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Shingles...the Short Story

Author: Nili N. Alai, MD, FAAD
Editor: William C. Shiel Jr., MD, FACR, FACR

Shingles, or herpes zoster, is a very common painful, blistering viral rash. Shingles is caused by reactivation of the chickenpox virus called varicella zoster virus (VZV). Shingles occurs in people who have previously been infected with the chickenpox virus at some point in their lives. Shingles usually occurs as a unilateral pain, burning, or tingling and blistering rash extending in a local pattern in the distribution of nerves. Common areas affected by shingles include the face, abdomen, back, buttocks, and chest. Red, itchy patches form across these areas and become small blisters that may be similar in appearance to chickenpox. The rash begins to clear after the blisters break and dry into scabs within two to three weeks.

Once people have had a single bout of chickenpox, the virus lies dormant in the nerve roots near the spinal cord or base of the facial nerve. It is thought that when a person has a weakened immune system or when their immunity to the varicella virus is diminished the virus can reactivate to inflame a nerve and cause shingles. Although shingles may happen at any age, it is most common in the fifth through sixth decades of life. Typically, shingles usually occurs most commonly in adults over the age of 60 or in those who are immunosuppressed (HIV, AIDS, or cancer patients).

Most people only get shingles once in their life. While it is not impossible to get shingles more than once, a recurrence is unlikely.

Shingles is often a severely painful skin condition. Some people may have pain in the general area days to weeks before the onset of the blisters. The most important clue to shingles diagnosis is unilateral pain and blisters on the skin. A typical shingles eruption never crosses the midline of the body and occurs only on one side: right or left. Extremely rare cases of shingles may become diffuse and spread to the entire body in patients with very compromised immune systems.

Common symptoms experienced with shingles include flu-like symptoms such as chills, fever, and fatigue, along with abdominal and back pain when those skin dermatomes are involved. In some cases when the virus has affected the facial area, people can experience loss of eye motion, drooping eyelids, taste problems, facial pain, headache, and hearing loss.

Effective treatments are available to help lessen the impact of shingles. For best prognosis and fastest recovery, early start of oral antiviral pills is most important. All shingles cases will eventually resolve with or without treatment.

Treatment started at the earliest stage of symptoms is helpful in shortening the duration and severity of the symptoms. Oral antihistamines like Benadryl may be used for itching, as well as oatmeal baths and calamine lotion. Analgesic medications like ibuprofen (Advil or Motrin), Tylenol, or Vicodin can be used for severe pain.

The most difficult complication of shingles tends to be the residual pain that may last in the area for months or years. Chronic pain lasting more than six weeks after the onset of shingles is called postherpetic neuralgia (PHN). Antiviral medications including acyclovir (Zovirax), if given within the first 48-72 hours of the occurrence of symptoms, can help reduce the length and severity of postherpetic neuralgia. Additional treatments are available for PHN.

Shingles is generally not contagious to those who have had chickenpox. Rarely, it may cause problems in pregnant women, infants, immunocompromised individuals, or people who have never had chickenpox. Touching the blisters or blister fluid may cause transmission of the varicella virus.

Varicella zoster virus is not "curable" because the virus stays dormant in the body for life. Once someone is initially exposed to the varicella virus, immunity develops that generally prevents a second bout of typical chickenpox. However, this immunity may fade over time, making older adults more prone to a later onset of a limited recurrence of the chickenpox virus as shingles.

Testing for shingles may include viral cultures, Tzanck prep (microscopic exam and staining of skin), and blood testing for titers of antibodies to the varicella virus.

Shingles prevention steps include vaccination. There is a U.S. FDA-approved vaccine (Zostavax) for adults 60 years of age and older to help lessen the risk of shingles. Zostavax is a live attenuated vaccine and therefore carries a small risk of shingles when administered. There is also a U.S. FDA-approved chickenpox vaccine called Varivax which is used primarily in a single dose for children between 12-18 months of age or older who have not had chickenpox.

Reference:

Fitzpatrick''s Dermatology in General Medicine


Last Editorial Review: 9/16/2009 4:05:46 PM




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