What is Shingles?
Shingles, or herpes zoster, is a rash caused from the varicella-zoster virus, which is also the cause of chickenpox. This virus remains inactive after someone has had chickenpox. The virus may reactivate in the nerves in adulthood, causing the painful rash. The understanding why some people develop shingles and others don’t isn’t understood; typically there is just one attack and patients are often older than age 60, had chickenpox as a baby and have an otherwise immune system issues.
Herpes zoster is interesting in that if a child is exposed to someone with shingles, he or she will likely develop chickenpox if unvaccinated. If an adult comes into contact with someone with shingles – the illness is not infectious.
Preliminary symptoms of shingles include tingling and burning before a rash appears. From there, the rash typically increases to small blisters, which burst and create small ulcers. Within 2–3 weeks, the ulcers heal. The rash is often seen on the spine, stomach and chest, although it may also be found on the face and mouth. Other symptoms reported included abdominal pain, chills, facial distortion due to muscle cramping, fever, headaches, joint pain, swollen glands and vision issues.
A viral infection of the nerve roots, shingles (varicella zoster) can be very painful. It often causes a rash on one side of the body, the left or right, and is most common in older adults and people with weak immune systems. The good news is, most people who get shingles will get better and won’t get it again.
As children, we were all exposed to this same virus that causes chickenpox. After an attack of chickenpox, the virus remains in our nerve tissues and may reappear later in life in the form of shingles. Lucky for most of us, it usually stays inactive or dormant throughout our lives, but approximately 500,000 cases of shingles are seen annually.
In and of itself, shingles isn’t all that bad. It’s what happens to the three percent of shingles sufferers who also experience prolonged pain. Called postherpetic neuralgia, this complication causes severe pain to the area involved in the eruption and may last for months—even years—after shingles heals.
Before it manifests itself, the virus hides in a nerve bundle called the dorsal root ganglia or DRG. Once it leaves the DRG, it follows the nerve path and leaves its mark—a fiery red rash with little pustules. You may first experience a headache, flu-like symptoms, and sensitivity to light, followed by itching, tingling, or pain in the area where the rash may develop. With prompt treatment, the rash usually goes away after about two weeks. If all goes well—and it normally does—the little virus goes back into hiding and doesn’t cause any more problems.
How do we get Shingles?
You can’t catch shingles from someone else who has shingles. It’s most common in older adults and people with weakened immune systems because of stress, injury, infection, certain medications, and other reasons. Unfortunately, there’s no way to predict who may be affected or not, but we do know that about 500,000 shingles cases develop every year.
Areas of Shingles Infection
Your doctor can make the diagnosis by looking at your skin and asking questions about your medical history. Tests are rarely needed, but may include taking a skin sample to see if the skin is infected with the virus that causes shingles. Blood tests may show an increase in white blood cells and antibodies to the chickenpox virus but cannot confirm that the rash is due to shingles.
Shingles typically affects the chest, on one side only. The next most common place is the face, then the lower back and leg. It can also affect the eye and cause intense pain to the sclera, the white portion of the eye.
First Signs of Shingle Infection
First comes the rash, then small raised fluid-filled pustules develop. They begin to itch and break open—this is when the virus is most contagious. It is very important to keep the rash covered and not allow anyone to touch the area.
Herpes zoster usually clears in 2 to 3 weeks and rarely recurs. If the virus affects the nerves that control movement (the motor nerves), you may have temporary or permanent weakness or paralysis.
Sometimes, the pain in the area where the shingles occurred may last from months to years. See: Postherpetic neuralgia
Your doctor may prescribe a medicine that fights the virus, called an antiviral. The drug helps reduce pain and complications and shorten the course of the disease. Acyclovir, famciclovir, and valacyclovir may be used.
The medications should be started within 24 hours of feeling pain or burning, and preferably before the blisters appear. The drugs are usually given in pill form, in doses many times greater than those recommended for herpes simplex or genital herpes. Some people may need to receive the medicine through a vein (by IV).
Strong anti-inflammatory medicines called corticosteroids, such as prednisone, may be used to reduce swelling and the risk of continued pain. These drugs do not work in all patients.
Other medicines may include:
- Antihistamines to reduce itching (taken by mouth or applied to the skin)
- Pain medicines
- Zostrix, a cream containing capsaicin (an extract of pepper) that may reduce the risk of postherpetic neuralgia
Cool wet compresses can be used to reduce pain. Soothing baths and lotions, such as colloidal oatmeal bath, starch baths, or calamine lotion, may help to relieve itching and discomfort.
Resting in bed until the fever goes down is recommended.
The skin should be kept clean, and contaminated items should not be reused. Nondisposable items should be washed in boiling water or otherwise disinfected before reuse. The person may need to be isolated while lesions are oozing to prevent infecting other people who have never had chickenpox — especially pregnant women.
Immediately contact your primary care physician to prescribe an antiviral medicine; an over-the-counter pain medication may also be needed. If the pain doesn’t subside one to two weeks after the rash goes away, you may need to begin interventional therapies. These include a nerve block to interrupt the pain signal from the virus and stronger nerve medications such as Gabapentin (Neurontin), Toprimate (Topamax), or Pregabalin (Lyrica). Used for seizure disorders, these medications block the painful signal that is felt from the viral inflammation in the nerve bundle.
What are the complications of shingles?
Sometimes, the pain in the area where the shingles occurred may last for months or years. This pain is called postherpetic neuralgia. It occurs when the nerves have been damaged after an outbreak of shingles. Pain ranges from mild to very severe pain. It is more likely to occur in people over 60 years.
Other complications may include:
- Another attack of shingles
- Blindness (if shingles occurs in the eye)
- Infection, including encephalitis or sepsis (blood infection) in persons with weakened immune systems
- Bacterial skin infections
- Ramsay Hunt syndrome if shingles affected the nerves in the face
It’s important to seek prompt treatment for this condition to minimize the risk of complications. These include persisting neuralgia or painful nerve sites, scarring where the rash erupted, nerve paralysis, and even encephalitis.
If all else fails and you still have severe pain along the rash area, then interventional procedures can be offered such as Spinal Cord Stimulation or an Intrathecal Pump Delivery System. Many different medications can be used in a pump—types that stop the pain associated with shingles are Bupivicaine, an anesthetic, and Clonidine, a blood pressure medication.
Avoid touching the rash and blisters of persons with shingles or chickenpox if you have never had chickenpox or the chickenpox vaccine.
A herpes zoster vaccine is available. It is different than the chickenpox vaccine. Older adults who receive the herpes zoster vaccine are less likely to have complications from shingles. Adults older than 60 should receive the herpes zoster vaccine as part of routine medical care.
Anyone who has had chickenpox may get shingles later in life. Bu the U.S. Food and Drug Administration (FDA) recently approved a vaccine that might help prevent shingles or make it less painful if it does occur. One dose of the shingles vaccine, known as Zostavax, is recommended for adults 60 years of age and older. The FDA does not recommend this vaccine for people who have already had shingles.
For people who’ve never had chickenpox, the varicella vaccine can help avoid the virus that causes both chickenpox and later shingles. Those with no history of chickenpox should also avoid contact with people who have shingles or chickenpox. Fluid from shingles blisters is contagious, and exposure to it can cause chickenpox (but not shingles) in people who have already had shingles.
- Sampathkumar P, Drage LA, Martin DP. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009 Mar;84(3):274-80. [PubMed]
- Whitley RJ. Varicella-Zoster virus. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap 137.
- Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2010. Ann Intern Med. 2010;152:36-39.