A Unique Case of Herpes Zoster Within One Week of Varicella Zoster Vaccination

The varicella zoster virus (VZV) vaccine is a live, attenuated vaccine recommended for patients aged sixty years and older. In the clinical trials, VZV vaccine reduced the risk of developing zoster by 51.3%.¹ Additionally, the vaccine helps prevent post-herpetic neuralgia (PHN).

The VZV vaccine is derived from the Oka/Merck strain of live, attenuated VZV. Of note, the Oka strain is also used in varicella vaccines.²

Since the VZV vaccine is a live, attenuated vaccine, it is contraindicated in patients with a primary or acquired immunodeficiency state, such as human immunodeficiency virus, leukemia, or lymphoma. Likewise, it is recommended that the VZV vaccine not be administered to individuals who are receiving immunosuppressive therapy, including high-dose corticosteroids.³ According to the Advisory Committee on Immunization Practices (ACIP), high-dose corticosteroid therapy is defined as two or more weeks of ≥ 20 mg/day of prednisone (or equivalent). After discontinuing high-dose corticosteroids, it is advised that patients wait at least four weeks before receiving the varicella zoster vaccine.² Per the CDC guidelines, patients receiving low-to-moderate doses of systemic corticosteroids can receive the VZV vaccine as low-to-moderate doses of systemic corticosteroids are not considered to be sufficiently immunosuppressive to warrant concern for vaccine safety.

A 76 year-old Caucasian male presented with a three day history of a vesicular rash localized to the left lateral neck, shoulder, and proximal upper extremity. The rash was not accompanied by pruritus, burning, or pain. Additionally, the patient denied experiencing prodrome symptoms, such as paresthesia, pain, burning, and/or pruritus, prior to developing the cutaneous eruption. Review of systems was unremarkable. His past medical history was significant for a recent episode of allergic contact dermatitis due to poison ivy, which was managed by his primary care physician with a short seven-day taper of oral methylprednisolone. Within a couple days of completing the methylprednisolone taper, the patient received the VZV vaccine, which was administered subcutaneously into the left upper extremity. He subsequently developed the vesicular rash seven days after receiving the vaccine.

Physical exam findings were significant for a confluent, erythematous, vesicular eruption in a dermatomal distribution on the left inferior/lateral neck, left clavicle, left shoulder and proximal upper extremity (Figure 1). These findings were consistent with herpes zoster (aka, shingles). The patient was immediately started on a seven-day course of oral valacyclovir. Since the rash was asymptomatic, no topical anti-inflammatory medications were prescribed. The patient reported improvement in the eruption within 2-3 days of starting oral valacyclovir. The rash remained asymptomatic. Of note, after starting valacyclovir, the patient indicated he experienced mild, intermittent left-sided headaches, which resolved with over-the-counter ibuprofen. Otherwise, his review of systems remained unremarkable. Of note, no samples were collected from the rash to determine if the varicella zoster virus was derived from the vaccine versus a wild-type strain.

With respect to lower facial rejuvenation, the ultimate goal of treatment is to decrease perioral fines lines and wrinkles, add volume, and create a more even skin tone. More recently there has been a paradigm shift with the use of combinations of noninvasive rejuvenating modalities to achieve more desirable, longer lasting results. In a published Consensus Recommendation from 2008, experts agreed that combination treatment with filler and botulinum toxin was standard for lower facial rejuvenation.⁶ A multicenter, randomized study of BoNTA and HA fillers alone or in combination for lower facial rejuvenation demonstrated superior, longer lasting effects with combination therapy compared to either treatment alone.⁵ Combination therapy likely results in superior outcomes because botulinum toxin decreases perioral muscle contraction, thus decreasing perioral movement and increasing the durability and longevity of filler.^5,7