Shingles

Introduction

Written accounts of people afflicted with shingles (also known as herpes zoster) date to the 9th century A.D., when a Persian physician named Rhazes noticed a small, fluid-filled blister similar in appearance to smallpox. The condition was believed to be smallpox until the 17th century.

Shingles is, of course, better understood today, and the condition is fairly prevalent. In the United States, more than a million new cases of shingles are diagnosed each year. Among affected individuals, 10% to 20% develop further complications, such as postherpetic neuralgia (PHN) or ophthalmic herpes zoster (shingles in the eye).

What is it?

Shingles is a viral infection caused by the varicella zoster virus, which also causes chickenpox, a common infection among children. When the chickenpox rash heals, the virus remains in the nervous system of the affected individual in a dormant, or inactive, state. If the individual's immune system is weakened, the virus can be reactivated and shingles can appear. You can learn more about this process by reading the "What causes it?" section.

Shingles appears as an itchy, painful, blistering rash that generally affects only limited areas of the skin, and is often on one side of the body. In most people, this rash typically disappears within 3 to 5 weeks. Shingles can lead to long-term, painful conditions after the rash and blisters have healed, such as postherpetic neuralgia (PHN, nerve pain that persists after the rash is gone) and ophthalmic herpes zoster (shingles in the eye). About 20% of people with shingles develop PHN, and about 10% develop ophthalmic herpes zoster. To learn more about these complications, click on the links below.

Shingles is not a life-threatening infection unless the affected individual has a weakened immune system due to illness or use of certain medications. Individuals with HIV infection or AIDS, organ transplant receivers, and patients with cancer who are receiving chemotherapy are at the greatest risk of serious complications or even death. But for most people, shingles symptoms disappear in 3 to 5 weeks with no complications.

Postherpetic neuralgia (PHN)

Postherpetic neuralgia (PHN), a complication of shingles, causes a severe, constant pain or periods of intense pain that can last for months or even years - long after the shingles rash has healed. The pain is associated with the damage that the varicella zoster virus causes to the nerves. In the most severe cases, the pain can be debilitating and cause insomnia, loss of appetite, and depression.

The kind of pain, its intensity, and the area or part of the body that is involved depends on which nerves have been most damaged by the virus. Generally, affected individuals experience one or more of the following types of pain: a deep, persistent aching or burning pain; a jabbing, shooting, or stabbing pain; or a feeling of discomfort that is caused even by the lightest touch or exposure to cold temperatures

Age is the major risk factor for PHN, which occurs most commonly in older persons. Other risk factors include an outbreak of shingles around the eye and severe pain during the first few days of a shingles episode. PHN is normally not life-threatening. However, paralysis has been reported in 1% to 5% of patients with this condition.

Ophthalmic herpes zoster

Ophthalmic herpes zoster (or shingles of the eye) is another complication of shingles. The condition is diagnosed when the varicella zoster virus attacks the skin around the eye or the eye itself, which can lead to temporary or permanent blindness. Afflicted individuals typically have a rash with small blisters on the forehead and around the eye, usually on one side of the face.

About 10% of patients with shingles go on to develop ophthalmic herpes zoster. The condition is more prevalent among patients with weakened immune systems due to illness (for example, HIV/AIDS or cancer) or use of certain medications (such as chemotherapy).

What causes it?

Although caused by the same virus that causes chickenpox, shingles does not occur in the same way. Shingles, unlike chickenpox, cannot be spread through the air from an affected individual to another person. Only individuals who have had chickenpox can develop shingles, which results when the dormant chickenpox virus in the individual's nervous system is reactivated.

Any weakening of the body's immune system can cause the varicella zoster virus to "reawaken" and appear in adulthood as shingles, although the exact reasons are not entirely understood. The immune system can be weakened by aging; sunburn; use of steroids; illnesses such as cancer, HIV/AIDS, and colds; medical treatments such as chemotherapy and radiation therapy; periods of increased stress; and excessive alcohol intake.

