Shingles

Definition

Shingles (or Herpes zoster - zoster for short) is an adult reactivation of a childhood chicken pox infection. However, instead of covering large parts of the body (as in chicken pox), the skin rash usually appears only on a small area of skin, in rows like shingles on a roof.

Description

A typical shingles rash follows the path of certain nerves on one side of the body; generally on the trunk, buttocks, neck, face or scalp, and usually stops abruptly at midline. Shingles is common in the elderly and rare among the young. About two-thirds of all cases occur in persons over 50. It afflicts both sexes equally.

Most people suffer only one attack, although repeat bouts occasionally occur, usually at the same site as the first eruption.

If shingles occur on the face, the nose and cornea of the eye are often involved. This condition (known as zoster keratitis) can lead to blindness if untreated, so anyone with shingles on the upper face, no matter how mild, should see a physician at once.

A tingling at the tip of the nose may herald possible eye involvement. When the trigeminal facial nerve and the eyes are affected, people are more likely to experience prolonged post-shingles pain.

With advancing age, there's an increasing chance of being left with irritating discomfort, vision impairment or severe pain after the zoster rash heals.

An attack of shingles generally begins with feverish discomfort (chills, headache or an upset stomach), possibly accompanied by a preliminary itching or burning sensation. Pain may precede the rash by a few days (occasionally mistaken for a heart attack, lung infection or back problem), but the discomfort is more commonly felt during and/or after the rash.

The rash, typically confined to one side of the body, starts as a series of raised red spots surrounded by a swollen area that turns into clear blisters, which become cloudy, dry out and crust over. The spots may bleed and become very itchy and painful. In a few, especially the immunosuppressed, attacks are severe with the rash covering a wide area. The rash may take three to four weeks to heal. Shingles pain that occurs without a rash is known as zoster sine herpete. Normally, once the herpetic rash fades, the area stops hurting and full recovery follows.

Causes and Risk Factors

Anyone who has had chicken pox has the potential to develop herpes zoster (or shingles), because the same virus that causes chicken pox causes zoster. The virus remains in a dormant state in certain nerve cells of the body, anywhere from months to years, and then it reactivates, causing zoster.

About 20 percent of the population is affected at some time in their life. What prompts the virus to "awaken" and cause problems in normal, healthy people is not clear. Most physicians believe there is a temporary decrease in the body's immune response, which somehow removes the shackles on the virus, allowing it to start reproducing and to move along nerve fibers toward the skin.

The fact that the disease occurs more often in people older than 50 (although children can get it too), supports this concept, as the immune response is believed to wane in older people. Trauma or stress can also trigger a zoster attack.

A slightly different group are people who are "immunosuppressed," that is, whose immunological systems are weakened and they are unable to fight off disease normally. They are more prone to develop zoster and more likely to have a serious form of it. This includes people with leukemia or lymphoma cancer, people who have undergone chemotherapy or radiation therapy for cancer, people who have had organ transplants (and are taking drugs that ward off transplant rejection, but depress the immune response) and people with diseases that affect the immunological system, such as AIDS.

Symptoms

Here's how the disease typically progresses: The earliest indication is excessive sensitivity in a band-like region of the skin on one side of the trunk, head, face, or neck, or in one arm or thigh. That sensitivity is soon replaced by pain, an often intense burning, itching or stabbing sensation.

Fatigue and low-grade fever sometimes accompany the pain. At this early stage, the symptoms can puzzle patient and doctor alike, sometimes mimicking heart disease or some other internal disorder. After four or five days, the painful area develops a bumpy, reddish rash. A day or two later, that rash turns into the unmistakable hallmark of shingles: groups of tiny, clear blisters surrounded by a red base. Over the following two or three weeks, the blisters become brownish, dry out, form a rust and drop off, sometimes leaving small, pigmented areas.

Before the shingles rash appears, you may have a slight fever and feel mildly fatigued. Because shingles involves infection of a nerve, you may feel some itching, tenderness, stinging, burning or pain, even before the rash appears. The pain may be felt from front to back, especially in the chest or face, and is usually felt on just one side. This may be mistaken for the pain of an ulcer, heart attack, migraine headache, appendicitis or lower back problem.

