Shingles

Etiology

The shingles is a viral disease due to a reactivation of the Virus chicken pox-shingles or VZV, for Varicella Zoster Virus, pertaining to the family of the herpes virus, which is the virus responsible for the Varicelle.

Epidemiology

The annual Incidence lies between 1.5 and 4 new cases for thousand. It is much more frequent in the elderly like at the patient immunodéprimé (of which AIDS). The monitoring of the evolution of the incidence in France is carried out by the Réseau Sentinels of the Inserm.

The frequency of the pains post-zostérienne reaches nearly 40% in the elderly

With the acute phase

Feelings of burns can appear.

Symptomatic treatment

The treatment of the shingles is in general purely symptomatic:

local Care:

Toilet with tepid water with nonaggressive soap (dermatological bread, soap will surgras…) and not disinfectant.
Disinfectant after the toilet: for example Chlorhexidine or Fluorescein, in aqueous Solution (and not alcoholic, too aggressive). This treatment is intended to avoid the bacterial surfection (impetiginisation).

In the event of pains:

Antalgic S of class I (Paracetamol) to III (Morphine) according to the painful intensity.
Some Benzodiazepine S like the Clonazepam (Rivotril®).
the Anti-inflammatoires (stéroïdiens and not stéroïdiens) are disadvised.

Anti-pruriginous in the event of strong itchings, the aggravation of the lesions by scraping involving a cicatricial risk.

Antiviral treatment, reserved with particular cases

The antiviral treatment, which acts directly on the infectious agent responsible for the shingles, in theory is reserved for the cases for which complications are to be feared. That thus relates to primarily the immunodéprimés patients and the ophthalmic shape of the shingles.

When it is indicated, the treatment must be started most precociously possible.

The molecules available likely of beings active on the VZV are the Aciclovir (Zovirax®), the Valaciclovir (Zelitrex®) and the Famciclovir (Oravir®).

At the immunodéprimé patient

The antiviral treatment is systematic, calling classically upon the Aciclovir by intravenous way, at least a week. To valaciclovir and famciclovir it by oral way are sometimes used.

The effectiveness of the treatment being marked if it is begun in the first three days, the ideal would be that a immunodéprimé patient knows the first signs of appearance of the shingles, in order to start the treatment most precociously possible.

Treatment of the ophthalmic shingles

The antiviral treatment is systematic. To aciclovir or valaciclovir it, used by oral way over one duration of at least a week, are indicated to avoid the ocular complications.

The ophthalmic shingles must be systematically taken charges some in urgency by a specialist, who will consider treatment appropriateness complementary (to aciclovir in opthalmic pomade, corticothérapie local and/or general) according to the ocular type of attack.

Treatment of the otitic shingles

There still, because of the risk of persistence of a facial paralysis, the antiviral treatment is systematic. In spite of this treatment, the risk persists however. To note that the Corticothérapie is contra-indicated for certain at the beginning of treatment.

At the patient immunocompétent

The antiviral treatment is proposed on the subjects of more than 50 years, to prevent the more frequent pains post zostériennes starting from this age. It calls upon valaciclovir or famciclovir by oral way during 7 days.

In the adult of less than 50 years, and in the same goal, some very propose also the same treatment in the event of eruption Florida, or of intense pains at the time of the prodromic phase or the eruptive phase. In France, the antiviral treatment of the shingles at the subjects immunocompétents of less than 50 years is not the assumption of responsibility object by the Health insurance.

Remotely: problem of the pains post zostériennes

The principal molecules used, in addition to usual analgesics, are the Amitriptyline (Laroxyl® Elavil®), the Gabapentine (Neurontin®) and the Carbamazépine (Tegretol®). The amitriptyline involves a reduction in half of the intensity of the pains at 50% of the patients, with a less frequency of paroxysms douloureux.
There exist also treatments calling upon physical techniques, like the transcutanée neurostimulation, or the weekly injection intrathécale of méthylprednisolone + lidocaïne .

Prevention

The usual vaccine against chicken pox at the nourisson currently did not show an effectiveness on the prevention of the shingles (primarily because of the lack of retreat, vaccination taking place in childhood and the shingles occurring after about sixty).

A vaccine against the shingles, more strongly proportioned and close to that used for the children against chicken pox, is under development. Intended to be injected in the elderly, it makes it possible to decrease of almost 50% the risk to develop a shingles, and to 65% occurred of the pains post-zostérienne. This effectiveness decreases however with the age.

Vaccination is logically not recommended at the immunodéprimée person, whereas the risk of infection by the virus is real. In the event of Clerc's Office of marrow or among patients of the AIDS, to aciclovir it in treatment continuous is a possible and shown prevention.

Contagiousness

Since blisters and crusts of the shingles, in the same way that those of chicken pox, contain the VZV, there exists a risk contagious for the not immunized people (i.e. those which never made chicken pox): these people can then develop chicken pox (and not a shingles which is an internal reactivation of old chicken pox). For a patient reaches shingles, the people to be avoided are thus very the young children and the expectant mothers, as well as the immuno-depressed people at which chicken pox could have serious consequences.

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