今日の臨床サポート

帯状疱疹(皮膚科)

著者: 渡邉大輔 愛知医科大学 皮膚科学講座

監修: 戸倉新樹 掛川市・袋井市病院企業団立 中東遠総合医療センター 参与/浜松医科大学 名誉教授

著者校正/監修レビュー済:2021/04/21
患者向け説明資料

概要・推奨   

  1. 抗ウイルス薬は、皮疹出現後72時間以内に投与を開始することが望ましい(推奨度1)
  1. 抗ウイルス薬は7日間投与する(推奨度2)
  1. たとえ臨床的に軽症だからといって内服量を減量すべきではない(推奨度3)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要と
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
渡邉大輔 : 講演料(マルホ,大鵬,第一三共,GSK,武田,田辺三菱)[2021年]
監修:戸倉新樹 : 講演料(田辺三菱,サノフィ,マルホ,協和キリン),研究費・助成金など(ノバルティス,レオファーマ)[2021年]

改訂のポイント:
  1.  定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
ポイント:
  1. 帯状疱疹は脊髄後根神経節に潜伏感染した水痘・帯状疱疹ウイルス(VZV)の再活性化により発症する疾患である。
  1. 帯状疱疹は水痘既感染者なら誰でも発症し得る疾患だが、60歳を超えるとその発症率は急激に上昇する。
  1. 典型的な症例は臨床診断可能であるが、鑑別すべき疾患は丹毒、毛包炎、接触皮膚炎、殿部ヘルペスなどがある。
  1. イムノクロマト法による皮疹部からのウイルス抗原検出が診断に有用である。
  1. 典型例では抗ウイルス薬の内服、点滴で治療可能だが、頭頚部の帯状疱疹では眼科的、耳鼻科的合併症を伴うものもある。
  1. 最も多い合併症は帯状疱疹後神経痛(PHN)であり、高齢者、急性期の皮疹や疼痛の重症例では発症リスクが高まる。
  1. 皮疹出現後72時間以内の抗ウイルス薬投与開始が理想的であり、早期受診、診断が重要である。
 
予防:
  1. 欧米ではすでに帯状疱疹予防ワクチンは使用可能であったが、わが国でも2016年3月より、50歳以上の成人に対し、水痘ワクチンを帯状疱疹予防目的で接種することが可能となった。ただし、明らかに免疫機能に異常のある疾患を有する者および免疫抑制を来す治療を受けている者などの接種不適合者が存在することに注意する。
 
  1. ワクチンにより帯状疱疹の予防は可能である(推奨度2)
  1. 帯状疱疹ワクチンの効果に関するシステマティックレビュー(RCおよびそれに準ずる7研究のまとめ)[1]で、60歳以上、総計52,269人でのワクチン/プラセボの有効性、安全性をみたところ、帯状疱疹発症のリスク比(RR)は0.49、年齢層別では60歳代(RR=0.36)が70歳代(RR=0.63)に比べ効果が高かった。ワクチン接種による全身性副反応のRRは1.29、局所副反応のRRは4.51で、70歳代に比べ60歳代でより高頻度にみられた。
問診・診察のポイント  
  1. 帯状疱疹は脊髄後根神経節に潜伏感染したVZVの再活性化により発症する疾患である。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

