Management of herpes zoster (shingles) during pregnancy

Abstract

An infection with the varicella-zoster virus (VZV) causes both varicella and herpes zoster (HZ). Although rare, the development of HZ does occur during pregnancy. Maternal HZ does not result in increased foetal mortality, and the passage of VZV to the foetus rarely occurs. However, HZ does increase maternal morbidity. Upon infection with HZ, patients typically present with a viral prodrome preceding the appearance of the characteristic zoster rash. HZ is usually diagnosed clinically by the zoster rash, but can also be confirmed by a polymerase chain reaction and an enzyme-linked immunosorbent assay. Pregnant women with an uncomplicated HZ should be treated with oral acyclovir. The major complications of HZ are subacute herpetic neuralgia and post-herpetic neuralgia. Other complications include zoster ophthalmicus, disseminated HZ and secondary bacterial infections. Regarding prophylaxis, the varicella and the zoster vaccines are not recommended for pregnant women, and it is important to advise non-immune pregnant women to avoid an exposure to VZV. Although HZ infection has a minimal effect on the foetus, maternal HZ and its complications cause a significant burden. It is important to focus care on the mother with appropriate treatment and management of complications as they develop.

Herpes Zoster in Pregnancy

“…The most commonly affected dermatomes innervate the thorax, head, or neck. In pregnant women, outbreaks are most common in the scapular and intercostal area, right along the bra line . In rare and serious cases, cranial or central nerves can be affected, potentially leading to ocular or neurologic complications.…”

“…Typical progression of herpes zoster involves a prodromal period, followed by active lesions, then a gradual resolution, with pain being the last symptom to resolve. During the prodromal stage, approximately 80% of individuals experience preherpetic neuralgia, often described as itching, tingling, or burning in the affected area within 5 days prior to eruption of lesions . Other prodromal symptoms, such as a headache, fatigue, malaise, or low‐grade fever, occur in less than 20% of individuals .…”

“…However, herpes simplex virus (HSV) infection may occur in a dermatomal distribution and be mistaken for herpes zoster; therefore, HSV screening may be warranted in cases of recurrent lesions. In instances in which pain is severe along the thoracic dermatomes and lesions have not yet erupted, prodromal symptoms may seem suspicious for gallbladder disease, appendicitis, or myocardial infarction . When lesions present in an atypical pattern and additional diagnostic approaches are warranted, polymerase chain reaction (PCR) testing of lesions or other bodily fluids is preferred over other methods, such as direct immunofluorescence assay or viral cultures, because of its high sensitivity and specificity and quickly available results …”

“…Valacyclovir can be substituted if the required 5 times daily dosing of acyclovir presents problems in treatment adherence, as the drugs have similar safety profiles . Intravenous administration may be considered for severe or complicated cases or for immunocompromised individuals . Neither corticosteroids nor topical antiviral treatments are recommended for treatment of herpes zoster or its associated symptoms in pregnant women…”

“…During the prodromal stage, approximately 80% of individuals experience preherpetic neuralgia, often described as itching, tingling, or burning in the affected area within 5 days prior to eruption of lesions. 8 Other prodromal symptoms, such as a headache, fatigue, malaise, or low-grade fever, occur in less than 20% of individuals. 9 Lymph nodes that drain the affected area may also become enlarged and tender.…”