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December 20th, 2016

Shingles ~ What You Need to Know

What Is Shingles?

Shingles is the return of an infection long forgotten from childhood. Current medical thinking is that when a childhood case of chickenpox resolves, the virus causing it does not vanish. Instead, it migrates from the skin, along the path of nerves, to a collection of nerve cells called a ganglion, which resides close to the spinal cord or brain. Then, when the immunity containing the virus in the ganglia diminishes, the virus reemerges along the distribution of the nerve causing an outbreak.


What Are the Symptoms?

Symptoms usually begin with an unusual feeling in a broad localized area called a dermatome. The feeling can be a sensation of tingling, itching, or, more usually, pain. Thereafter the area may become reddened and very slightly swollen. Small blisters then form in the area and the sensation may change to burning, throbbing, or stabbing. The blisters may enlarge and coalesce and the contained fluid changes from clear to cloudy. The blisters then rupture, scab over, and gradually resolve.


Often, this ends the episode entirely; but, sometimes there are sequelae. The most frequent of these are scars in the area and pain long after the resolution of the blisters.


Who Gets Shingles?

Shingles can afflict anyone who has previously been infected with chickenpox. However, certain risk factors substantially increase the possibility of being afflicted. Common risk factors include immunosuppressive therapy either for autoimmune diseases or for transplant rejection prevention, and TNF (Tumor Necrosis Factor) inhibitors such as are used in the treatment of rheumatoid disease.


Diseases that pose risk factors for shingles are inflammatory bowel disease, rheumatoid arthritis, chronic obstructive pulmonary disease, asthma, chronic kidney disease, lymphoma, multiple myeloma, HIV, acute lymphocytic leukemia, and depression.


However, the most common risk factor is age. The probability of shingles increases with age and reaches 50% in those over 85 years old. Only 10% of shingles patients are younger than 20 years old.


Incidence of shingles is also reported to be higher in whites by 75% and in females. 


Since the introduction of widespread chickenpox vaccination in 1995, the incidence of shingles may decrease as the vaccinated population ages.


Can You Get Shingles Without Ever Having Been Infected with Chickenpox?

Technically, no. But, practically, one may forget ever having had chickenpox, especially if the case was mild. The US Centers for Disease Control (CDC) estimates that 99.5% of those born in the US and over 40 years of age have been infected with chicken pox.


Additionally, shingles is possible in persons who have been exposed to the attenuated virus by chicken pox vaccination. However, the likelihood of shingles here is much less than in those exposed to the wild virus in community- acquired chickenpox.


Finally, children have gotten shingles because their mother contracted chickenpox when she was pregnant with them.


Can Shingles Recur?

Yes, shingles recurs in about 4% of shingles sufferers.


What Are the Consequences of Shingles?

The most common complication of shingles is post-herpetic neuralgia (PHN). It is a continuation, or sometimes reappearance after a brief respite, of the pain that accompanies the shingles episode. Occasionally the quality of the pain or discomfort changes somewhat. PHN may last for months or years. Like shingles itself, PHN also increases in likelihood with age. 50% of shingles victims over the age of 60 develop PHN.


A less serious complication from a shingles episode is localized bacterial infection from scratching the skin lesions. More serious but rare complications are meningo-encephalitis, ischemic stroke, spread of shingles far beyond the original restricted distribution, paralysis, and blindness, deafness, or facial weakness from shingles of the face.


Is There a Test for Shingles?

Although laboratory tests for shingles virus exist, they are generally used only in unusual circumstances as in cases in which the typical symptoms do not appear or cases in which an early recognition of the attack is needed because of a patient’s low immunity.


The physician typically diagnoses shingles from the appearance of the involved skin and the history provided by the patient.


What Is the Treatment for Shingles?


The most specific treatment for shingles is one of the antiviral drugs. These are most effective when begun within 72 hours of appearance of the rash, but they have some effect even when given later. These drugs can both shorten and soften the attack and reduce the risk of subsequent PHN.


Nonspecifically, there are numerous options for the treatment of the pain associated with shingles and PHN. These involve analgesics such as ibuprofen or sometimes stronger, anti-seizure medications, antidepressants, and sometimes corticosteroids. Nerve injection is also used. Sometimes a capsaicin cream or lidocaine path is helpful.


Of course, the best way to approach a problem is not to have it, so let us go on to discuss prevention.


Shingles Prevention - Chicken Pox Vaccination


Since shingles is reactivation of a childhood chickenpox infection, an effective approach is the two-dose vaccination against chickenpox. It will prevent chickenpox in about 90% of those vaccinated and will shorten and reduce the severity of the chickenpox infection in the rest. By herd immunity, it also reduces the community frequency of chickenpox, thus protecting those who cannot be vaccinated.


Shingles Prevention - Shingles Vaccination


Those who have already had chickenpox can also be vaccinated but with the single-dose shingles vaccine. Because the incidence of shingles, and, in those afflicted by shingles, the incidence of PHN increases substantially with age, the CDC recommends shingles vaccination for all those 60 years of age and older. The Infectious Disease Society of America is more aggressive and recommends shingles vaccination for those 50 years of age and older.


The shingles vaccine is not perfect, but it reduces the incidence of shingles by 70% in those aged 50-59, by 64% in those aged 60-69, and by a somewhat lesser amount in those 70 years of age and older.


Testing for a previous chicken pox infection is not required for shingles vaccination. Even those with a past attack of shingles can be vaccinated, since a subsequent attack of shingles is still possible. Of course, the shingles vaccination is not a treatment for a current attack of shingles or PHN.


Since the virus in the shingles vaccine is severely weakened, but still live, it is contraindicated in pregnancy and in those with immunodeficiency states, leukemia, lymphoma, HIV, tuberculosis, or those on immunosuppressive therapy, chemotherapy, or radiation therapy.




Shingles is a disease that eventuates in a great deal of pain, suffering, and disability. Further, treatments are only partially effective in many and ineffective in some. We are fortunate to live at a time when there are vaccines to substantially reduce the frequency and severity of chickenpox, shingles, and post-herpetic neuralgia. All who are candidates for these vaccinations are well advised to take advantage of them to keep our lives and senior years free of disability and pain.


Thomas Falasca, DO


More on shingles in this informative video!














































































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