Shingles: Symptoms, Causes, and Treatment
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1. Introduction
Because accurate clinical diagnosis of the prodromal phase is diagnostically challenging, difficult to distinguish from herpes simplex, there is sometimes little warning before the rash becomes widespread. However, diagnosis is important and early treatment can prevent devastating neuralgic pain and painful chronic complications which are worst in elderly patients. Efficacy of therapy is dependent upon patient presentation to medical attention during the first 72 hours of rash onset, making the knowledge for the patient concerning symptoms, causes, and treatment of the utmost importance.
Shingles is an eruptive viral skin infection, with a history of good drug treatment and poor drug therapy. It is a localized, self-healing, often painful rash caused by reactivation of latent varicella zoster virus. Known to many as the virus that causes chicken pox, varicella zoster is one of the many Herpes viruses. After chicken pox infection, it lies dormant in nerve cell bodies and is reactivated in later life as herpes zoster, usually after age 50.
There the argument ends. Many people have no alternative. They are taking only one drug, and few can afford the time off work, medical expenses, pain, and emotional suffering that sifting through multiple changes of treatment occasionally brings. Ultimately, it is counterproductive to the health and well-being of these individuals to seek a new treatment for their skin conditions if drug safety has not already compromised their general health.
Litt's Drug Eruption and Reaction Database, which includes dermatological drug eruptions, is an extremely useful resource for drug-safety information. By searching for and reading about the drug in question, it is usually possible to find a suitable alternative for patients who have experienced a dermatological adverse event.
1.1. Definition of Shingles
Shingles typically presents as a unilateral, painful, vesicular rash, which is usually restricted to one or two dermatomes and may be accompanied by somatic or autonomic symptoms. The most common complication of shingles is post-herpetic neuralgia, which describes the pain that persists after the rash has healed. Usually, resolution of shingles symptoms, causes, and treatment is obtained within 2-4 weeks in healthy adults, but it is not uncommon for it to take longer and sometimes they are permanent. This occurs over a third for adults over 60 years of age. This is an especially debilitating disease in older age, and even though it is a virus with no cure, there are now specific treatments and vaccines for it.
Shingles is a viral infection caused by the Varicella Zoster virus, a type of herpes virus, and it is the same virus that causes chickenpox. The FDA approved a vaccine for shingles in 2006, and the CDC and American College of Physicians Advisory Committee on Immunization Practices now recommend vaccination for all adults 60 years and older, even if you have had a prior episode of shingles. This is a renewed revision in recommendation from being a selective vaccine. In 2011, the FDA approved shingles immunization for adults 50-59 years of age. There are an estimated one million cases of shingles each year in the United States. The huge health concerns and quadrupling in incidence of shingles in the United States has led to major efforts in vaccine use and prevention. Shingles predominantly affects the elderly and those with immune systems that have been compromised due to medication, disease, or cancer treatment. This is important to keep in mind as there are nearly 1.3 million cases of rheumatoid arthritis in the United States, many of which use immune system compromising agents for treatment. These patients have a two to threefold increased risk for infection.
1.2. Importance of Understanding Symptoms, Causes, and Treatment
Common and severe complications of shingles can occur either from the disease itself or from a painful condition affecting the skin known as post-herpetic neuralgia. Duration and costs of hospital stay for serious complications of shingles can also be significantly reduced with vaccination. So understanding and having knowledge about the disease can not only affect the decisions and quality of life of the individual suffering from the disease but also have an impact on the overall cost, duration of illness, and resources used in healthcare.
In the case of shingles, knowledge is key. The more you know about this common and often painful condition, the better able you will be to work with your healthcare provider to manage and control the symptoms and lessen the effect it has on your life. In addition to knowing the signs of shingles, understanding the risk factors and potential complications of the disease can help you make an informed decision concerning your treatment choices. An in-depth understanding of the features classical to shingles, how it is diagnosed, and the way it can be treated is also essential and will be of benefit to anyone who develops this painful and sometimes debilitating condition. With this in mind, the following discussion provides a comprehensive overview of knowledge on shingles, considering the cause, symptoms, diagnosis, treatment, and prevention of the disease.
2. Symptoms of Shingles
2.2 Pain and Sensitivity Shingles pain can be mild or intense. Some people have described the feeling of the pain as a sharp sensation, while others liken it to an aching feeling. The pain may be felt from the spine of the person where the outbreak occurred. If the rash of the outbreak is around the waistline or chest, it is very possible that the pain can be felt in other areas of the body. The starting location of the pain usually is the area where the rash will develop. Pain and rash usually occur at the same time. This occurrence can cause pain to turn into a severe and unbearable level. The pain will continue until the outbreak has cleared, which can be anywhere from 2-4 weeks.