Who has it?

Each year, one million Americans develop shingles. Approximately 10% of adults will get shingles at some point during their lifetime, usually after the age of 50.

The good news is that most people do not get shingles more than once because they develop immunity to the virus. However, about 1% to 5% of individuals will suffer a recurrence of shingles either in the original area on the body or a different area. Individuals may be most susceptible to recurrent attacks when they are run down or have a weakened immune system.

Shingles affects men and women and people of all races equally. Although shingles can affect adults at any age, the elderly and individuals with weakened immune systems are most susceptible to developing the condition.

A woman who has active chickenpox or shingles within a few weeks of giving birth can pass the varicella zoster virus to her unborn infant. About one-third of babies who are exposed to the virus in this way go on to develop shingles before their 5th birthdays.

What are the risk factors?

A person must have had a bout of chickenpox to develop shingles. Any person who has had chickenpox is therefore at risk for developing shingles.

Risk of developing shingles increases with age. The risk of adults over the age of 60 is 10 times as great as that of children under the age of 10. Shingles are more common in individuals with a weakened immune system. The following factors can weaken an individual's immune system:

  • Common cold or flu
  • Sunburn
  • Cancer
  • HIV/AIDS
  • Chemotherapy
  • Radiation therapy
  • Use of steroids for a prolonged period of time
  • Stress or anxiety
  • Excessive use of alcohol

Shingles is not contagious - that is, it cannot be passed from one person to another. However, individuals who have never had chickenpox or who have not received the chickenpox vaccine could get chickenpox - not shingles - if exposed to someone with an active shingles rash.

What are the symptoms?

The first signs of shingles often include itching; stabbing, shooting pains; a tingling feeling in or under the skin; redness on the skin of the affected area; fever; chills; headache; and stomach upset. After a few days, a rash appears as a band or a patch of raised dots, usually on one side of the body, around the waistline or on one side of the face or the trunk. The rash eventually develops into red, fluid-filled, round, painful blisters. The blisters typically begin to dry out within a few days or weeks.

Individuals with post-herpetic neuralgia (PNH), a complication of shingles, can continue to have pain, ranging from mild to severe and debilitating, for months or years after the skin rash has healed.

How is it treated?

By recognizing and controlling the factors that can contribute to a shingles attack - for example, high stress levels or excessive consumption of alcohol - individuals may be able to prevent a recurrence of shingles. And although there is no cure, treatment for shingles can help reduce pain and discomfort and speed healing of the blisters and rash.

Antiviral medications such as acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir) offer substantial relief and significantly reduce the duration of symptoms for most affected individuals. Starting an antiviral medication within 72 hours of the first sign of a shingles attack is generally recommended to help speed healing and possibly reduce the risk of developing complications such as postherpetic neuralgia (PHN).

Pain medications can also offer relief. For mild to moderate pain, acetaminophen (Tylenol) or over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin, Advil), naproxen (Aleve), and ketoprofen (Orudis KT) can be effective. For moderate to severe pain, more powerful pain killers may be needed, such as prescription NSAIDs or narcotic analgesics. Corticosteroids (for example, prednisone, methylprednisolone, cortisone, and hydrocortisone) are also sometimes prescribed to reduce the pain, discomfort, inflammation, redness, and itching associated with the rash and blisters.

For postherpetic neuralgia (PHN), medications for nerve pain may be needed. These include anti-seizure drugs (Neurontin, Lyrica) antidepressants (Cymbalta), a lidocaine patch 5 % (Lidoderm), or capsaicin cream (Dolorac, Trixaicin, Zostrix, Zostrix-HP).

For ophthalmic herpes zoster, antivirals are used to fight the varicella zoster virus and prevent it from spreading to a larger area of the face and the eye. Other treatments include pain medicines, corticosteroids, and cool compresses. If you think you might have ophthalmic shingles, it is extremely important that you consult your primary doctor or an ophthalmologist immediately for treatment and advice to prevent permanent eye damage.

