Shingles (Herpes Zoster)

Terry Murphy, MD

ED Medical Director

Samaritan Hospital

Shingles, also know as herpes zoster, is an acute infection by the varicella-zoster virus.  This is the same virus that causes chickenpox.  Shingles is a reactivation of exactly the same virus that has lain dormant for years after the initial chickenpox infection in an area of the body’s spinal cord nerves.  This sudden reactivation causes the virus to spread down the nerve and infect the skin usually; though muscles and organs such as the eye, ear or brain can, much less commonly, also be involved.

The cause for the sudden reactivation after 5 – 70 years is not known, though we do know that when the body’s immune system is weakened such as from diseases like cancer, AIDS, lymphoma or use of certain medications; shingles is more likely to occur.

Ninety-five percent of adults in the U.S. have the varicella-zoster virus dormant in their body and about 500,000 outbreaks of shingles occur each year.  Shingles occurs with increasing age (more commonly after the 6th decade) and occurs in equal frequency in men and women, but is 25% less frequent in African-Americans.

Typically, patients will first notice tingling or burning pain or hyper-sensitivity to touch along the course of the skin that has become infected through the nerve to that area.  The skin sensation is always on one side only and generally involves the trunk (back, chest, and abdomen).  Less commonly, the head, face or an extremity will be the infected area.  The pain can be mild to severe.  This phase is referred to as the prodromal phase of the disease and is a time of common misdiagnosis or delayed diagnosis.  (I personally know three individuals initially suspected of having gall bladder disease who developed the classic shingles rash several days later.)

During the acute phase, usually two or three days after the onset of skin symptoms, patients typically develop areas of blotchy red rash along the course of the infected nerve, followed in 24-36 hours by the presence of small blisters.  These blisters contain fluid that is extremely high in the virus and anyone who has not had varicella-zoster infection (chickenpox) previously can be easily infected by contact with this fluid.

Over the next several days, the blisters rupture and areas of ulcerated skin that develop crusts appear.  Gradually, during the recuperative phase, these crusts fall off and most patients return to their normal health status.

It is not usual for patients to not only have pain and a rash; but also, to have constitutional symptoms such as fever, muscle aches, headache and fatigue.  These viral induced symptoms typically last 3-7 days.

Infections of the face (eye or ear) can lead to devastating consequences such as blindness or deafness, and patients who are physically debilitated or who have a compromised immune system can develop brain, spinal cord or blood infections.  Fortunately, the occurrence of these serious complications are uncommon. However, one complication that is not uncommon and increases in frequency with the age of onset of the shingles attack, is persistent pain in the area of infection, despite healing of the rash.

This persistent pain, called post herpetic neuralgia, can last for months to years.  Fortunately, this complication resolves in most people within 6 months of their infection.

Post herpetic neuralgia occurs in only 4% of patients ages 30-50, but in 50%  of patients who are 80+ years old.

Patients with shingles should seek medical attention early as there are medications that shorten the course of the illness, reduce the risk of post herpetic neuralgia and treat the complications of shingles if they occur.

A number of medications (Acyclovir, Famciclovir and Valacyclovir) that are specific anti-viral medications have been shown to reduce symptoms and lower the risk of post herpetic neuralgia for many, but not all, patients.  Ideally, these medications should be begun within 1-2 days of onset of symptoms.  There have been some studies that indicate if oral prednisone, a hydrocortisone medicine, is taken along with an anti-viral medication; the intensity of the acute pain is diminished.

Probably most importantly though, is the recent approval of a vaccine that has pretty good efficacy for preventing shingles.  This vaccine has attenuated live varicella- zoster virus that boosts immunity against shingles.  It reduces the occurrence of shingles overall in patients over 60 by 50%, and in the younger subset of 60-69 year old patients, by 64%.  It is currently recommended for healthy adults over age 60.

This article is intended to provide useful information, not medical advice. This information cannot, and is not meant to, replace consultation with your physician regarding your individual circumstances.