster vaccine live (Zostavax)

Used for the prevention of herpes zoster (shingles) in patients ≥60 years (ACIP guidelines); not used for the treatment of herpes zoster

Administer 0.65 mL (entire vial contents) SC in the deltoid region of the upper arm

Note: In March 2011, the Food and Drug Administration (FDA) lowered the approved age for use of Zostavax to 50-59y. Zostavax was already approved for use in individuals aged 60 years or older. ^[3]

Approval was based on a multicenter study, the Zostavax Efficacy and Safety Trial (ZEST). ^[3] The trial was conducted in the United States and 4 other countries in 22,439 people aged 50-59y. Participants were randomized in a 1:1 ratio to receive either Zostavax or placebo. Participants were monitored for at least 1y to see if shingles developed. Compared with placebo, Zostavax significantly reduced the risk of developing zoster by approximately 70%.

CDC. Shingles (Herpes Zoster). Centers for Disease Control and Prevention (CDC). Available at https://www.cdc.gov/shingles/hcp/clinical-overview.html. 2017 October 17; Accessed: February 6, 2018.

[Guideline] Dooling KL, Guo A, Patel M, Lee GM, Moore K, Belongia EA, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018 Jan 26. 67 (3):103-108. [Medline]. [Full Text].

Schmader KE, Levin MJ, Gnann JW Jr, McNeil SA, Vesikari T, Betts RF, et al. Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years. Clin Infect Dis. 2012 Apr. 54 (7):922-8. [Medline]. [Full Text].

Williams WW, Lu PJ, O’Halloran A, Kim DK, Grohskopf LA, Pilishvili T, et al. Surveillance of Vaccination Coverage among Adult Populations – United States, 2015. MMWR Surveill Summ. 2017 May 5. 66 (11):1-28. [Medline]. [Full Text].

Lal H, Cunningham AL, Godeaux O, Chlibek R, Diez-Domingo J, Hwang SJ, et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med. 2015 May 28. 372 (22):2087-96. [Medline]. [Full Text].

Cunningham AL, Lal H, Kovac M, Chlibek R, Hwang SJ, Díez-Domingo J, et al. Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older. N Engl J Med. 2016 Sep 15. 375 (11):1019-32. [Medline]. [Full Text].

CDC. Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States 2018. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/vaccines/schedules/hcp/adult.html. 2018 Feb 06; Accessed: February 6, 2018.

Richard Lichenstein, MD Professor, Pediatric Emergency Department, University of Maryland School of Medicine

Richard Lichenstein, MD is a member of the following medical societies: American Medical Association, American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Varicella-Zoster (Shingles) Organism-Specific Therapy 

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