Health

What You Should Know About Shingles

by Kate Wicker

According to the Centers for Disease Control and Prevention, shingles affects approximately one million people each year and, as Krauss can attest, the condition can be quite painful and debilitating. "Progress was slow. I was out of work for four weeks and then eased my way back by working partial days for two weeks," she says. "It took three months for all the redness to go away and I had numbness in my left arm until May.

The good news is early diagnosis can help make treatment more effective and a new shingles vaccine may help people avert the painful condition. Here's a look at some of the most frequently asked questions about shingles.

Shingles, medically known as herpes zoster, is a blistering skin rash that is caused by the varicella zoster virus. "Most adults were infected by this virus as children in the form of chicken pox," says Phillip Kennedy, M.D., a family physician at the Center for Primary Care and president of the Doctors Hospital medical staff. "After the initial infection, the virus stays in the body in a dormant state and can reappear in the form of shingles."

Fifteen to 30 percent of people infected with the chicken pox virus develop shingles later in life, but it's not completely clear why the virus hibernates in some people without ever waking yet reactivates in others causing the painful shingles rash to develop. "What we think is that changes in the immune system, either due to age or disease of the immune system, cause the virus to re-express itself in the form of shingles," explains Ramon Parrish, M.D., a physician with MCG Family Medicine.

Not surprisingly, shingles is far more common in the older population as well as in people who have compromised immune systems. "Over half of the cases of shingles occur in people over age 60," says Dr. Kennedy.

If you're thinking of quarantining Grandpa because of his recent shingles diagnosis, rest easy. "You can't give someone shingles," Dr. Parrish says. Remember, shingles occurs due to the breakdown of the immune system and a subsequent reactivation of the chicken pox virus. That said, someone with shingles can give a person chicken pox—providing the individual has never been exposed to the virus. Likewise, those with shingles should steer clear of anyone with a weak immune system.

"The first thing that usually happens is pain. It's usually sharp and sometimes described as tingling," says Dr. Parrish. "The pain usually occurs a day or two prior to the rash breaking out. Then you get red skin lesions, which gradually get dark and scab over." The skin rash and pain occur only on one side of the body.

Although the thought of blistering skin lesions conjures up images from a horror flick or plague-ridden medieval Europe, the symptoms, though painful, usually subside in about four weeks and rarely reappear. However, one in five sufferers develops a complication called postherpetic neuralgia (PHN)—recurrent, long-term nerve pain that can be debilitating. "Postherpetic neuralgia is the most common complication of shingles. It occurs along the nerve that was affected by the virus. [The pain] can be severe and disabling, persist for years and can be difficult to treat," says Dr. Phillips.

Krauss regrettably is member of the PHN club. "All the visible signs have cleared up with no scarring; however,I still have pain and discomfort," she admits.

Three FDA-approved drugs are currently used to help manage shingles symptoms: acyclovir, valacyclovir and famciclovir. "These [antiviral] medications work by interrupting the virus's ability to reproduce," says Dr. Phillips.

"They're like antibiotics for viruses," Dr. Parrish adds. "They treat the actual disease."

The key with these meds is to start treatment early. "Antivirals have been shown to be most effective when begun as soon as possible after a diagnosis—ideally within the first 72 hours," says Krauss.

But this can be problematic given shingles's oftentimes obscure symptoms. Although Krauss received an official diagnosis about four days after first noticing her shingles red flags, many patients aren't as lucky. "Diagnosing shingles can be a challenge before the rash appears and, at times when the pain precedes the rash in the abdomen or chest, it can lead to diagnostic tests being ordered to rule out things such as heart disease or even appendicitis," says Dr. Phillips.

That's why it's important not to ignore your symptoms. "Beware of any pain or unusual rashes, especially if they seem to be only on one side of the body," advises Krauss. Aside from antiviral medications, there are other treatments available to help alleviate the pain associated with shingles. "Narcotic pain medications are available and often work," says Dr. Parrish. In addition, a Lidocaine patch—the same medicine that is commonly used to numb the skin for patients who have to have stitches in the ER—can be applied to the rash. The Lidocaine patch requires a prescription, but an over-the-counter remedy called Zostrix-HP is available as well. It's a cream that can be directly applied to the skin once the lesions have crusted over. When applied to the skin, Zostrix has been shown to reduce levels of substance P—a neurochemical involved in transmitting pain impulses to the brain. Interestingly, Zostrix's active ingredient—capsaicin—is the same ingredient responsible for the jalapeno pepper's spicy jolt.

The obvious precaution with using capsaicin creams, according to Dr. Parrish, is to wear gloves during application and to avoid getting it in your eyes or other mucous membrane areas. "It could cause some painful burning," he says.

Research has also shown that early treatment with a short course (generally one to two weeks) of steroids can decrease the intensity and duration of pain associated with shingles. As for postherpetic neuralgia, there's currently no cure, but anti-seizure medications are commonly used to decrease the pain associated with the complication, according to Dr. Phillips. Zostrix has also been used to target pain caused by PHN.

Krauss's personal treatment plan included the use of antivirals as well as pain medications, but she also found that just taking it easy helped her cope with the discomfort. "Rest seemed to help," she says. "If I got excited or upset, the pain seemed to worsen. Heat also made the symptoms worse, so I avoided direct heat on any of the lesions."

Recently, shingles has caught the eye of the media after the Advisory Council for Immunization Practice, an influential government advisory panel that is considered the worldwide guru for making vaccine recommendations, advised that all Americans 60 and older get vaccinated against shingles. The CDC has also made a provisional recommendation pending further research. Yet the new recommendation remains controversial for a number of reasons.

First, recommending a vaccine is one thing, but getting it to the people who need it is a different story altogether. "The problem with Zostavax [the shingles vaccine] for those with Medicare is that it's one of the first immunizations to be paid for by Part D. Most doctors can't bill for Part D, so if they stock and provide it to Medicare patients, the patient will have to pay for it and then file a claim to their Part D provider." A cumbersome process, no doubt, and some people may not have the money to pay for the vaccine out of pocket before being reimbursed. Likewise, not all private insurance companies are covering the vaccine, which carries a hefty price tag (somewhere in the neighborhood of $150), according to Dr. Parrish. Nor is it an easy vaccine to administer. "The vaccine has to remain frozen. When it's thawed, it has to be used within 30 minutes," says Dr. Parrish.

But its expense and scrupulous handling requirements are just the tip of the iceberg. Even if you've got the dough to shell out and a physician who has Zostavax in stock, the vaccine is not universally effective. "It only reduces the cases by half and reduces the incidence of postherpetic neuralgia by two-thirds," Dr. Parrish says. Another interesting fact is that an increase in the prevalence of shingles in the United States is expected as the result of another fairly recent immunization recommendation. "Adults appear to get a boost to their immune system when they're around kids with chicken pox, but we're now vaccinating kids against chicken pox," says Dr. Parrish. "When we do that, the incidence of shingles rises." In fact, research has shown that the incidence of shingles doubles with the widespread administration of the chicken pox vaccine. For this reason, Great Britain has decided against requiring immunization against chicken pox in children. "It's a trade-off," Dr. Parrish says. "We're trying to protect children against the complications of chicken pox, but there's definitely a benefit to kids having chicken pox in terms of preventing shingles."

The bottom line is you have to weigh the pros and cons. "Patients need to be aware of the risks and benefits of the shingles vaccine," Dr. Parrish advises. No big news there. When it comes to your health care—whether it's deciding if the shingles vaccine is right for you or making some other important health decision, it's always wise to get educated, be an advocate for yourself and have a candid dialogue with your physician about the best course of action.