For more information on the drugs used to treat shingles and its complications, click on the links below.

Helping Yourself

For people who are having a shingles episode, the following tips can be helpful:

  • Follow your doctor's advice for taking medications to treat your symptoms.

  • See your doctor regularly during a shingles attack so that your progress can be closely monitored.

  • Avoid people who have not had chickenpox (or who have not received the chickenpox vaccine). Although shingles is not contagious, someone who has never had chickenpox or received the vaccine could get chickenpox from you, because the two diseases are caused by the same virus.

  • Use cool compresses to relieve discomfort and pain.

  • Eat a healthy diet even though your appetite may be reduced by the pain and discomfort associated with your condition.

  • Talk to your doctor if a pain medication is not working, so he or she can prescribe a different kind of drug that may manage your pain more effectively.

  • Talk to your doctor about appropriate medicine if depression becomes a problem.

  • Wear looser garments if your clothes rub your rash or are otherwise uncomfortable.

  • Don't scratch, pick, or rub the affected skin, because you may worsen your rash and blisters or promote new lesions.

  • Be patient. Most cases of shingles run their course within a month.

  • Avoid alcoholic beverages during a shingles outbreak to keep your immune system working at its highest level to fight your condition.

What is on the horizon?

Researchers face two major challenges in their fight against shingles. The first challenge is to find a drug that will cure this viral infection when it strikes. The second is to learn more about the varicella zoster virus so the disease can be prevented, especially in patients known to be at high risk.

Recently, the Food and Drug Administration (FDA) approved Zostavax, a new vaccine to reduce the risk of shingles, for use in people 60 years of age and older. It is estimated that the vaccine may prevent almost 250,000 new cases of shingles that occur each year in the United States.

Also, The National Institute of Neurological Disorders and Stroke is investigating a long-acting preparation of morphine, a type of narcotic pain killer, as a possible treatment for the pain associated with postherpetic neuralgia. In addition, testing on a more potent form of the chickenpox vaccine will begin soon. If this new vaccine is more effective than the existing one and if immunization of all children becomes widespread, shingles might never be a concern for this generation of children or for future generations when they reach adulthood.

References

Acosta E, Balfour H. Acyclovir for treatment of postherpetic neuralgia: efficacy and pharmacokinetics. Journal of Antimicrobial Agents and Chemotherapy. 2001;45: 2771-2774.

Fitzpatrick T. Varicella and Herpes Zoster. Dermatology in General Medicine. 5th ed. vol 2. New York: McGraw Hill; 1999: 2427-2450.

Gorbach S, Bartlett J. Varicella Zoster Virus. In: Infectious Diseases. 2nd ed. Philadelphia: W.B. Sanders; 1998. pages 1311-1323, 2081-2084.

Herpes Zoster. American Academy of Dermatology website. Available at: http://www.aad.org/pamphlets/herpesZoster.html. Accessed December 2007.

Oxman MN, Levin MJ, et al. A Vaccine to Prevent Herpes Zoster and Postherpetic Neuralgia in Older Adults. N Engl J Med. 2005; 352: 2271-2284.

Raja S, Haythornthwaite JA, Pappagallo M, Clark MR, Travison TG, Sabeen S, et al. Opioids versus antidepressants in postherpetic neuralgia: a randomized, placebo-controlled trial. Neurology. 2002;59(7):1015-1021.

Rowbotham M, Harden N, Stacey B, Bernstein P, Magnus-Miller L. Gabapentin for the treatment of postherpetic neuralgia. Journal of the American Medical Association. 1998;280(21):1837-1842.

Zostavax prescribing information. Merck & Co., Inc. Whitehouse Station, NJ. July 2007.

Shingles Health Condition Last Updated: December 2007

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

Back