The trunk, neck and back are the most common areas for the rash, but in some cases, the eye, face and the tip of the nose are affected. If this occurs, you should see your doctor immediately so that medication can be prescribed to keep the blisters from spreading.

Treatment

Onset

The skin of patients with herpes zoster is highly inflamed, tender and responsive to the slightest touch. In the acute phase of illness, measures to relieve those sensations and provide local comfort will soothe the rash of zoster, just as they would an acute sunburn.

Wet dressings or compresses with aluminum acetate (or Burow's solution - Domeboro) help protect sensitive areas and keep clothes from rubbing against skin lesions. Topical agents include calamine-containing lotions and creams, 10 percent trolamine salicylate (Aspercreme), and silver sulfadiazine (Silvadene Cream).

To pharmaceutically attack shingles, three drugs have been shown effective in combating this condition: acyclovir (Zovirax), famciclovir (Famvir) and valacyclovir (Valtrex).

Currently, oral acyclovir (Zovirax) is the antiviral agent most often used to reduce inflammation, relieve acute pain and prevent long-term pain in patients with herpes zoster - especially in patients 55 to 60 years of age and older.

Treatment with famciclovir (Famvir) may significantly reduce the pain and recovery time. Experts believe that the drug works by stopping the virus that damages the nerves.

Another drug, oral valacyclovir (Valtrex), may be comparable to acyclovir in treating shingles. Valacyclovir is better absorbed than acyclovir and reduces pain faster.

Post Pain

After an attack of shingles, persisting and often intense pain (known as postherpetic neuralgia) can drag on anywhere from months to more than a year. Attacks of shingles become more common at later ages, and the likelihood of developing postherpetic neuralgia also increases.

The culprit appears to be a chain of amino acids, known as substance P, normally contained in fine nerve endings. When the nerves are damaged, they release substance P, which then triggers pain. The pain after shingles presumably results from persisting damage to nerves, which respond by leaking their substance P. Of the many treatments for postherpetic neuralgia, none are reliably effective.

The first line of defense is topical formulations, such as aspirin with ether, indomethacin with ether, or lidocaine or lidocaine with prilocaine. One currently favored approach is to combine the anti-epileptic agent, carbamazepine (Tegretol), and the antidepressant drug, amitriptyline (Elavil). They work by suppressing either the release of substance P or the response to it. Injecting local anesthetics to block nerve transmission can be a helpful but elaborate and expensive measure.

Another treatment option is rubbing a cream containing capsaicin (Zostrix, Zostrix-HP) over the painful area of skin. Capsaicin itself can produce intense stinging because it stimulates nerve endings to release substance P, but if exposure is sustained, capsaicin prevents nerves from reaccumulating substance P, thus depleting their stores and preventing further release.

More controversial options to relieve pain are injections of steroid drugs and the use of acupuncture or the related technique TENS (Transcutaneous Electrical Nerve Stimulation - a method of pain relief achieved by the application of minute electrical impulses to nerve endings that lie beneath the skin).

The lack of predictably beneficial treatment for postherpetic neuralgia has prompted a focus on its prevention. Careful definitions and methods are required to distinguish relief of early pain from prevention of late pain, although there is a considerable overlap in the symptoms of shingles and postherpetic neuralgia. Studies evaluating the use of corticosteroids, such as triamcinolone (Mycolog-II, Myco-Triacet II, Mytrex), prednisolone (Pedipred) and prednisone (Deltasone, Orasone) are being conducted.

Questions to Ask Your Doctor

Do any diagnostic tests need to be done?

Will any medications be prescribed? If so, what are the side effects?

If herpes affects the face or eyes, what treatment is recommended?

What are the chances that there may be permanent damage?

What can be done to prevent irreversible nerve damage?

Are there any signs or symptoms that the doctor should be notified of immediately?

Does calamine lotion help decrease itching?

Are there any home remedies or measures to decrease the discomfort?

Is it contagious?

Can the herpes spread to other parts of the body?

What measures should be taken to prevent it from spreading?

Should a pain specialist be consulted?

Will vitamins help boost the immune system and help the nerve endings?