まずは15日間無料トライアル
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: Anna M Z Gagliardi, Brenda Nazaré Gomes Silva, Maria R Torloni, Bernardo G O Soares
雑誌名: Cochrane Database Syst Rev. 2012 Oct 17;10:CD008858. doi: 10.1002/14651858.CD008858.pub2. Epub 2012 Oct 17.
Abstract/Text BACKGROUND: Herpes zoster or, as it is commonly called, 'shingles' is a neurocutaneous disease characterised by the reactivation of varicella zoster virus (VZV), the virus that causes chickenpox, which is latent in the dorsal spinal ganglia when immunity to VZV declines. It is an extremely painful condition which can often last for many weeks or months, impairing the patient's quality of life. The natural aging process is associated with a reduction of cellular immunity which predisposes to herpes zoster. Vaccination with an attenuated form of VZV activates specific T cell production, therefore avoiding viral reactivation. A herpes zoster vaccine with an active virus has been approved for clinical use among older adults by the Food and Drug Administration and has been tested in large populations.
OBJECTIVES: To evaluate the effectiveness and safety of vaccination for preventing herpes zoster in older adults.
SEARCH METHODS: We searched the following sources for relevant studies: CENTRAL 2012, Issue 7, MEDLINE (1948 to July week 1, 2012), EMBASE (2010 to July 2012), LILACS (1982 to July 2012) and CINAHL (1981 to July 2012). We also reviewed reference lists of identified trials and reviews for additional studies.
SELECTION CRITERIA: Randomised controlled trials (RCTs) or quasi-RCTs comparing zoster vaccine with placebo or no vaccine, to prevent herpes zoster in older adults (mean age > 60 years).
DATA COLLECTION AND ANALYSIS: Two review authors independently collected and analysed data using a data extraction form. They also carried out an assessment of risk of bias.
MAIN RESULTS: We identified eight RCTs with a total of 52,269 participants. Three studies were classified at low risk of bias. The main outcomes on effectiveness and safety were extracted from one clinical trial with a low risk of bias. Four studies compared zoster vaccine versus placebo; one study compared high-potency zoster vaccine versus low-potency zoster vaccine; one study compared refrigerated zoster vaccine versus frozen zoster vaccine; one study compared live zoster vaccine versus inactivated zoster vaccine and one study compared zoster vaccine versus pneumococcal polysaccharide vaccine (pneumo 23).Confirmed cases of herpes zoster were less frequent in patients who received the vaccine than in those who received a placebo: risk ratio (RR) 0.49 (95% confidence interval (CI) 0.43 to 0.56), with a risk difference (RD) of 2%, and number needed to treat to benefit (NNTB) of 50. Analyses according to age groups indicated a greater benefit in participants aged 60 to 69 years, RR 0.36 (95% CI 0.30 to 0.45) and in participants aged 70 years and over, RR 0.63 (95% CI 0.53 to 0.75). Vaccine-related systemic adverse effects were more frequent in the vaccinated group (RR 1.29, 95% CI 1.05 to 1.57, number needed to treat to harm (NNTH) = 100). The pooled data risk ratio for adverse effects for participants with one or more inoculation site adverse effect was RR 4.51 (95% CI 2.35 to 8.68), and the NNTH was 2.8 (95% CI 2.3 to 3.4). Side effects were more frequent in younger (60 to 69 years) than in older (70 years and over) participants.
AUTHORS' CONCLUSIONS: Herpes zoster vaccine is effective in preventing herpes zoster disease. Although vaccine benefits are larger in the younger age group (60 to 69 years), this is also the age group with more adverse events. In general, zoster vaccine is well tolerated; it produces few systemic adverse events and injection site adverse effects of mild to moderate intensity.

PMID 23076951  Cochrane Database Syst Rev. 2012 Oct 17;10:CD008858. do・・・
著者: Robert H Dworkin, Robert W Johnson, Judith Breuer, John W Gnann, Myron J Levin, Miroslav Backonja, Robert F Betts, Anne A Gershon, Maija L Haanpaa, Michael W McKendrick, Turo J Nurmikko, Anne Louise Oaklander, Michael N Oxman, Deborah Pavan-Langston, Karin L Petersen, Michael C Rowbotham, Kenneth E Schmader, Brett R Stacey, Stephen K Tyring, Albert J M van Wijck, Mark S Wallace, Sawko W Wassilew, Richard J Whitley
雑誌名: Clin Infect Dis. 2007 Jan 1;44 Suppl 1:S1-26. doi: 10.1086/510206.
Abstract/Text The objective of this article is to provide evidence-based recommendations for the management of patients with herpes zoster (HZ) that take into account clinical efficacy, adverse effects, impact on quality of life, and costs of treatment. Systematic literature reviews, published randomized clinical trials, existing guidelines, and the authors' clinical and research experience relevant to the management of patients with HZ were reviewed at a consensus meeting. The results of controlled trials and the clinical experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and valacyclovir as first-line antiviral therapy for the treatment of patients with HZ. Specific recommendations for the use of these medications are provided. In addition, suggestions are made for treatments that, when used in combination with antiviral therapy, may further reduce pain and other complications of HZ.

