Management of Herpes Zoster Reactivation in Individuals with Varicella Antibodies

Understanding Herpes Zoster Reactivation

The presence of varicella antibodies indicates prior exposure to VZV and identifies patients at risk for future reactivation infection, with reactivation risk increasing with advancing age and immunosuppression 2
Reactivation risk increases with advancing age and immunosuppression, with herpes zoster occurring most frequently during the first year following chemotherapy treatment or following receipt of blood, bone marrow, or solid organ transplants 2, 4

Lesions progress from erythematous macules to papules and then to vesicles, which may coalesce, form bullae, and scab before healing, with a typical presentation including prodromal pain that often precedes skin findings by 24-72 hours 1, 2
In immunocompetent hosts, lesions continue to erupt for 4-6 days with total disease duration of approximately 2 weeks, while in immunocompromised patients, skin lesions may develop over a longer period (7-14 days) and generally heal more slowly without effective antiviral therapy 1, 2

High-dose intravenous acyclovir remains the treatment of choice for VZV infections in compromised hosts, while oral antiviral therapy with acyclovir, valacyclovir, or famciclovir should be initiated within 72 hours of rash onset in immunocompetent patients 1, 2
Oral acyclovir, famciclovir, and valacyclovir should be reserved for mild cases of VZV disease in patients with transient immune suppression, and consider oral therapy to complete treatment once the patient has shown a clinical response to IV acyclovir 1, 2

Recipients of allogeneic blood and bone marrow transplants routinely take acyclovir or valacyclovir during the first year following transplant for prevention of VZV and HSV reactivation, and the adjuvanted recombinant zoster vaccine (RZV) is recommended as a preventive strategy for immunocompromised patients to reduce the incidence and severity of VZV reactivations 1, 2, 4
Varicella zoster immunoglobulin within 96 hours of exposure is recommended for varicella-susceptible patients exposed to individuals with active VZV infection 5

Without adequate treatment, some immunocompromised patients develop chronic ulcerations with persistent viral replication, complicated by secondary bacterial and fungal superinfections, and if skin lesions suspicious of VZV develop in patients already taking antivirals, antiviral resistance should be investigated 1, 2