2.1 Rash and Blister Formation Rash and blisters are common skin manifestations. This occurs in one area of the body, and very severe pain is usually the first sign of a shingles outbreak. A rash can develop in a band or small area. The shingles rash is a skin disorder and not a life-threatening disease. The rash will turn into clusters of clear blisters. The blisters will turn yellow, dry up, and crust over. The rash usually lasts 2-4 weeks, and the blisters take about 2-3 weeks to heal.
Many people who suffer from shingles are unaware that the disease was in their system, and only those with an outbreak of shingles can recognize what the beginning symptoms feel like at the start. These changes are very common and related to the shingles virus. Some of the common symptoms include:
2.1. Rash and Blister Formation
The pain experienced from the rash and blisters can range from mild to severe and will be at its highest within the first 7 days of the rash appearing. This is due to the blisters being in the most acute stage, where the skin is broken and moist. Any form of pain and discomfort from the rash should always be reported to a doctor, as in some cases early treatment of the rash can prevent further complications in the infection.
The formation of the blisters differentiates shingles from other conditions that cause rashes. The blisters, which contain an infectious virus, will continue to appear on the skin in clusters for around three to five days. The skin over the blisters will then dry up and form scabs in 7-10 days. At this point, the blisters and scabs will begin to heal, generally clearing after 2-4 weeks. The completion of the healing process is when the effects of shingles on the skin will cease, with any skin infection and scarring from the blisters being rare.
The appearance of a rash is the initial symptom of shingles. The rash will usually develop on one side of the body, the back or chest, but it can sometimes appear on the face and neck. In comparison to the rash of chickenpox, the rash in shingles usually only develops on a small area of the skin rather than being scattered all over the body. However, the similarity lies in the progression of the rash, where the red spots will develop on the skin into fluid-filled blisters.
2.2. Pain and Sensitivity
2.2. Pain and Sensitivity Often the pain can be very intense and is described as aching, burning, stabbing, or shock-like. Post-herpetic neuralgia is the persistence of pain for months or even years after the rash has healed. It is the most common complication of shingles and the likelihood of developing post-herpetic neuralgia increases with age. It is especially common in people over 60 and those with weakened immune systems. Pain and symptoms other than the rash (which can be very minimal) are your body's way of showing you that the virus is still active. If young, the development of shingles and the presence of pain is a sign of a strong immune system. This is because the virus will often only resurface when the immune system is weak.
2.1. Rash and Blister Formation The first symptoms of shingles may include headache, sensitivity to light, and flu-like symptoms without a fever. This can be followed or preceded by pain, itching, or tingling at the sight of developing rash. A rash can develop anywhere on the body but will be on either the right or left side of the body and will not cross over to the other side. The rash will turn into clusters of blisters in 3-4 days and will then dry up and scab in 7-10 days. The rash can be quite painful and itchy and can lead to infection of the skin. Sometimes people mistake an outbreak of herpes zoster for bites, hives, bruises or another skin problem.
2.3. Itching and Tingling Sensations
Most people with shingles experience itching, tingling or extreme discomfort in the area of the affected skin several days before a rash appears. This symptom may occur without a rash, making it difficult to diagnose. The location and duration of the pain is more variable than the rash. It generally begins without warning one to two days before the appearance of the rash. It can be intense. In the region of the rash, the pain may be diffuse, dull, burning or sharp and it often localized. For some people, the pain can be severe and is accompanied by heightened sensitivity to touch. It is possible that you may have symptoms of shingles but not develop the rash. Pain that occurs without a rash is more difficult to diagnose; however, some of these patients have later been proven to have had shingles. Steady application of cool, wet compresses may help alleviate the pain. For itching, try an oatmeal bath preparation (i.e., Aveeno colloidal oatmeal) or 3% hydrogen peroxide solution. During a recurrent outbreak, it is advisable to clip the fingernails to prevent virus inoculation of the skin and secondary bacterial infection. In some people, shingles can cause long-term nerve damage. This condition is called post-herpetic neuralgia. The pain associated with post-herpetic neuralgia may be constant and severe and is less likely to improve as time goes on. If you are over 60, your risk of post-herpetic neuralgia is higher. The best chance of affecting the pain of post-herpetic neuralgia is by treating the shingles as aggressively as possible.
3. Causes of Shingles
VZV is the causative agent of chickenpox and shingles. The virus is only found in humans. VZV is transmitted through the respiratory system in the developed world, giving the person chickenpox. The virus then remains in a dormant state in the dorsal root ganglia of the sensory nervous system after recovery from chickenpox. If the virus is reactivated in its active state, it will cause shingles rather than a recurrence of chickenpox. The reason for the virus' reactivation is not entirely known, but it is thought to be due to the lowering of cell-mediated immunity to VZV as a person gets older. This theory is supported by the facts that shingles typically develops in the elderly and in those who are immunosuppressed. It is also thought that reactivation of the virus may be due to immunosuppressive therapy. This could give a biological explanation as to why stress is a trigger for shingles, as stress hormones and stress-related physiological changes can lead to immunosuppression. High doses of systemic steroids is another known cause of immunosuppression. The VZV vaccine is now becoming more widespread and could possibly be a primary prevention method of shingles, as well as a prevention of reactivation of the virus in those who have had chickenpox, because the vaccine strain of the virus becomes latent in the body and could act as a booster, thereby preventing reactivation of wild-type VZV. A study following 38,000 individuals age 60 and older is looking at the ability of the vaccine to protect against shingles.
3.1. Varicella-Zoster Virus (VZV)
The varicella zoster virus, or VZV, is the virus responsible for both chickenpox and shingles. It is a member of the herpes virus family, and the same virus is responsible for two conditions. Once someone has had chickenpox, VZV remains in their nervous system in a dormant state. At some point in the person's life, VZV can reactivate and cause shingles, though not everyone who has had chickenpox will develop shingles. VZV is most commonly thought to reactivate due to old age, a weakened immune system, or stress, but the exact mechanisms for reactivation are not fully understood. Both chickenpox and shingles can only be transmitted person-to-person, usually through fluid from the blisters. A person who has not had chickenpox or the chickenpox vaccine can get chickenpox from close contact with a person who has shingles. This is because the shingles blisters contain the same VZV as the chickenpox blisters. Someone who gets infected with VZV and has never had chickenpox will develop chickenpox, not shingles. After the blisters have crusted over, the person is no longer contagious.
3.2. Reactivation of VZV
The VZV is the sole etiologic agent of both varicella (chickenpox) and zoster (shingles). Primary infection with VZV results in varicella. After recovery from varicella, the virus becomes latent in neural tissue. In the majority of persons, viral genomes can be demonstrated in latently infected ganglia even in the absence of antibodies to VZV (Gershon et al., 1984). Although the precise mechanisms of establishment and maintenance of viral latency are not fully understood, it is clear that VZV, like HSV, can reactivate and cause disease, perhaps years or decades after the initial infection. The first indication that VZV becomes latent and can later reactivate was discovered in histological studies of ganglia from elderly patients who had no history or signs of zoster.
3.3. Risk Factors for Developing Shingles
Diseases and treatments which affect cell-mediated immunity can increase the risk of developing shingles. Immunosuppressive drugs given to transplant patients and the use of corticosteroids can reactivate the virus and cause a shingles outbreak. HIV infection commonly leads to extensive shingles outbreaks and individuals can get shingles at an early age if they are diagnosed with HIV. Cancers such as leukemia and lymphoma are also risk factors for developing shingles. It is estimated that shingles occurs at least twice as often in individuals with cancer compared to the general population. The use of radiation and chemotherapy treatment can also increase the risk of shingles at the particular site where the treatment was provided.
Development of shingles is due to active re-infection with varicella-zoster virus (VZV). There is a decline in cell-mediated immunity to VZV with increasing age. This is associated with a decreased ability to keep the virus latent. Studies have shown that shingles occurs about 10-15 times more often in individuals with a history of childhood chickenpox in comparison to those who have been vaccinated against VZV. This is likely to be due to the ability of the vaccine to prevent reactivation of the virus in its latent state. A history of herpes simplex infections also increases the risk of developing shingles.
4. Treatment for Shingles
There are a number of other measures that people with shingles can take to help speed their recovery and reduce the pain. The rash should be given air as much as possible. This may involve spending periods of time at home without dressing. A non-stick dressing may be used to cover the rash when it is in a stage where it can damage clothing. Taking a lukewarm bath for 15-20 minutes, 3-4 times a day, can help relieve pain and itching. Soaking the rash in water for short periods can also help. Soak a cloth in water or a Burow's solution, cool, and apply to the rash and blisters.
Shingles is not usually a serious illness, but the pain can be debilitating. The sooner treatment is started, the better it works. Antiviral medications, when started early in the course of the disease, can reduce the severity of shingles and lower the risk of developing postherpetic neuralgia. Acyclovir, famciclovir or valacyclovir are examples of antiviral medications that may be prescribed. Strong painkillers and other drugs may be needed if the pain is severe. If the rash is in the eye area, the patient should see a doctor immediately as the virus can cause permanent eye damage. Corticosteroids, which are medications that lower swelling, are sometimes given with the antiviral medication. It is not clear if they help. Patients with mild to moderate pain can be treated with over-the-counter pain medications. Those with more severe pain may need prescription painkillers. Opioid painkillers (codeine, morphine or oxycodone) may cause constipation. It is important to make sure you are taking enough laxatives with them. If pain is still a problem after using these medications, a pain specialist can help. An injection of local anesthetic and corticosteroid around the spinal nerves may be effective but the evidence supporting this is not strong. Nerve blocks, where medication is injected around the spine, are also used. Tricyclic antidepressants and anticonvulsant medication have been found to help the pain of shingles. These can have side effects and it is important to discuss this with your doctor. A number of other pain-relief measures can be tried. Physiotherapists can teach ways of relieving pain without taking medication. Acupuncture and TENS are therapies which can help some people. Psychological therapies can help people come to terms with the pain, improve their sleep and reduce stress, all of which will help reduce pain in the long term.
4.1. Antiviral Medications
Antiviral medications are used primarily to stop the virus from multiplying and to shorten the duration of shingles. They are most effective if started within 72 hours of the appearance of the rash, but they may be given in some cases to help prevent postherpetic neuralgia. These medications are taken in pill form. Commonly prescribed antiviral regimens for adults are acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir). Treatment usually lasts for 7 days. Side effects of the medication are generally mild and may include headache, nausea, and diarrhea. In rare cases, more serious side effects can occur, including kidney problems and allergic reactions.
4.2. Pain Management
Capsaicin, lidocaine skin patches, and nerve blocks are local anesthetics that can be used to treat the burning pain often associated with shingles. They have generally been found to be effective for short-term pain relief. Opioid pain medications can be used for severe pain, but are often not very effective for shingles pain. If given, they should be used with caution and for the shortest duration possible. Massage has been explored as a pain management option for chronic conditions and appears to have potential benefit for certain subsets of patients. As a whole, finding the right pain management regimen for shingles is an individual process and often requires much trial and error to find the best approach.
There are several effective drugs for shingles. Drugs such as acetaminophen (Tylenol) can be used to reduce fever. Tricyclic antidepressant drugs, such as amitriptyline, desipramine (Norpramin), and protryptiline have been used with some success to reduce the pain associated with shingles. These drugs can cause drowsiness and dry mouth. Other more standard non-steroidal anti-inflammatory medications can be used as well. Steroids, such as prednisone, are powerful drugs that should not be used if shingles is suspected, as they can lead to further complications. If a patient already has complications that are not improving, steroids may be given but with extreme caution and only under the watchful eye of a physician. In cases where there are severe complications from shingles, such as those involving the eye or brain, strong antiviral drugs may be given in conjunction with a steroid. It is considered vital to treat shingles in its acute phase with these antiviral drugs to prevent potential continual pain that can last for months to years. Anti-seizure medications, such as gabapentin and pregabalin, have also been shown to reduce nerve pain associated with shingles and even help pain that is unrelieved by standard medications.
4.3. Home Remedies and Self-Care
Keep the rash clean and dry. It is important to keep the affected area clean, as the shingles blisters that appear on the skin can become infected with bacteria. This can then cause a spreading of the infection and a delay in the shingles' healing process. An effective way to clean the rash is to use a mixture of 1 teaspoon of an antibacterial solution, such as Dettol or Savlon, and 4.5 litres of water. Cotton wool, soaked in the solution, should be used to gently dab the rash. After cleaning, it is recommended that the rash be left to dry naturally in the air, if possible. If you have to cover the rash, e.g. with a bandage or article of clothing, make sure that the material is clean and that it can breathe. This helps prevent the rash from becoming overly moist and weeping with fluid, which can then lengthen the recovery time. If there is any itchiness or discomfort, the use of an appropriate lotion or calamine can alleviate the irritation. The application of a lotion to the rash will help to keep the skin hydrated and supple, and avoid it becoming dry and cracked. Some people find that the use of cornstarch or baking soda on the rash is comforting. These can be applied using a cotton wool or gauze pad.