PMID 17143845  Clin Infect Dis. 2007 Jan 1;44 Suppl 1:S1-26. doi: 10.1・・・
著者: K R Beutner, D J Friedman, C Forszpaniak, P L Andersen, M J Wood
雑誌名: Antimicrob Agents Chemother. 1995 Jul;39(7):1546-53.
Abstract/Text Acyclovir treatment of acute herpes zoster speeds rash healing and decreases pain and ocular complications. The limited oral bioavailability of acyclovir necessitates frequent dosing. Valaciclovir, the l-valyl ester of acyclovir, is rapidly and almost completely converted to acyclovir in vivo and gives three- to fivefold increases in acyclovir bioavailability. In a randomized, double-blind, multicenter study, the safety and efficacy of oral valaciclovir given at a dosage of 1,000 mg three times daily for 7 or 14 days and oral acyclovir given at a dosage of 800 mg five times daily for 7 days were compared in immunocompetent adults aged > or = 50 years with herpes zoster. Patients were evaluated for 6 months. The intent-to-treat analysis (1,141 patients) showed that valaciclovir for 7 or 14 days significantly accelerated the resolution of herpes zoster-associated pain (P = 0.001 and P = 0.03, respectively) compared with acyclovir; median pain durations were 38 and 44 days, respectively, versus 51 days for acyclovir. Treatment with valaciclovir also significantly reduced the duration of postherpetic neuralgia and decreased the proportion of patients with pain persisting for 6 months (19.3 versus 25.7%). However, there were no differences between treatments in pain intensity or quality-of-life measures. Cutaneous manifestations resolved at similar rates in all groups. Adverse events were similar in nature and prevalence among groups, and no clinically important changes occurred in hematology or clinical chemistry parameters. Thus, in the management of immunocompetent patients > or = 50 years of age with localized herpes zoster, valaciclovir given at 1,000 mg three times daily for 7 days accelerates the resolution of pain and offers simpler dosing, while it maintains the favorable safety profile of acyclovir.

PMID 7492102  Antimicrob Agents Chemother. 1995 Jul;39(7):1546-53.
著者: G De Benedittis, A Lorenzetti
雑誌名: Pain. 1996 Apr;65(1):45-51.
Abstract/Text The efficacy of topical aspirin/diethyl ether (ADE) mixture in the treatment of acute herpetic neuralgia and postherpetic neuralgia, suggested in a previous open-label study (De Benedittis et al. 1992), has been evaluated in a double-blind crossover placebo-controlled study as compared with two other NSAID (indomethacin and diclofenac) drug/ether mixtures. The study included 37 patients (15 with acute herpetic neuralgia (AHN) and 22 with postherpetic neuralgia (PHN)). Comparative treatment results showed that only aspirin (but not indomethacin and diclofenac) was significantly superior to placebo, as compared with baseline and duration of pain relief (P < 0.05 and P < 0.01, respectively), in both AHN and PHN groups. Good-to-excellent results were achieved by 87% of AHN patients and by 82% of PHN patients treated with the ADE mixture, with no significant differences between the two groups. On the whole, patients with trigeminal involvement, less severe pain and with dysaesthetic quality of pain yielded best results.

PMID 8826489  Pain. 1996 Apr;65(1):45-51.
著者: Anita K Satyaprakash, Anne Marie Tremaine, Arwen A Stelter, Rosella Creed, Parisa Ravanfar, Natalia Mendoza, Satish K Mehta, Peter L Rady, Duane L Pierson, Stephen K Tyring
雑誌名: J Infect Dis. 2009 Jul 1;200(1):26-32. doi: 10.1086/599381.
Abstract/Text BACKGROUND: A phase 2 trial was conducted to evaluate the efficacy of a topical antiviral, sorivudine, as an adjuvant to valacyclovir for the treatment of acute herpes zoster.
METHODS: In this randomized, placebo-controlled, double-blind trial, 25 patients were treated with either sorivudine or placebo cream. All patients began 7 days of valacyclovir treatment on day 3. Zoster lesion swab samples and samples of peripheral blood mononuclear cells were collected periodically throughout the study and were analyzed for varicella-zoster virus (VZV) DNA by use of both qualitative and real-time polymerase chain reaction. Serum samples collected periodically throughout the study were analyzed for VZV DNA by use of real-time polymerase chain reaction.
RESULTS: VZV DNA was detected in all 3 sample types, and the number of viral copies correlated with the progression of herpes zoster. No statistically significant differences were seen between the placebo- and sorivudine-treated groups with respect to clinical characteristics or laboratory test results.
CONCLUSION: The detection of VZV DNA in the serum and peripheral blood mononuclear cells of all 25 zoster patients documents that viremia is a common manifestation of herpes zoster. Sorivudine cream appears to be a safe and well-tolerated adjuvant therapy; however, further phase 2 studies are needed to determine its clinical efficacy for the treatment of herpes zoster. Trials registration. ClinicalTrials.gov identifier: NCT00652184.

