Deja Vu isn’t always pleasant. As a disease, Shingles is a perfect example of this statement. The peculiar name, Shingles, is derived from a Latin word, cingulum, meaning girdle or belt. An outbreak is actually a reactivation of a chickenpox infection that has been dormant in a person’s body– usually for decades. The Latin-derived name is descriptively appropriate; the shingles rash and pain occur in an area of the skin that is supplied by the sensory fibers of a single nerve (called a dermatome)–so, in fact, it does resemble a band of blisters on one side of the body–usually the torso. Early in the New Year 2002 when many of us are reassessing our achievements and our actions in 2001, it seems appropriate to examine a disease that only occurs because of an infection that has already happened. Let’s explore facts about this unwelcome encore below.
Shingles is a reactivation of the varicella-zoster virus (also known as herpes zoster). As above,it’s the same virus that gave most of us good ole Chickenpox as children. Even though the fever, and itching, and plethora of crusting blisters on our bodies resolve, the virus retreats deep into nerve root cells near our spinal cords. . .and simply hibernates until it is reactivated. So, you can’t get Shingles if you haven’t already had chickenpox. Also, you can’t GIVE Shingles to anybody else. Since it’s a reactivation of an infection you already have in your own body, Shingles victims are a contagious threat only to people who have never had chickenpox. And,those chickenpox-naive folks must have direct contact with the blisters of Shingles and/or with contaminated clothing,bandages, etc.to become infected. You can’t catch it from seeing someone with Shingles across the room, in a store, etc.
What’s the typical course of Shingles? Usually, an itchy, burning pain precedes the rash by 1 to 5 days, and it occurs in a defined nerve root distribution. In the early absence of a rash, depending on the location of the affected nerve, the pain is frequently mistaken for an earache, pleurisy, a kidney stone,appendicitis, a gallbladder attack, or even a heart attack. It’s not unusual for a person to go through several non revealing studies before the subsequent blistering bandlike rash yields a definitive diagnosis. The rash usually begins as small, clustered blisters which may become dark or pustular before they ultimately scab, dry up and disappear. This whole process from start to finish generally takes three to five weeks in a typical, uncomplicated scenario. Unfortunately, not everybody with Shingles is this lucky. There’s a prolonged pain syndrome called Postherpetic Neuralgia (PHN) that can occur in some folks–lasting weeks to years after the rash clears and disappears. I’ll talk more about this dastardly condition later. Too, if the rash becomes infected with bacteria, it generates a secondary infection that must be treated with antibiotics. And rarely, encephalitis, partial facial paralysis, and ear or eye damage may occur. If you’re suspicious that you’re developing Shingles on your face, it’s critical that you contact your doctor as soon as possible.
Statistically, 1 in 5 of us with prior chickenpox infections will have Shingles during our lifetimes. Fortunately, most people have only one outbreak, but up to 5% will have more than one. Although children can get Shingles, it is more common in people over the age of 50. It’s unclear what prompts the virus to “reawaken” in healthy people. But a temporary weakening of one’s immune system seems to be a common denominator that allows the virus to multiply and move along nerve fibers from the spinal cord to the skin. Illness, trauma, and stress can all be triggers for this reactivation. It’s an infection that truly gets you when you’re “already down and out.” Seems appropriate that in Italy, shingles is also called St. Anthony’s Fire!
Unfortunately, shingles occurs most often in the elderly. Over 50% of the cases occur in folks over 60, and a person over age 80 has a five times greater risk of developing shingles than adults between the ages of 20 and 40. Additionally, the weakened immune systems of patients with cancer, advanced HIV infections, leukemia,and lymphoma make these people much more likely candidates for a shingles outbreak. Last but not least, in some of our treatments such as chemotherapy, radiation therapy, immunosuppression of patients after transplanted organs, and/or treatment with prolonged courses of steroids, we medical folks increase a person’s risk of Shingles as well. Any weakness the sleeping Shingles virus detects in the armor of the immune system can tempt it to raise it’s blistered head, and march up nerve fiber highways to wreak havoc on the skin’s surface.
Treatment of this dastardly demon used to be confined to aspirin and cold compresses. Though it generally runs its natural course and resolves without specific treatments, we have three antiviral drugs: acyclovir, valacyclovir, and famcyclovir that can significantly reduce the severity and duration of an attack. But any of the three must be started early. . .generally efficacy wanes substantially if a person is over 2 days into an outbreak. Additionally, there’s evidence that the drugs may help to stave off postherpetic neuralgia. . .especially if they’re begun immediately in an outbreak.
Of course, treatment of the pain is also important, and can range from aspirin, acetaminophen, and ibuprofen to narcotics, and occasionally even nerve blocks. Too, there are topical preparations that can numb the skin, or ‘trick’ pain fibers into moderating the levels of discomfort. Short blasts of steroids are sometimes used in combination with antiviral drugs in especially severe infections. . especially when they involve the face.
Unfortunately, Postherpetic neuralgia affects 20% of all people with shingles, and the incidence increases to 40% in shingles patients over the age of 60. Treatment of this painful complication is diverse, and unfortunately not predictably effective in all folks. Frequent use of pain relievers is common. Drugs actually belonging to antiseizure and antidepressant classes can be very helpful in decreasing the severity of chronic pain. A topical anesthetic patch which delivers lidocaine directly into the skin with little systemic absorption can be a godsend for some sufferers. TENS units (transcutaneous electrical nerve stimulators) generate low-level pulses of electrical current directly to the skin’s surface, and the tingling sensation they create may diminish pain intensity as well. And, as last resorts, invasive procedures such as nerve blocks, and even injections of steroid/anesthetic mixtures directly into the spine have been tried in more severe and recalcitrant cases. Chronic pain of any kind can destroy one’s quality of life, so please pursue your options aggressively if you become the unfortunate victim of PHN.
Of course, PREVENTION is always the best option when possible. Prior to 1995, about 95% of the U.S. population developed chickenpox before age 18. But the chickenpox vaccine was released by FDA at that time, and it seems to be 75–85% effective in preventing chickenpox. Even in folks who do catch the natural infection after immunization, their infections are uniformly milder. The vaccine is made from an attenuated (weakened) form of the live varicella-zoster virus; it intentionally creates a very mild chickenpox-like reaction in children while inducing enough immunity to prevent them from getting the natural infection. Obviously, if you can’t get chickenpox, you won’t get shingles either since “you can’t have one without the other. . .” Also, in 1999 a cooperative 5 year clinical study of a Shingles Vaccine was begun in this country. 22 sites nationwide are recruiting about 38,000 adults over the age of 60 who have had chickenpox (but not shingles) to test the vaccine efficacy in preventing shingles. Like the chickenpox vaccine, the shingles vaccine is made from attenuated varicella-zoster virus, but it’s intentionally more potent in an effort to boost the natural immunity to the virus that seems to decline with advancing age. This is the reason that folks over 60 have the much higher shingles risk. Anyway, it’s hoped that by boosting the body’s immune response, the shingles vaccine will be able to prevent shingles from ever occurring. Since the study won’t complete until 2004. . .stay tuned.
Enough already! But, I hope you now understand that you can’t catch Shingles from somebody, and that you won’t have Shingles yourself if you haven’t had chickenpox. If you suspect you’re developing a shingles outbreak, contact your doctor as soon as possible. Early treatment can make a big difference in moderating the infection. We’ve unroofed the facts about Shingles. . .now time to put a lid on ’em!
Stephen L. Hines, M.D.