Commentary
Article
Although Rare, Shingles in Children Can Occur
Author(s):
Although shingles is more common in adults, children who have had chickenpox or the chickenpox vaccine can develop shingles.
Primary infection by varicella-zoster virus (VZV) causes chickenpox. After chickenpox resolves, VZV stays in sensory nerve cells as an inactive infection. Reactivation of the virus causes shingles, also known as herpes zoster (HZ), a painful blistering rash that typically appears on 1 side of the body.
Shingles rash | Image credit: irontrybex | stock.adobe.com
Although shingles is more common in adults, children who have had chickenpox or the chickenpox vaccine can develop shingles. A review, published in The Pediatric Infectious Disease Journal, describes the epidemiology, risk factors, clinical course, and management of shingles in children.
The incidence of pediatric shingles is approximately 0.74 cases per 1000 person-years. Vaccination for VZV significantly reduces the incidence of shingles. Interestingly, in vaccinated children who developed shingles, both the vaccine strain and the wild VZV strain have been identified as causative. In addition to being unvaccinated, other risk factors for developing shingles include the following:
- Contracting chickenpox before the first birthday
- Asian or Caucasian descent
- Immunosuppression
- Human immunodeficiency virus (HIV) or other acute infections
- Asthma
The clinical course of shingles in children is similar to that in adults, except for a decreased incidence of pain. Pain is reported in less than half of pediatric patients and is uncommon in vaccinated children. In immunocompromised children, fever is more common and distribution of dermatome (the area of skin supplied by a single spinal nerve) involvement can differ relative to immunocompetent children.
Complications from shingles include bacterial superinfection of skin lesions (the most common complication in children), meningitis, sepsis, facial palsy, uveitis or keratitis, and postherpetic neuralgia. Unique complications include HZ-ophthalmicus (eye pain, inflammation, visual impairment), Ramsey Hunt syndrome (facial palsy, hearing loss, ear pain), and laryngeal HZ (severe throat pain and difficulty swallowing).
Diagnosis of shingles relies primarily on clinical presentation. Anti-VZV antibody testing and polymerase chain reaction testing may be used to determine a patient’s vaccination status and origin of infection, respectively.
Antiviral drugs such as acyclovir, famciclovir, valaciclovir, and brivudine are used to treat shingles. These drugs limit the appearance of new lesions and accelerate healing. Antiviral treatment should be considered in all children within 72 hours of disease onset. Children presenting after 72 hours may still benefit from these treatments especially in cases with face or neck lesions, severe rash/dermatitis, or complications.
Drug choice depends on the health care professional’s experience, drug availability, and patient-specific needs such as other medical conditions or medications. Dosing is typically oral, but immunosuppressed children and children with serious complications may require hospitalization, intravenous dosing, and dose adjustments. Duration of dosing is typically 7 days or until 2 days after appearance of new lesions. The most common adverse effects include headache and nausea/vomiting.
The authors of the review reported on potential links between pediatric shingles and increased risk for immune deficiencies or malignancies. They recommend considering screening for immunodeficiencies in regions with a higher incidence of HIV and poor access to regular medical care. They suggest choosing laboratory or imaging tests to detect neoplasms based on symptoms, medical history, and physical examination.