PMID 19469706  J Infect Dis. 2009 Jul 1;200(1):26-32. doi: 10.1086/599・・・
著者: Ying Han, Jingjing Zhang, Ning Chen, Li He, Muke Zhou, Cairong Zhu
雑誌名: Cochrane Database Syst Rev. 2013 Mar 28;3:CD005582. doi: 10.1002/14651858.CD005582.pub4. Epub 2013 Mar 28.
Abstract/Text BACKGROUND: Postherpetic neuralgia is a common, serious painful complication of herpes zoster. Corticosteroids are anti-inflammatory and might be beneficial. This is an update of a review first published in 2008 and previously updated in 2010.
OBJECTIVES: To examine the efficacy of corticosteroids in preventing postherpetic neuralgia.
SEARCH METHODS: We updated the searches for randomised controlled trials (RCTs) of corticosteroids for preventing postherpetic neuralgia in the Cochrane Neuromuscular Disease Group Specialized Register (16 April 2012), CENTRAL (2012, Issue 3), MEDLINE (January 1966 to April 2012), EMBASE (January 1980 to April 2012), LILACS (January 1982 to April 2012), and the Chinese Biomedical Retrieval System (1978 to 2012). We also reviewed the bibliographies of identified trials, contacted authors and approached pharmaceutical companies to identify additional published or unpublished data.
SELECTION CRITERIA: We included all RCTs involving corticosteroids given by oral, intramuscular, or intravenous routes for people of all ages with herpes zoster of all degrees of severity within seven days after onset, compared with no treatment or placebo but not with other treatments. We did not include quasi-RCTs (trials in which a systematic method of randomisation such as alternation or hospital number was used).
DATA COLLECTION AND ANALYSIS: Two authors identified potential articles, extracted data, and independently assessed the risk of bias of each trial. Disagreement was resolved by discussion among the co-authors.
MAIN RESULTS: Five trials were included with 787 participants in total. All were randomised, double-blind, placebo-controlled parallel-group studies. We conducted a meta-analysis of two trials (114 participants) and the results gave moderate quality evidence that oral corticosteroids did not prevent postherpetic neuralgia six months after the onset of herpes (RR 0.95, 95% CI 0.45 to 1.99). One of these trials was at high risk of bias because of incomplete outcome data, the other was at low risk of bias overall. The three other trials that fulfilled our inclusion criteria were not included in the meta-analysis because the outcomes were reported at less than one month or not in sufficient detail to add to the meta-analysis. These three trials were generally at low risk of bias. Adverse events during or within two weeks after stopping treatment were reported in all five included trials. There were no significant differences in serious or non-serious adverse events between the corticosteroid and placebo groups. There was also no significant difference between the treatment groups and placebo groups in other secondary outcome analyses and subgroup analyses. The review was first published in 2008 and no new RCTs were identified for inclusion in subsequent updates in 2010 and 2012.
AUTHORS' CONCLUSIONS: There is moderate quality evidence that corticosteroids given acutely during zoster infection are ineffective in preventing postherpetic neuralgia. In people with acute herpes zoster the risks of administration of corticosteroids do not appear to be greater than with placebo, based on moderate quality evidence. Corticosteroids have been recommended to relieve the zoster-associated pain in the acute phase of disease. If further research is designed to evaluate the efficacy of corticosteroids for herpes zoster, long-term follow-up should be included to observe their effect on the transition from acute pain to postherpetic neuralgia. Future trials should include measurements of function and quality of life.

PMID 23543541  Cochrane Database Syst Rev. 2013 Mar 28;3:CD005582. doi・・・
著者: F X Borruat, E R Buechi, B Piguet, P Fitting, L Zografos, C P Herbort
雑誌名: Klin Monbl Augenheilkd. 1991 May;198(5):358-60. doi: 10.1055/s-2008-1045980.
Abstract/Text We compared the frequency of severe ocular complications secondary to Herpes Zoster Ophthalmicus (HZO) in 232 patients. They were divided into three groups: 1) patients without treatment (n = 164); 2) patients treated adequately (n = 48) with acyclovir (ACV; 5 x 800 mg/d orally and ophthalmic ointment 5 x /d for a minimum of 7 days, given within three days after skin eruption); and, 3) patients treated inadequately (n = 20) with ACV (only topical treatment, insufficient doses, interrupted treatment, delayed treatment). Patients with no treatment or with inadequate treatments showed the same frequency of severe ocular complications (21% (34/164) and 25% (5/20), respectively). In contrast, when adequate treatment of ACV was given complications occurred in only 4% (2/48) of cases. This study emphasizes the need for prompt (within three days after skin eruption) and adequate (5 x 800 mg/d for at least 7 days) treatment of ACV to prevent the severe complications of HZO.

PMID 1886356  Klin Monbl Augenheilkd. 1991 May;198(5):358-60. doi: 10・・・

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから