Shingles

Shingles occurs when the virus that causes chickenpox starts up again in your body. After you get better from chickenpox, the virus "sleeps" (is dormant) in your nerve roots. In some people, it stays dormant forever. In others, the virus "wakes up" when disease, stress, or aging weakens the immune system. It is not clear why this happens. But after the virus becomes active again, it can only cause shingles, not chickenpox.

You can't catch shingles from someone else who has shingles. But a person with a shingles rash can spread chickenpox to another person who hasn't had chickenpox and who hasn't gotten the chickenpox vaccine. Shingles is a reactivation of the varicella-zoster virus, a type of herpes virus that causes chickenpox. After you have had chickenpox, the virus lies inactive in your nerve roots and remains inactive until, in some people, it flares up again. When the virus becomes active again, you get shingles instead of chickenpox.

Anyone who has had even a mild case of chickenpox can get shingles. People who have a weak immune system are vulnerable to reactivation of the virus that causes shingles. Many factors can weaken your immune system, including aging, injury, and illness. Some medicines slow down the immune system. For example, medicines that destroy cancer cells ( chemotherapy) can interfere with the immune system.

Who gets Shingles

Anyone who has had chickenpox can get shingles. You have a greater chance of getting shingles if you:

• • Are older than 50.
    
  • Have an autoimmune disease that causes your immune system to attack your body’s own tissues.
    
  • Have another health problem or stress that weakens the immune system.
    

If you have never had chickenpox and have not gotten the chickenpox vaccine, avoid touching someone who has shingles or chickenpox. If you are at least 60 years old, you can get a vaccine that may prevent shingles or make it less painful if you do get it.

Transmitting shingles

Exposure to shingles will not cause you to get shingles. But if you have not had chickenpox and have not gotten the chickenpox vaccine, you can get chickenpox if you are exposed to shingles. Someone with shingles can expose you to chickenpox if you come into contact with the fluid in the shingles blisters. If you cover the shingles sores with a type of dressing that absorbs fluid and protects the sores, you can help prevent the spread of the virus to other people.

Treating shingles

There is no cure for shingles, but treatment may help you get well sooner and prevent other problems. Call your doctor as soon as you think you may have shingles. The sooner you start treatment, the better it works. Treatment may include:

• • Antiviral medicines to help you get well sooner and feel less pain. Medicines to help long-term pain. These include antidepressants, pain medicines, and skin creams.
  • Good home care can help you feel better faster. Take care of any skin sores, and keep them clean.
  • Take your medicines as directed. And use over-the-counter pain medicines to relieve pain.

    

Avoid contact with people until the rash heals. While you have shingles, you can spread chickenpox to people who have never had chickenpox and who haven't gotten the chickenpox vaccine. Be extra careful to avoid people with weak immune systems and pregnant women and babies who have never had chickenpox and have never gotten the vaccine

Shingles is caused by the same virus that causes chickenpox. After an attack of chickenpox, the virus remains in the tissues in your nerves. As you get older, or if you have an illness or stress that weakens your immune system, the virus may reappear in the form of shingles.

Early symptoms of shingles include headache, sensitivity to light, and flu-like symptoms without a fever. You may then feel itching, tingling, or pain where a band, strip, or small area of rash may appear several days or weeks later. A rash can appear anywhere on the body but will be on only one side of the body, the left or right. The rash will first form blisters, then scab over, and finally clear up over a few weeks. This band of pain and rash is the clearest sign of shingles.



The rash  caused by shingles is more painful than itchy. The nerve roots that supply sensation to your skin run in pathways on each side of your body. When the virus becomes reactivated, it travels up the nerve roots to the area of skin supplied by those specific nerve roots. This is why the rash can wrap around either the left or right side of your body, usually from the middle of your back toward your chest. It can also appear on your face around one eye. It is possible to have more than one area of rash on your body. A few people won't get a rash, or the rash will be mild. Most people who get shingles will not get the disease again.

Shingles symptoms happen in stages. 

• At first you may have a headache or be sensitive to light. You may also feel like you have the flu but not have a fever.
  
• Later, you may feel itching, tingling, or pain in a certain area. That’s where a band, strip, or small area of rash may occur a few days later. The rash turns into clusters of blisters. The blisters fill with fluid and then crust over. It takes 2 to 4 weeks for the blisters to heal, and they may leave scars. Some people only get a mild rash, and some do not get a rash at all.
  
• It’s possible that you could also feel dizzy or weak, or you could have long-term pain or a rash on your face, changes in your vision, changes in how well you can think, or a rash that spreads. If you have any of these problems from shingles, call your doctor right away.

Prodromal stage - before the rash appears

• Pain, burning, tickling, tingling, and/or numbness occurs in the area around the affected nerves several days or weeks before a rash appears. The discomfort usually occurs on the chest or back, but it may occur on the belly, head, face, neck, or one arm or leg.
  
• Flu-like symptoms (usually without a fever), such as chills, stomachache, or diarrhea, may develop just before or along with the start of the rash.
  
• Swelling and tenderness of the lymph nodes may occur.
  
• Active stage (rash and blisters appear)
  
• A band, strip, or small area of rash appears. It can appear anywhere on the body but will be on only one side of the body, the left or right. Blisters will form. Fluid inside the blister is clear at first but may become cloudy after 3 to 4 days. A few people won't get a rash, or the rash will be mild.
  
• A rash may occur on the forehead, cheek, nose, and around one eye ( herpes zoster ophthalmicus ), which may threaten your sight unless you get prompt treatment. 2
  
• Pain, described as "piercing needles in the skin," may occur along with the skin rash.
  
• Blisters may break open, ooze, and crust over in about 5 days. The rash heals in about 2 to 4 weeks, although some scars may remain. 

Postherpetic neuralgia (chronic pain stage)

• Postherpetic neuralgia is the most common complication of shingles. It lasts for at least 30 days and may continue for months to years. Symptoms are: 4
  
• Aching, burning, stabbing pain in the area of the earlier shingles rash.
  
• Persistent pain that may linger for years.
  
• Extreme sensitivity to touch.
  
• The pain associated with postherpetic neuralgia most commonly affects the forehead or chest. This pain may make it difficult for the person to eat, sleep, and perform daily activities. It may also lead to depression.
  
• Shingles may be confused with other conditions that cause similar symptoms of rash or pain, such as herpes simplex
• infection or appendicitis.
  

Complications of shingles include

• Postherpetic neuralgia, which is pain that does not go away within 1 month. It may last for months or even years after shingles heals. Postherpetic neuralgia affects up to 10% to 15% of those who experience shingles. 5 It is more common in people age 50 and older and in people who have a weakened immune system due to another disease, such as diabetes or
• HIV infection. People who have severe pain and rash during shingles have an increased risk for postherpetic Disseminated zoster, which is a blistery rash that spreads over a large portion of the body and can affect the heart, lungs, liver, pancreas, joints, and intestinal tract. Infection may spread to nerves that control movement, which may cause temporary weakness.
  
• Cranial nerve complications. If shingles affects the nerves originating in the brain (cranial nerves), complications may include: Inflammation, pain, and loss of feeling in one or both eyes. The infection may threaten your vision. A rash may appear on the side and tip of the nose (Hutchinson's sign).
  
• Intense ear pain, a rash around the ear, mouth, face, neck, and scalp, and loss of movement in facial nerves ( Ramsay Hunt syndrome). Other symptoms may include hearing loss, dizziness, and ringing in the ears. Loss of taste and dry mouth and eyes may also occur.
  
• Inflammation, and possibly blockage, of blood vessels, which may lead to stroke.
  
• Scarring and skin discoloration.
  
• Bacterial infection of the blisters.
  
• Muscle weakness in the area of the infected skin before, during, or after the episode of shingles.


Call your doctor immediately if

• Any sign of shingles develops (such as pain or changes in vision) on or in the area of your forehead, nose, eye, or eyelid.
  
• Any symptoms of shingles develop (such as headache, stiff neck, dizziness, weakness, hearing loss, or changes in your thinking and reasoning abilities) that affect your central nervous system.
  
• Skin sores spread to parts of your body beyond the original area of the rash .
  
• You think you have a bacterial skin infection in the same area as the shingles rash, or your rash has not healed in 2 to 4 weeks.
  
• You develop pain in your face or are unable to move muscles in your face.

  

Call your doctor today if

• You suspect you might have shingles. There are medicines that can limit your pain and rash. The earlier you start treatment for shingles, the better the results.
  
• If you think you have shingles, see a doctor as soon as possible. Early treatment with antiviral medicines may help reduce pain and prevent complications of shingles, such as disseminated zoster or postherpetic neuralgia.
  
• If intense pain persists for more than 1 month after the skin heals, see your doctor to find out whether you have postherpetic neuralgia.
   

There is no cure for shingles, but treatment may shorten the length of illness and prevent complications.

Treatment options include:

Antiviral medicines to reduce the pain and duration of shingles.    
Pain medicines, antidepressants, and topical creams to relieve long-term pain.

Initial treatment

As soon as you are diagnosed with shingles, your doctor probably will start treatment with antiviral medicines. If you begin medicines within the first 2 days of seeing the shingles rash , you have a lower chance of having later problems, such as postherpetic neuralgia. Early treatment of shingles is important, because the problems that can arise can be serious and resistant to treatment. For example, 40% to 50% of people with postherpetic neuralgia do not respond to treatment 

Most common Treatment for Shingles

• Antiviral medicines, such as acyclovir, famciclovir, or valacyclovir, to reduce the pain and the duration of shingles.
  
• Over-the-counter pain medicines, such as acetaminophen, aspirin, or ibuprofen, to help reduce pain during an attack of shingles.
  
• Topical antibiotics, applied directly to the skin, to stop infection of the blisters.
  
• Corticosteroids also may be used to reduce pain in people younger than 50 who have had a recent outbreak of shingles.
  
  

 
Ongoing treatment

• Antidepressant medicines, such as a tricyclic antidepressant (for example, amitriptyline).
  
• Topical anesthetics, such as lidocaine patches, to numb the area.
  
• Anticonvulsant medicines, such as gabapentin or pregabalin.
  
• Opioids, such as codeine.
  
• Topical creams containing capsaicin may provide some relief from pain. Capsaicin may irritate or burn the skin of some people, and it should be used with caution.
  
• If you have pain that persists longer than a month after your shingles rash heals, your doctor may diagnose postherpetic neuralgia, the most common complication of shingles. Postherpetic neuralgia can cause pain for months or years. It affects 10% to 15% of those who experience shingles. Treatment to reduce the pain of postherpetic neuralgia includes the weekly application of liquid nitrogen spray over the region.  Enough is applied to get a 1 or 2 second frost.  Early studies have shown that the pain severity is significantly reduced after 3 to 5 sessions.  

   

Treatment if the condition gets worse

• In some cases, shingles causes long-term complications. Treatment depends on the specific complication.
  
• Postherpetic neuralgia is persistent pain that lasts months or even years after the shingles rash heals. Certain medicines, such as anticonvulsants, antidepressants, and opioids, can relieve pain. Most cases of postherpetic neuralgia resolve within a year. In very rare cases, surgical treatment may be used to treat postherpetic neuralgia by cutting nerves to help block pain signals.
  
• Disseminated zoster is a blistery rash over a large portion of your body. It may affect your heart, lungs, liver, pancreas, joints, and intestinal tract. Treatment may include both antiviral medicines to prevent the virus from multiplying and antibiotics to stop infection.
  
• Herpes zoster ophthalmicus  is a rash on the forehead, cheek, nose, and around one eye, which could threaten your sight. You should seek prompt treatment from an ophthalmologist for this condition. 2 Treatment may include rest, cool compresses, and antiviral medicines.
  
• If the shingles virus affects the nerves originating in the brain (cranial nerves), serious complications involving the face, eyes, nose, and brain can develop. Treatment depends on the nature and location of the complication.
   

Medications

Medicines can help limit the pain and discomfort caused by shingles, shorten the time you have symptoms, and prevent the spread of the disease. Medicines also may reduce your chances of developing shingles complications, such as postherpetic neuralgia or disseminated zoster. Early treatment of shingles is important, because the possible complications can be serious and resistant to treatment. For example, 40% to 50% of people with postherpetic neuralgia do not respond to treatment. 5

Medication Choices


Medicines to treat shingles when the rash  is present (active stage) may include:

• • Over-the-counter pain medicines, such as acetaminophen, aspirin, or ibuprofen, to help reduce pain.
    
  • Antiviral medicines, to reduce the pain and duration of shingles.
    
  • Topical antibiotics, which are applied directly to the skin, to stop infection of the blisters.
    
  • Corticosteroids also may be used to reduce pain in people younger than 50 who have had a recent outbreak of shingles.
    

Medicines to treat postherpetic neuralgia pain may include:


• • Over-the-counter pain medicines, such as acetaminophen, aspirin, or ibuprofen.
    
  • Tricyclic antidepressants, such as amitriptyline.
    
  • Topical medicines, such as a lidocaine patch.
    
  • Anticonvulsants, such as gabapentin or pregabalin.
    
  • Corticosteroids, such as prednisone.
    
  • Weekly Liquid nitrogen sprays over the region.
    
  • Nerve block injections.
    
  • Opioids, such as codeine, oxycodone, and morphine.
     

What To Think About

For some people, nonprescription pain relievers (analgesics) are enough to help control pain caused by shingles or postherpetic neuralgia.

A prescription medicine called pregabalin ( Lyrica) has been approved for the treatment of pain caused by postherpetic neuralgia. In tests, it provided rapid and long-lasting pain relief.