Update in Herpes Zoster Prevention and the Role of Dermatologists

January 2019 | Volume 18 | Issue 1 | Original Article | 18 | Copyright © January 2019

Kayla H. Felix MS,a Constance E. Ediale MS,a,b Amy J. McMichael MDa

aWake Forest School of Medicine, Department of Dermatology, Winston-Salem, NC bMedical College of Georgia, Athens, GA

Abstract
A recombinant vaccine (HZ/su) was approved in 2017 to prevent herpes zoster (HZ) infection and associated sequelae with greater efficacy and safety than its live precursor. Though dermatologists regularly encounter patients with HZ infection, recommendation of vaccination by dermatologists and other physicians has been minimal in past years. Overall patient awareness and utilization of the HZ vaccines has subsequently been low. While HZ/su touts several improvements over the live vaccine, dermatologists still face obstacles to vaccine recommendation and administration including concerns of efficacy, limited availability, and complex cost and reimbursement for administration. Additionally, dermatologists have not historically played a systematic role in the recommendation and administration of vaccines. A review of literature was completed to identify the current role of dermatologists in HZ prevention, the efficacy and safety of HZ/su, potential barriers to recommendation by dermatologists, and the feasibility of vaccine administration in dermatology offices. Pubmed/MEDLINE was used as the primary search database. Ultimately, widespread encouragement of dermatologists to recommend vaccination against HZ is crucial, and dermatologists are in a prime position to make the vaccine more accessible to their patient population. J Drugs Dermatol. 2019;18(1):18-22.

INTRODUCTION

Herpes zoster (HZ, shingles) is an infection of the skin caused by the reactivation of latent varicella-zoster virus (VZV), the causative agent of “chickenpox”. After primary infection by VZV, the virus establishes lifelong latency within the sensory ganglia, typically emerging in late adulthood as shingles. Clinically, patients present during the eruptive phase with a painful, vesicular, dermatomal rash preceded by neuropathic pain. While adults over the age of 50 years are at an increased risk of developing HZ, it can affect individuals at any age.1 The risk increases tremendously with age, due to immunosenescence, and it is estimated that almost 50% of individuals over age 85 will experience shingles.2,3 According to the CDC, the annual incidence of shingles is approximately 4 cases per 1,000 person-years, when all ages are considered.4 Among individuals aged 60 years or older, the incidence increases to 10 cases per 1,000 person-years.4 The diagnosis and treatment of shingles is not limited to specific specialties. A 2009 study showed that health care encounters for HZ occurred in both inpatient and outpatient settings, in- cluding visits to primary care physicians (PCPs), specialists, and urgent care centers.5 Primary VZV infection and subsequent HZ have early and distinct skin manifestations and are thus regularly treated by dermatologists and PCPs. In a survey of nearly 600 PCPs, about half offered a shingles vaccine in office.6 Despite skin involvement, there are few reports of the role dermatologists have in encouraging vaccination against HZ. This review will summarize current offerings for shingles prevention, the impact dermatologists may have in the prevention of HZ, and interventions that fit with the mission of dermatologists.

Preventative Approaches

Acutely, HZ is treated using antiviral therapy, yet this treatment has no ability to prevent long-term sequelae.7,8 Of those who suffer from HZ, it is estimated that approximately 20% of people over the age of 60 will suffer from post-herpetic neuralgia (PHN), a chronic neuropathic pain that remains long after clearance of the dermatomal rash.9,10 Individuals may also suffer from depression, sleep disturbances, inability to perform daily activities, and an overall low quality of life.11 Other complications and sequelae of shingles include HZ ophthalmicus, bacterial superinfection of lesions, and cranial nerve palsies.12 To prevent the severe symptoms of acute HZ and the potential for sequelae, vaccines have been developed. Zostavax (zoster vaccine live or ZVL) was approved in 2006 by the FDA and recommended by the CDC for use in immunocompetent adults ≥60 years.13 It was the sole vaccine used to prevent shingles until October 2017, when Shingrix (zoster subunit vaccine– recombi- nant, adjuvanted or HZ/su) was approved for the treatment of HZ and prevention of PHN. Despite efficacy of the live vaccine,14,15 the 2015 National Health Interview Survey (NHIS) by the CDC suggests that, nationally, roughly only 30.6% of individuals ≥ age 60 had received ZVL by the end of 2015.16 In 2014, of the 50 states and D.C., utilization ranged from 18% in Mississippi to about 47% in Vermont, with the median falling around 33%.17