Abstract and Introduction
Abstract
The lifetime risk for herpes zoster (HZ) of approximately 1 in 3 is increased with advancing age, a family history of HZ, diseases with altered immune function, immunosuppression, physical trauma and psychological stress. In dermatology, monotherapy with current biologics does not increase risk, however systemic steroids, Janus kinase inhibitors and combination biologic/conventional disease-modifying antirheumatics do. The recombinant zoster vaccine (RZV, Shingrix®), an adjuvanted non-live subunit vaccine against the glycoprotein E subunit of varicella zoster virus, is approved for prevention of HZ in adults ≥50 years of age, and adults ≥18 years of age who are or will be at increased risk of HZ due to immunodeficiency or immunosuppression due to disease or treatment. It is administered as two 0.5 ml intramuscular injections 2–6 months apart. In immunocompromised individuals, the spacing between injections may be reduced to 1–2 months. Where possible, the first dose should be administered at least 14 days before onset of immunosuppressive treatment. Studies in immunocompetent individuals have shown high efficacy including prevention of HZ, postherpetic neuralgia and other complications, with persistence of effect 10 years after vaccination. The acceptable safety profile and efficacy in five different immunocompromised populations support its use in at-risk adult dermatologic patients.
Introduction
New oral and biologic treatments are being developed to treat common conditions such as atopic dermatitis and psoriasis. Some of these treatments may increase HZ, the recurrent infection caused by reactivation of the varicella-zoster virus (VZV). The lifetime risk is approximately 1 in 31 and increases with advancing age,[2] immunosuppression,[2] a family history of HZ,[3] systemic lupus erythematosus[4,5] rheumatoid arthritis,[4,5] inflammatory bowel disease,[4,5] chronic renal disease,[5] cancer,[5] multiple sclerosis,[4] psoriasis,[4] asthma,[5] chronic obstructive pulmonary disorder (COPD),[5] diabetes mellitus,[5] depression,[5] physical trauma[5] and psychological stress (Table 1).[5,6]
Typical clinical features include a prodrome with pruritus, tingling and/or pain followed by painful erythematous macules, papules and vesicles on an erythematous base over a single dermatome.[2] The eruption crusts over and usually heals within 4 weeks,[2] however, complications such as postherpetic neuralgia (PHN) may persist for >1 year particularly in those over age 70 years.[7] Recurrent HZ occurs in up to 6.41% of individuals.[8] In immunocompromised patients, the eruption can be multi-dermatomal,[9] bilateral,[10] disseminated11 or necrotic,[12] and there is a higher rate of HZ related complications.[13]
In 2006 in the US and 2011 in Canada, the first HZ vaccine, a single dose, subcutaneous, live attenuated vaccine, Zostavax™ was approved. This vaccine was discontinued in 2020 in the US and 2022 in Canada. Shingrix®, an adjuvanted non-live subunit vaccine against the glycoprotein E subunit of VZV (recombinant zoster vaccine, RZV), received approval in 2017 for immunocompetent individuals 50 years of age and older, and in 2021 for individuals 18 years of age or older who are or will be at increased risk of HZ due to immunodeficiency or immunosuppression due to disease or treatment.[14] It has to be first reconstituted before administration and used within 6 hours after reconstitution. It is administered as two 0.5 ml intramuscular injections 2–6 months apart.[14] In immunocompromised individuals the spacing between injections may be reduced to 1–2 months.[14] Health Canada recommends that the first dose be administered at least 14 days before onset of immunosuppressive treatment.[15] If this is not possible, it should be administered during periods with less immunosuppression when the immune response is expected to be stronger.[13] For patients treated with rituximab, it is recommended that RZV be administered at least 5 months after the last dose and at least 4 weeks before the next dose of rituximab.[16,17]
Skin Therapy Letter. 2023;28(4):4-6. © 2023 SkinCareGuide.com
