Shingles

Definition

Shingles, also called herpes zoster, gets its name from both the Latin and French words for belt or girdle and refers to girdle-like skin eruptions that may occur on the trunk of the body. The virus that causes chickenpox , the Varicella zoster virus (VSV), can become dormant in nerve cells after an episode of chickenpox and later re-emerge as shingles.

Initially, red patches of rash develop into blisters . Because the virus travels along the nerve to the skin, it can damage the nerve and cause it to become inflamed. This condition can be very painful. If the pain persists long after the rash disappears, it is known as post-herpetic neuralgia (PHN).

Description

Any individual who has had chickenpox can develop shingles. Between 600,000 and one million Americans

are diagnosed with shingles each year. Overall, approximately 20% of those who have had chickenpox as children develop shingles at some time in their lives. People of all ages—even children—can be affected, but the incidence increases with age. Newborns, bone marrow and other transplant recipients, and individuals with immune systems weakened by disease or drugs are also at increased risk. However, most individuals who develop shingles do not have any underlying malignancy or other immunosuppressive condition.

Causes & symptoms

Shingles erupts along the course of the affected nerve, producing lesions anywhere on the body. The condition may cause severe nerve pain. The most common areas to be affected are the face and trunk, which correspond to the areas where the chickenpox rash is most concentrated. There is usually a line of eruptions running from the spine along the path of the affected nerve on one side of the body.

The disease is caused by a reactivation of the chickenpox virus that has lain dormant in certain nerves following an episode of chickenpox. Exactly how or why this reactivation occurs is not clear. In 2002 clinicians pointed out that one of the causes of increasing cases of shingles was actually the success of chicken pox vaccinations. It is believed that the reactivation is triggered when the immune system becomes weakened as a result of age, stress, fatigue , certain medications, chemotherapy, or diseases such as cancer or HIV. Furthermore, in persons with HIV, shingles can be an early sign that the immune system has deteriorated.

Early signs of shingles are often vague and can easily be mistaken for other illnesses. The condition may begin with fever and malaise (a vague feeling of weakness or discomfort). Within two to four days, severe pain, itching , and numbness/tingling (paresthesias) or extreme sensitivity to touch (hyperesthesia) can develop, usually on the trunk and occasionally on the arms and legs.

Pain may be continuous or intermittent, usually lasting one to three weeks. It may occur at the time of the eruption, but can precede the eruption by days, occasionally making the diagnosis difficult.

Signs and symptoms may include the following:

• itching, tingling, or severe burning pain
• red patches that develop into blisters
• dense clusters of small blisters that ooze and crust
• swollen lymph nodes

Diagnosis

Diagnosis usually is not possible until the skin lesions develop. Once they develop, however, the pattern and location of the blisters and the type of cell damage displayed are characteristic of the disease. This feature allows an accurate diagnosis based primarily upon the physical examination. Although tests are rarely necessary, they may include the following:

• Viral culture of skin lesion.
• Microscopic examination using a Tzanck preparation. This involves staining a smear obtained from a blister. Cells infected with the herpes virus appear very large and contain many dark cell centers or nuclei.
• Complete blood count (CBC) may show an elevated white blood cell count (WBC), a nonspecific sign of infection.

Treatment

A person with shingles should immediately see a doctor or health practitioner. Although the condition generally clears up within three to five weeks, treatment can ease the painful symptoms. Alternative medicine remedies and therapies will not cure shingles, but they will provide pain relief, reduce inflammation, and speed recovery.

Herbal remedies

Many herbs can be used to treat shingles. Some remedies involve brewing tea and then consuming and/or applying it to the affected area. Herbs used to treat shingles include:

• Red pepper, also known as capsicum or cayenne , is so effective that it's an ingredient in commercial ointments approved by the U.S. Food and Drug Administration. Commercial preparations include Zostrix and Capzasin-P. Red pepper is hot, so the ointment should be applied only to healed blisters. Red pepper is useful for treating painful PHN.
• Topical applications of lemon balm, licorice , or peppermint may reduce pain and blistering. These herbs may be brewed as teas and then consumed and applied to the skin.
• Herbal antivirals, such as echinacea , can be effective in fighting infection and boosting the immune system.
• Calendula ointment or lotion works to counter the virus.
• Sedative herbs such as passionflower can be brewed for a tea. Such herbs can help with treatment of post-herpetic neuralgia.
• Vervain helps relieve pain and inflammation. St. John's wort, lavender, chamomile , and marjoram also help relieve inflammation.

Homeopathic remedies

A person with shingles should consult a homeopath for specific remedies and dosages. Homeopathic remedies include Ranunculus, which is effective for shingles on the trunk. It is also taken for itching. A homeopath may recommend Rhus toxicodendron for blisters and Arsenicum album or Hypericum for pain.

Traditional Chinese medicine

Practitioners of traditional Chinese medicine (TCM) recommend acupressure and acupuncture to alleviate pain. Acupuncture can help with post-herpetic neuralgia. In addition, a TCM practitioner may recommend herbal remedies such as Chinese gentian root, which is used to treat the liver. In addition, Chinese skullcap root is combined with water and used as a folk remedy for treating shingles in China. Also, certain herbal combinations can treat specific symptoms and contributing causes. For example, Long Dan Xie Gan Tang can quell the accumulation of damp toxic heat in the liver. For damp infected painful eruptions on the torso, Huang Qin Gao can be applied to the surrounding area.

Diet and nutrition

To boost the immune system, supplement the diet with vitamin B during the first one or two days. Until health returns, continue to supplement with vitamin B complex , high levels of vitamin C with bioflavonoids , and calcium .

Food seasoned with red pepper (capsicum) may provide relief, as may foods containing the amino acid lysine . High-lysine foods include soybeans, black bean sprouts, lentils, parsley , and peas.

Home remedies

Cool wet compresses may help reduce pain while blisters or crusting is present. Patients may be made more comfortable with the application of a cloth dipped in one-quarter cup (60 ml) of white vinegar mixed in two quarts (1.9 l) of lukewarm water. Compresses should be used twice daily for 10 minutes. When blisters dry up, the compresses may be discontinued.

Soothing treatments such as colloidal oatmeal baths, starch baths or lotions, and calamine lotion may help to relieve itching and discomfort.

When the crusts and scabs are separating, the skin may become dry, tight, and cracked. If that happens, a small amount of plain petroleum jelly can be applied to the area three or four times daily.

Ayurvedic medicine

Ayurveda is an Indian healing science that is more than 5,000 years old. Treatment is based on maintaining a balance between the body and the world. Treatment for shingles may include applying a turmeric paste to the skin.

Relaxation techniques

Relaxation techniques can be used to treat symptoms of shingles. Techniques such as hypnotherapy and yoga can help a person relax.

Flower remedies

Flower remedies are liquid concentrates made by soaking flowers in spring water. Also known as flower essences, 38 remedies were developed by the homeopathic physician Edward Bach during the 1930s. A 39th combination formula, known as Rescue Remedy is taken to relieve stress. The remedy is taken by placing several drops under the tongue four times daily. Alternately, the drops may be added to a glass of water. The patient drinks the mixture throughout the day.

Reflexology

Reflexology is the manipulation of the foot to bring the body into balance. Reflex points on the foot correspond to parts of the body. These points can be treated by a reflexologist or at home by following instructions on a reflex chart.

Allopathic treatment

The antiviral drugs acyclovir, valacyclovir, and famciclovir can be used to treat shingles. These drugs may shorten the course of the illness. More rapid healing of the blisters results when drug therapy is started within 72 hours of the onset of the rash. In fact, the earlier the drugs are administered the better, because early cases can sometimes be halted. If taken later, these drugs are less effective but may still lessen the pain. Antiviral drug treatment does not seem to reduce the incidence of post-herpetic neuralgia (PHN), but recent studies suggest famciclovir may cut the duration of PHN in half.

Side effects of typical oral doses of these antiviral drugs are minor, with headache and nausea reported by 8–20% of patients. Severely immuno compromised individuals, such as those diagnosed with AIDS , may require intravenous administration of antiviral drugs. Corticosteroids such as prednisone may be used to reduce inflammation but they interfere with the functioning of the immune system. Corticosteroids in combination with antiviral therapy are also used to reduce severe pain and to treat severe infections , such as those affecting the eyes.

After the blisters heal, some people continue to experience PHN for months or even years. This pain can be excruciating. Consequently, the doctor may prescribe tranquilizers, sedatives, or antidepressants to be taken at night. Attempts to treat PHN with famciclovir have shown some promising results. When all else fails, severe pain may require a permanent nerve block.

Expected results

Shingles usually clears up within three to five weeks and rarely recurs. There have been reports that shingles cleared up several days after licorice ointment was applied to the skin or when the homeopathic remedy Ranunculus was taken.

If the nerves that cause movement are affected, temporary or permanent nerve paralysis and/or tremors may occur. Elderly or debilitated patients may have a prolonged and difficult course and recovery. For them, the eruption is typically more extensive and inflammatory, occasionally resulting in blisters that bleed, areas in which the skin actually dies, secondary bacterial infection, or extensive and permanent scarring.

Similarly, patients with compromised immune systems usually have more severe courses that are often prolonged for weeks to months. They develop shingles frequently and the infection can spread to the skin, lungs, liver, gastrointestinal tract, brain, or other vital organs.

Cases of chronic shingles have been reported in AIDS patients, especially when they have a decreased number of one particular kind of immune cell called CD4 lymphocytes. Depletion of CD4 lymphocytes is associated with more severe, chronic, and recurrent varicella zoster virus infections. Lesions are typical at the onset but may turn into ulcers that do not heal. Herpes zoster can lead to potentially serious complications.

Many individuals continue to experience persistent pain long after the blisters heal. This post-herpetic neuralgia can be severe and debilitating. The incidence of post-herpetic neuralgia increases with age, and episodes in older individuals tend to be of longer duration. Most patients under 30 years of age experience no persistent pain. By age 40, the risk of prolonged pain lasting longer than one month increases to 33%. By age 70, the risk increases to 74%. The pain can adversely affect quality of life, but it usually diminishes over time.

Other complications include secondary bacterial infections.

Prevention

Strengthening the immune system by making lifestyle changes is thought to help prevent the development of shingles. These changes include eating a well-balanced diet rich in essential vitamins and minerals, getting enough sleep, exercising regularly, and reducing stress.

In 2002, reports from a large, five-year study showed that researchers might be nearing a workable vaccine for shingles. The vaccine is 10 times stronger than the chickenpox vaccine and similar in nature. Study results were planned for release in mid-2004.

Resources

BOOKS

Cummings, Stephen, and Dana Ullman. Everybody's Guide to Homeopathic Medicines. New York: Putnam, 1997.

Duke, James A. The Green Pharmacy. Emmaus, PA.: Rodale Press, 1997.

Gottlieb, Bill. New Choices in Natural Healing. Emmaus, PA.: Rodale Press, 1995.

Keville, Kathi. Herbs for Health and Healing. Emmaus, PA.: Rodale Press, 1996.

L'Orange, Darlena. Herbal Healing Secrets of the Orient. Paramus, NJ: Prentice Hall, 1998.

Squier, Thomas Broken Bear, with Lauren David Peden. Herbal Folk Medicine. New York: Henry Holt, 1997.

Ullman, Dana. The Consumer's Guide to Homeopathy. New York: Putnam, 1995.

PERIODICALS

Landers, Susan J. "Rash of Pain: With an Increasingly Large Patient Population at Risk for Shingles, Researchers Focus on Uncovering New Ways to Prevent and Treat this Viral Response." American Medical News (April 1, 2002):32.

MacKenzie, Deborah. "The Hidden Catch: Although Chickenpox is Nasty, Vaccination Might Not be the Answer." New Scientist (May 4, 2002):7.

ORGANIZATIONS

American Academy of Dermatology. 930 N. Meacham Road, P.O. Box 4014, Schaumberg, IL 60168-4014. (708) 330-0230. http://www.aad.org/zoster.html.

American Botanical Council. P.O. Box 201660, Austin TX, 78720. (512) 331-8868. http://www.herbalgram.org.

Herb Research Foundation. 1007 Pearl St., Suite 200, Boulder, CO 80302. (303) 449-2265. http://www.herbs.org.

OTHER

MotherNature.com Health Encyclopedia. http://www.mothernature.com/ency.

Liz Swain

Teresa G. Odle

Shingles

Definition

Shingles, also called herpes zoster or zona, gets its name from both the Latin and French words for belt or girdle and refers to girdle-like skin eruptions that may occur on the trunk of the body. The virus that causes chickenpox, the varicella zoster virus (VSV), can become dormant in nerve cells after an episode of chickenpox and later reemerge as shingles. Initially, red patches of rash develop into blisters. Because the virus travels along the nerve to the skin, it can damage the nerve and cause it to become inflamed. This condition can be very painful. If the pain persists long after the rash disappears, it is known as postherpetic neuralgia.

Description

Any person who has had chickenpox can develop shingles. Approximately 500,000 cases of shingles occur every year in the United States, according to the National Institute of Allergy and Infectious Diseases (NIAID). Overall, approximately 20% of those who had chickenpox as children develop shingles at some time in their lives. People of all ages, even children, can be affected, but the incidence increases with age. Newborn infants, bone marrow and other transplant recipients, as well as indivduals with immune systems weakened by disease or drugs are also at increased risk. However, most individuals who develop shingles do not have any underlying malignancy or other immunosuppressive condition.

Causes and symptoms

Shingles erupts along the course of the affected nerve, producing lesions anywhere on the body and may cause severe nerve pain. The most common areas to be affected are the face and trunk, which correspond to the areas where the chickenpox rash is most concentrated. The disease is caused by a reactivation of the chickenpox virus that has lain dormant in certain nerves following an episode of chickenpox. Exactly how or why this reactivation occurs is not clear; however, it is believed that the reactivation is triggered when the immune system becomes weakened, either as a result of stress, fatigue, certain medications, chemotherapy, or diseases, such as cancer or HIV. Further, it can be an early sign in persons with HIV that the immune system has deteriorated.

In some cases, the virus appears to be reactivated by mechanical irritation or minor surgical procedures. In one instance, the patient had an attack of shingles following liposuction.

Early signs of shingles are often vague and can easily be mistaken for other illnesses. The condition may begin with fever and malaise (a vague feeling of weakness or discomfort). Within two to four days, severe pain, itching, and numbness/tingling (paresthesia) or extreme sensitivity to touch (hyperesthesia) can develop, usually on the trunk and occasionally on the arms and legs. Pain may be continuous or intermittent, usually lasting from one to four weeks. It may occur at the time of the eruption, but can precede the eruption by days, occasionally making the diagnosis difficult. Signs and symptoms may include the following:

• itching, tingling, or severe burning pain
• red patches that develop into blisters
• grouped, dense, deep, small blisters that ooze and crust
• swollen lymph nodes

Diagnosis

Diagnosis is usually not possible until the skin lesions develop. Once they develop, however, the pattern and location of the blisters and the type of cell damage displayed are characteristic of the disease, allowing an accurate diagnosis primarily based upon the physical examination.

Although tests are rarely necessary, they may include the following:

• viral culture of skin lesion
• microscopic examination using a Tzanck preparation. This involves staining a smear obtained from a blister. Cells infected with the herpes virus will appear very large and contain many dark cell centers or nuclei.
• complete blood count (CBC) may show an elevated white blood cell count (WBC), a nonspecific sign of infection
• Rise in antibody to the virus
• Polymerase chain reaction (PCR) analysis. PCR testing has been found to be much faster and significantly more accurate than culturing the virus.

Treatment

Shingles almost always resolves spontaneously and may not require any treatment except for the relief of symptoms. In most people, the condition clears on its own in one or two weeks and seldom recurs.

Cool, wet compresses may help reduce pain. If there are blisters or crusting, applying compresses made with diluted vinegar will make the patient more comfortable. Mix one-quarter cup of white vinegar in two quarts of lukewarm water. Use the compress twice each day for 10 minutes. Stop using the compresses when the blisters have dried up.

Soothing baths and lotions such as colloidal oatmeal baths, starch baths or lotions, and calamine lotion may help to relieve itching and discomfort. Keep the skin clean, and do not re-use contaminated items. While the lesions continue to ooze, the person should be isolated to prevent infecting other susceptible individuals.

Later, when the crusts and scabs are separating, the skin may become dry, tight, and cracked. If that happens, rub on a small amount of plain petroleum jelly three or four times a day.

The antiviral drugs acyclovir, valacyclovir, and famciclovir can be used to treat shingles. These drugs may shorten the course of the illness. Their use results in more rapid healing of the blisters when drug therapy is started within 72 hours of the onset of the rash. In fact, the earlier the drugs are administered, the better, because early cases can sometimes be stopped. If taken later, these drugs are less effective but may still lessen the pain. Antiviral drug treatment does not seem to reduce the incidence of postherpetic neuralgia, but recent studies suggest famciclovir may cut the duration of postherpetic neuralgia in half. Side effects of typical oral doses of these antiviral drugs are minor with headache and nausea reported by 8-20 % of patients. Severely immunocompromised individuals, such as those with AIDS, may require intravenous administration of antiviral drugs.

Corticosteroids, such as prednisone, may be used to reduce inflammation but they do interfere with the functioning of the immune system. Corticosteroids, in combination with antiviral therapy, also are used to treat severe infections, such as those affecting the eyes, and to reduce severe pain.

Once the blisters are healed, some people continue to experience pain for months or even years (postherpetic neuralgia). This pain can be excruciating. Consequently, the doctor may prescribe tranquilizers, sedatives, or antidepressants to be taken at night. As noted above attempts to treat postherpetic neuralgia with the antiviral drug famciclovir have shown some promising results. When all else fails, severe pain may require a permanent nerve block.

A newer medication to treat postherpectic neuralgia is pregabalin, to be marketed in the United States under the trade name Lyrica. Pregabalin was approved by the Food and Drug Administration in September 2004 for the treatment of diabetic neuropathy as well as postherpetic neuralgia. The drug has been shown to improve patients' sleep and overall quality of life as well as relieve pain. Its most common side effects are drowsiness, headache, dry mouth, and dizziness.

Alternative treatment

There are nonmedical methods of prevention and treatment that may speed recovery. For example, getting lots of rest, eating a healthy diet, exercising regularly, and minimizing stress are always helpful in preventing disease. Supplementation with vitamin B₁₂ during the first one to two days and continued supplementation with vitamin B complex, high levels of vitamin C with bioflavenoids, and calcium, are recommended to boost the immune system. Herbal antivirals such as echinacea can be effective in fighting infection and boosting the immune system.

Although no single alternative approach, technique, or remedy has yet been proven to reduce the pain, there are a few options which may be helpful. For example, topical applications of lemon balm (Melissa officinalis ) or licorice (Glycyrrhiza glabra ) and peppermint (Mentha piperita ) may reduce pain and blistering. Homeopathic remedies include Rhus toxicodendron for blisters, Mezereum and Arsenicum album for pain, and Ranunculus for itching. Practitioners of Eastern medicine recommend self-hypnosis, acupressure, and acupuncture to alleviate pain.

Prognosis

Shingles usually clears up in two to three weeks and rarely recurs. Involvement of the nerves that cause movement may cause a temporary or permanent nerve paralysis and/or tremors. The elderly or debilitated patient may have a prolonged and difficult course. For them, the eruption is typically more extensive and inflammatory, occasionally resulting in blisters that bleed, areas where the skin actually dies, secondary bacterial infection, or extensive and permanent scarring.

Similarly, an immunocompromised patient usually has a more severe course that is frequently prolonged for weeks to months. They develop shingles frequently and the infection can spread to the skin, lungs, liver, gastrointestinal tract, brain, or other vital organs. Cases of chronic shingles have been reported in patients infected with AIDS, especially when they have a decreased number of one particular kind of immune cell, called CD4 lymphocytes. Depletion of CD4 lymphocytes is associated with more severe, chronic, and recurrent varicella-zoster virus infections. These lesions are typical at the onset but may turn into ulcers that do not heal.

Potentially serious complications can result from herpes zoster. Many individuals continue to experience persistent pain long after the blisters heal. This pain, called postherpetic neuralgia or PHN, can be severe and debilitating. Postherpetic neuralgia can persist for months or years after the lesions have disappeared. The incidence of postherpetic neuralgia increases with age, and episodes in older individuals tend to be of longer duration. Most patients under 30 years of age experience no persistent pain. By age 40, the risk of prolonged pain lasting longer than one month increases to 33%. By age 70, the risk increases to 74%. The pain can adversely affect quality of life, but it does usually diminish over time. Another risk factor for PHN is female sex.

Other complications include a secondary bacterial infection, and rarely, potentially fatal inflammation of the brain (encephalitis ) and the spread of an infection throughout the body. These rare, but extremely serious, complications are more likely to occur in those individuals who have weakened immune systems (immunocompromised).

Prevention

Strengthening the immune system by making lifestyle changes is thought to help prevent the development of shingles. A lifestyle designed to strengthen the immune system and maintain good overall health includes eating a well-balanced diet rich in essential vitamins and minerals, getting enough sleep, exercising regularly, and reducing stress.

KEY TERMS

Acyclovir— An antiviral drug that is available under the trade name Zovirax, in oral, intravenous, and topical forms. The drug blocks the replication of the varicella zoster virus.

Antibody— A specific protein produced by the immune system in response to a specific foreign protein or particle called an antigen.

Corticosteroid— A steroid that has similar properties to the steroid hormone produced by the adrenal cortex. It is used to alter immune responses to shingles.

Famciclovir— An oral antiviral drug that is available under the trade name Famvir. The drug blocks the replication of the varicella zoster virus.

Immunocompromised— A state in which the immune system is suppressed or not functioning properly.

Postherpetic neuralgia (PHN)— The term used to describe the pain after the rash associated with herpes zoster is gone.

Tzanck preparation— Procedure in which skin cells from a blister are stained and examined under the microscope. Visualization of large skin cells with many cell centers or nuclei indicates a positive diagnosis of herpes zoster when combined with results from a physical examination.

Valacyclovir— An oral antiviral drug that is available under the trade name Valtrex. The drug blocks the replication of the varicella zoster virus.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Herpesvirus Infections." Section 13, Chapter 162 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Andrews, T. R., G. Perdikis, and R. B. Shack. "Herpes Zoster as a Rare Complication of Liposuction." Plastic and Reconstructive Surgery 113 (May 2004): 1838–1840.

Feder, H. M. Jr., and D. M. Hoss. "Herpes Zoster in Otherwise Healthy Children." Pediatric Infectious Disease Journal 451-457.

Jung, B. F., R. W. Johnson, D. R. Griffin, and R. H. Dworkin. "Risk Factors for Postherpetic Neuralgia in Patients with Herpes Zoster." Neurology 62 (May 11, 2004): 1545–1551.

Sabatowski, R., R. Galvez, D. Cherry, et al. "Pregabalin Reduces Pain and Improves Sleep and Mood Disturbances in Patients with Postherpetic Neuralgia: Results of a Randomised, Placebo-Controlled Clinical Trial." Pain 109 (May 2004): 26-35.

Stranska, R., R. Schuurman, M. de Vos, and A. M. van Loon. "Routine Use of a Highly Automated and Internally Controlled Real-Time PCR Assay for the Diagnosis of Herpes Simplex and Varicella-Zoster Virus Infections." Journal of Clinical Virology 30 (May 2004): 39-44.

ORGANIZATIONS

American Academy of Dermatology. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-0230. Fax: (847) 330-0050. 〈http://www.aad.org〉.

National Institute of Allergy and Infectious Diseases (NIAID). Office of Communications and Public Liaison, 6610 Rockledge Drive, MSC 6612, Bethesda, MD 20892-6612. 〈http://www.niaid.nih.gov〉.

Shingles

Definition

Shingles is infection by the varicella-zoster virus of the dorsal root ganglia of the spine. Equivalent terms for shingles are herpes zoster, zoster, zona, or acute posterior ganglionitis.

Description

Shingles is an infection of the central nervous system , in particular, the dorsal root ganglia of the spine, which migrates through sensory nerves to the skin. There it manifests (usually on the upper trunk) as painful, bumpy, fluid-filled eruptions or vesicles. Shingles may also cause nerve pain (neuralgia). The affected areas of skin are those supplied by sensory nerves radiating from the infected dorsal root ganglia. Sensory nerves from these ganglia serve non-overlapping, sharply bounded strips or areas of the skin called dermatomes. Because the left and right sides of the body are divided into separate sets of dermatomes, shingles lesions do not cross the midline of the body.

Demographics

The virus that causes shingles is usually contracted in childhood. It is the same virus that causes chicken pox, which is primarily a disease of childhood because it is highly contagious; that is, few individuals live to adulthood without contracting chicken pox. (This statement applies to the temperate zones of the world. For unknown reasons, chicken pox and shingles are less prevalent in tropical regions.) The virus that causes both chicken pox and shingles can, however, be contracted by an individual for the first time in adulthood. First infection, at whatever age it occurs, is called primary infection. Primary infection does not cause shingles; shingles arises from reactivation of virus introduced to the body by an earlier, primary infection.

Shingles arises in individuals who have already had chicken pox, and especially in people with weakened immune systems, such as the elderly or people receiving chemotherapy or bone marrow transplantation. Persons with AIDS are also vulnerable to shingles. Shingles incidence increases steadily with age. Among 10–19 year olds, the rate per 1,000 persons per year is only 1.38. In the 30–49 age range, it rises to 2.29 cases of shingles per 1,000 persons per year. By age 60–79, almost seven cases occur per 1,000 people per year, and this increases to 10 in the 80–89 age group.

Causes and symptoms

Shingles is caused by the varicella-zoster virus (VZV), also known as HHV-3. VZV is genetically similar to the herpes simplex viruses, the type of viruses that causes cold sores and genital herpes. Herpes simplex virus also takes up permanent residence in sensory nerve ganglia, but not in the dorsal root ganglia of the spine, as does VZV. In chicken pox, the virus is inhaled and begins replicating in the upper respiratory tract before spreading to the liver and other body systems.

Following primary infection, VZV remains as a symptomless infection in the dorsal root ganglia of the spinal cord. It may or may not become active again, that is, begin reproducing, later in life. Reactivation occurs more often in older people, probably as a result of decreased immune response with age. Reactivation may be symptomless, but usually causes shingles. Repeat episodes of shingles are rare (occurring in less than 4% of patients) because the immune system's response to VZV is boosted by a first shingles episode.

Chills, fever, malaise, gastrointestinal problems, and pain in the affected skin areas may precede appearance of skin eruptions by several days. Viral particles travel away from the spinal cord along the sensory nerves toward the skin, causing inflammation of those nerves, which may be painful. On the fourth or fifth day, skin vesicles begin to appear. The affected area is usually hypersensitive, and disabling pain (described as sharp, stabbing, or burning) may occur in the affected area. About the fifth day after appearing, the vesicles begin to crust or scab and the disease resolves within the next two weeks. There may be no visible aftereffects, although slight scarring from the vesicles may occur.

Especially in elderly patients, pain may persist for months or years after shingles has otherwise resolved. This pain, postherpetic neuralgia, is caused by damage to the dorsal root ganglia that renders them either spontaneously active (perceived as chronic pain) or hypersensitive to slight stimuli such as light touch.

VZV can become active in the cranial nerves as well as in the spinal ganglia. Involvement of branches of the trigeminal nerve (fifth cranial nerve) is most common. When the ophthalmic branch of the trigeminal nerve is involved, this condition is called herpes zoster ophthalmicus. It can cause swelling of the eyelid, pain, and other complications involving the eye. Herpes zoster ophthalmicus can also lead to weakness or partial paralysis (hemiparesis) on the opposite side of the body from the nerve affected, possibly by inducing irritation of the blood vessels in the brain. Infection of cranial nerves by reactivated VZV can also affect the hearing. When this occurs, it is usually associated with facial palsy and is known as Ramsay-Hunt syndrome.

Large amounts of free virus (i.e., virus not held inside cells) is present in the fluid-filled vesicles or bumps that erupt on the skin during shingles. Thus, people who are not resistant to VZV are easily infected by contact with persons having an outbreak of shingles. A particular strain of VZV can remain latent for decades and then reappear as a new epidemic.

Diagnosis

Diagnosis is based on history and symptoms. The person must have initially had chicken pox in order to have shingles. Definite diagnosis is difficult before eruption of the characteristic vesicles or bumps on the skin. Often persons with early shingles mistake the reddened, painful area as an accidental burn. Once vesicles appear, however, they are hard to mistake because of their dermatome-bounded distribution on the body. In children, shingles (VZV reactivation) must be differentiated from chicken pox (primary VZV infection). This is normally not difficult, as chicken pox vesicles occur widespread on the body and shingles lesions are usually limited to one area on the person's midsection. Herpes simplex virus can also produce vesicle eruptions similar to those of shingles. If there is doubt about which virus is present, virus from the patient can be cultured.

Treatment team

Unless there are complications such as in a person with AIDS, or a child with leukemia, a primary physician can usually treat shingles.

Treatment

Treatment for shingles is primarily with antiviral drugs , traditionally acyclovir but, more recently, famcyclovir and valacyclovir. Additionally, a live attenuated-virus vaccine for chicken pox has been licensed since 1995. The vaccine was developed to immunize children undergoing cancer treatment because chicken pox can cause severe complications in such children.

The pain associated with shingles, and with the postherpetic neuralgia that may linger (especially in older patients, after the condition has otherwise resolved), is best treated using combination therapy based on antivirals, antidepressants, corticosteroids, opioids (morphine), and topical agents (applied directly to the skin). The inexpensive amino acid lysine has also been reported to ease the symptoms of both herpes simplex infections and shingles.

Recovery and rehabilitation

Recovery from shingles for the otherwise healthy patient is straightforward and generally requires no special rehabilitation aid or therapy.

Clinical trials

As of mid 2004, several clinical trials related to shingles are recruiting patients. One is sponsored by the National Center for Research Resources, University of Texas, and titled "Randomized Study of Two Doses of Oral Valacyclovir in Immunocompromised Patients with Uncomplicated Herpes Zoster." The study seeks to investigate the efficacy of higher-than-standard doses of valacyclovir by assessing quality of life, pain level, and utilization of medical resources of patients treated with a higher-than-standard dose of valacylovir as compared to a control group treated with the standard dose. Contact information is University of Texas Medical Branch, Galveston, Texas, 77555-0209; Stephen K. Tyring is the recruiter, telephone: (281) 333-2288.

Another trial recruiting patients as of 2004 is sponsored by the Baylor College of Medicine, Texas Children's Hospital, and titled "Valacyclovir in Immunocompromised Children." The study seeks to learn how the body handles valacyclovir, its efficacy in treating immunocompromised children with shingles, and the side effects of such treatment. The recruiting inquiries in Pennsylvania is Children's Hospital of Philadelphia, Pennsylvania, 19104; Donna Sylvester, RN, phone: (215) 590-3284. The recruiting inquiries in Texas is Texas Children's Hospital, Houston, Texas, 77030; Susan Blaney, MD, phone: (832) 822-4215, e-mail: sblaney@bcm.tmc.edu, or Lisa R Bomgaars, MD, phone: (832) 824-4688, e-mail: lbomgaars@bcm.tmc.edu.

A third study ongoing in 2004 is sponsored by the drug maker NeurogesX and titled "Controlled Study of NGX-4010 for the Treatment of Postherpetic Neuralgia." NGX-4010 consists of a capsaicin dermal (skin) patch. Capsaicin is the active substance in chili peppers, and is used, paradoxically, both as an irritant and for pain relief. The purpose of this clinical trial is to evaluate the efficacy of a capsaicin patch for relief of postherpetic neuralgia. Contact information varies by state but can viewed at the National Institutes of Health Web site at <http://www.clinicaltrials.gov/ct/show/NCT00068081?order=3>.

Prognosis

Generally, the prognosis for persons with shingles is good. Shingles is almost never a life-threatening disease in otherwise healthy patients, and usually resolves without treatment in a few weeks. However, postherpetic neuralgia, which occurs more often in elderly patients, can be disabling and difficult to treat.

Persons who have an impaired immune system, such as those deficient in cytotoxic T lymphocytes, persons undergoing immune suppression (e.g., for organ transplant), and persons who have AIDS or leukemia may suffer more serious effects from shingles, as the reactivated virus sometimes disseminates from the dorsal root ganglia to other parts of the body. In these cases, complications can resemble those for primary infection of adults with VZV, namely, viral pneumonia, male sterility, acute liver failure, and (in pregnant women) birth defects.

Resources

BOOKS

Glaser, Ronald, and James F. Jones, (eds). Herpes Virus Infections. New York: Marcel Dekker, Inc., 1994.

Strauss, James H., and Ellen G. Strauss. Viruses and Human Disease. New York: Academic Press, Elsevier Science, 2002.

PERIODICALS

Ho, Charles C., "Use of Combination Therapy for Pin Relief in Acute and Chronic Herpes Zoster." Geriatrics (Dec. 1, 2001).

Johns Hopkins Medical Institutions. "Opioid Medications a Good Bet for Shingles-Related Pain." Ascribe Higher Education News Service (Oct. 7, 2002).

Madison, Linda K. "Shingles Update: Common Questions in Caring for a Patient with Shingles." Orthopaedic Nursing (Jan. 1, 2000).

"New Therapies Reduce Morbidity from Herpes Zoster." Ophthalmology Times (Jan. 1, 1999).

Sheff, Barbara, "Microbe of the Month: Varicella-Zoster Virus." Nursing (Nov. 1, 2000).

Smith, Angela D. "Lysine for Herpes Simplex Infections." Medical Update (Nov. 1, 2001).

OTHER

"NINDS Shingles Information Page." National Institute of Neurological Disorders and Stroke. April 28, 2004 (May 27, 2004). <http://www.ninds.nih.gov/health_and_medical/disorders/shingles_doc.htm>.

Larry Gilman, PhD

Herpes zoster

Description

Herpes zoster, also called shingles, and referred to as "zosteer", gets its name from both the Latin and French words for belt or girdle and refers to belt-like skin eruptions that may occur on the trunk of the body. The virus that causes chickenpox, the varicella zoster virus (VSV), can become dormant in nerve cells after an episode of chickenpox and later re-emerge as shingles. Any individual who has had chickenpox can develop shingles. People of all ages, even children, can be affected, but the incidence increases with age. There are many other conditions which can predispose to developing shingles. These include: newborn infants, bone marrow and other transplant recipients, and individuals with immune systems weakened by diseases like HIV or cancer, or drugs, such as those used in chemotherapy .

Shingles erupts along the course of the affected nerve, producing lesions anywhere on the body and may cause severe nerve pain. The most common areas to be affected are the face and trunk, which correspond to the areas where the chickenpox rash is most concentrated. The disease is caused by a reactivation of the chickenpox virus that has been dormant in certain nerves following an episode of chickenpox. Exactly how or why this reactivation occurs is not clear; however, it is believed that the reactivation is triggered when the immune system becomes weakened as in the examples described above. Early signs of shingles are often vague and can easily be mistaken for other illnesses. The condition may begin with fever and malaise (a vague feeling of weakness or discomfort). Within two to four days, severe pain, itching , and numbness/tingling (paresthesia) or extreme sensitivity to touch (hyperesthesia) can develop, usually on the trunk and occasionally on the arms and legs. Pain may be continuous or intermittent, usually lasting from one to four weeks. It may occur at the time of the eruption, but can precede the eruption by days, occasionally making the diagnosis difficult. Signs and symptoms may include the following:

• itching, tingling, or severe burning pain
• red patches that develop into blisters
• grouped, dense, deep, small blisters that ooze and crust
• swollen lymph nodes

Immunocompromised patients usually have a more severe course that is frequently prolonged for weeks to months. They develop shingles frequently and the infection can spread to the skin, lungs, liver, gastrointestinal tract, brain, or other vital organs.

Potentially serious complications can result from herpes zoster. Many individuals continue to experience persistent pain long after the blisters heal. This pain, called post-herpatic neuralgia, can be severe and debilitating. Post-herpetic neuralgia can persist for months or years after the lesions have disappeared.

Other complications include a secondary bacterial infection, and rarely, potentially fatal inflammation of the brain (encephalitis) and the spread of an infection throughout the body. These rare, but extremely serious, complications are more likely to occur in those individuals who have weakened immune systems (immunocompromised).

Causes

Herpes zoster has been reported in patients with many different types of cancer. However, the cancers that affect an individual's immune system, such as leukemia or lymphoma , are the types that place people at particular risk. Herpes zoster is also a particular problem after the various forms of cancer therapy. A study performed in 1998 looked at 766 episodes of herpes zoster infection at a large cancer center from 1972 to 1980. The highest risk of infection was present among patients with lymphoma and leukemia. In those who received radiation treatment and then developed herpes zoster, half of them developed this within seven months. They developed zoster on the area of their body where the radiation was given. This study showed that a period of months can pass before developing zoster as a consequence of radiation. In those who developed zoster after being treated with chemotherapy, half of them developed zoster within a month.

A study in 1999 looked at 215 consecutive patients who had received high-dose chemotherapy and autologous stem cell rescue to help determine what the incidence and severity of herpes zoster infection was. Herpes zoster was developed in 40 people. Over 80% of these infections occurred within six months of receiving the autologous stem cell rescue. Similar rates of herpes zoster have been seen in patients who received bone marrow transplants. A 1996 study looked at 107 children who had received bone marrow transplants for various malignancies. Thirty-three percent of these children developed herpes zoster. Approximately 90% of the cases developed within one year from the time of bone marrow transplant.

Treatments

Shingles almost always resolves spontaneously and may not require any treatment except for the relief of symptoms. In most people, the condition clears on its own in one or two weeks and seldom recurs. The antiviral drugs acyclovir, valacyclovir, and famciclovir can be used to treat shingles. These drugs may shorten the course of the illness. Their use results in more rapid healing of the blisters when drug therapy is started within 72 hours of the onset of the rash. In fact, the earlier the drugs are administered, the better, because early cases can sometimes be stopped. If taken later, these drugs are less effective but may still lessen the pain. Antiviral drug treatment does not seem to reduce the incidence of post-herpetic neuralgia, but recent studies suggest famciclovir may cut the duration of post-herpetic neuralgia in half. Side effects of typical oral doses of these antiviral drugs are minor with headache and nausea reported by 8-20% of patients. Severely immunocompromised individuals, such as those with cancer, may require intravenous administration of antiviral drugs. Preventive administration of acyclovir to seropositive patients (people who have evidence in their blood of past infection with varicella) who undergo leukemia induction or bone marrow transplant not only effectively prevents herpes zoster recurrence but also reduces the severity of chemotherapy-induced mucositis . Therefore, acyclovir prophylaxis should be considered in seropositive patients, especially if they have had a recurrence during previous chemotherapy cycles.

Alternative and complementary therapies

Cool, wet compresses may help reduce pain. If there are blisters or crusting, applying compresses made with diluted vinegar will make the patient more comfortable. The patient can mix one-quarter cup of white vinegar in two quarts of lukewarm water, and use the compress twice each day for 10 minutes. The patient should stop using the compresses when the blisters have dried up.

Soothing baths and lotions such as colloidal oatmeal baths, starch baths or lotions, and calamine lotion may help to relieve itching and discomfort. The skin should be kept clean, and contaminated items should not be re-used. While the lesions continue to ooze, the person should be isolated to prevent infecting other susceptible individuals.

Later, when the crusts and scabs are separating, the skin may become dry, tight, and cracked. If that happens, the patient can rub on a small amount of plain petroleum jelly three or four times a day.

There are non-medical methods of prevention and treatment that may speed recovery. For example, getting lots of rest, eating a healthy diet, exercising regularly, and minimizing stress are always helpful in preventing disease. Supplementation with vitamin B₁₂ during the first one to two days and continued supplementation with vitamin B complex, high levels of vitamin C with bioflavonoids, and calcium, are recommended to boost the immune system. Herbal antivirals such as echinacea can be effective in fighting infection and boosting the immune system. Patients should consult physician before taking supplements.

Although no single alternative approach, technique, or remedy has yet been proven to reduce the pain, there are a few options which may be helpful. For example, topical applications of lemon balm (Melissa officinalis ) or licorice (Glycyrrhiza glabra ) and peppermint (Mentha piperita ) may reduce pain and blistering. Homeopathic remedies include Rhus toxicodendron for blisters, Mezereum and Arsenicum album for pain, and Ranunculus for itching. Practitioners of Eastern medicine recommend self-hypnosis, acupressure, and acupuncture to alleviate pain. All of these or similar alternative therapies should be discussed with the treating physician before using.

See Also Antiviral therapy

Resources

BOOKS

Berger, Joseph. Cecil Textbook of Medicine, 21st Ed. Philadelphia: W.B. Saunders Company, 2000.

Lockie, Andrew. The Family Guide to Homeopathy: Symptoms and Natural Solutions. Prentice Hall Press, 1989.

Thomsen, Thomas Carl. Shingles. Cross River Press, 1990.

PERIODICALS

Balfour, Henry H. "Varicella Zoster Virus Infections in Immunocompromised Hosts." American Journal of Medicine 85 (29 August 1988): 68-72.

Bilgrami, S. et al. "Varicella zoster virus infection associated with high-dose chemotherapy and autologous stem-cell rescue." Bone Marrow Transplant 23 (March 1999): 469-74.

Kawasaki, H. et al. "Herpes zoster infection after bone marrow transplantation in children." Journal of Pediatrics 128 (March 1996):353-58.

Rusthoven, J. J. et al. "Varicella-zoster infection in adult cancer patients. A population study." Archives of Internal Medicine 148 (July 1988):1561-1566.

Perren, Timothy J., et al. "Prevention of Herpes Zoster in Patients by Long-Term Oral Acyclovir After Allogeneic Bone Marrow Transplantation." American Journal of Medicine 85 (29 August 1988): 99-101.

Wood, Martin J., et al. "Efficacy of Oral Acyclovir Treatment of Acute Herpes Zoster." American Journal of Medicine 85 (August 29, 1988): 79-83.

ORGANIZATION

American Academy of Dermatology. 930 N. Meacham Road, PO Box 4014, Schaumberg, IL 60168-4014. (708) 330-0230. http://www.aad.org. 29 June 2001.

David Greenberg, M.D.

KEY TERMS

Acyclovir

—An antiviral drug that is available under the trade name Zovirax, in oral, intravenous, and topical forms. The drug blocks the replication of the varicella zoster virus.

Antibody

—A specific protein produced by the immune system in response to a specific foreign protein or particle called an antigen.

Famciclovir

—An oral antiviral drug that is available under the trade name Famvir. The drug blocks the replication of the varicella zoster virus.

Immunocompromised

—A state in which the immune system is suppressed or not functioning properly.

Post-herpetic neuralgia

—The term used to describe the pain after the rash associated with herpes zoster is gone.

Valacyclovir

—An oral antiviral drug that is available under the trade name Valtrex. The drug blocks the replication of the varicella zoster virus.

herpes zoster infection of a ganglion (nerve center) with severe pain and a blisterlike eruption in the area of the nerve distribution, a condition called shingles. The causative organism is varicella zoster, a common, filtrable virus that is also known to cause chicken pox. Herpes zoster usually affects persons past middle life. It most often involves the area of the upper abdomen and lower chest, but may appear along other nerve pathways including that leading to the eye; serious ocular complications can lead to blindness. The disease can be treated with antivirals, and aspirin and other analgesics are used to relieve pain. Although it is generally nonrecurrent, it can permanently damage nerves and lead to postherpetic neuralgia, whose often severe, persistent pain is more difficult to control.

Shingles

What Is Shingles?

What Are the Symptoms of Shingles?

What Is the Treatment for Shingles?

Who Is at Risk for Shingles?

What Other Diseases Can Herpes Zoster Cause?

Resources

Shingles is caused by a viral infection of the sensory nerves of the skin and causes a painful rash on the skin. The medical name for shingles is “herpes zoster.” The virus that causes herpes zoster is the same virus that causes chickenpox (varicella).

KEYWORDS

for searching the Internet and other reference sources

Dermatology

Infectious diseases

Viruses

Zoster

What Is Shingles?

A person cannot develop shingles unless he or she has had chickenpox. Shingles is caused by the same virus that causes chickenpox, the herpes zoster virus. Whereas chickenpox is a highly contagious disease, shingles usually is not transmitted from one person to another. However, a person can develop chickenpox from coming in direct contact with the blisters on a person with shingles. After recovering from chickenpox, the herpes zoster virus may remain in part of the nervous system for years without causing any illness. Shingles may be brought on as a side effect of another disease, such as Hodgkin’s disease (a cancer of the lymph system), or from treatments that suppress the immune system*. However, most of the time, there is no known cause for the virus to become active and cause shingles.

* immune system

fights germs and other foreign substances that enter the body.

What Are the Symptoms of Shingles?

The affected skin area first feels sensitive, and then becomes painful. Before blisters from shingles develop, a person may have chills and fever, feel tired, and have an upset stomach. These symptoms may last for 3 or 4 days. By the fourth or fifth day, a rash made up of small red spots appears. The small red spots turn into blisters that are filled with the herpes zoster virus. After another few days, the blisters become yellow and dry out. Crusts develop over the dried-out blisters. When they drop off after several weeks, they sometimes leave small scars.

Usually, the rash and blisters involve a limited area of skin, most often on one side of the chest, abdomen, or face.

What Is the Treatment for Shingles?

Treatment for shingles is directed mainly at reducing the pain involved. Medications are also used to attack the viruses. Wet compresses applied to the affected areas can sometimes soothe the pain. Mild pain relievers such as acetaminophen can be used.

Who Is at Risk for Shingles?

Shingles occur mostly in older people whose immune systems are no longer able to keep the virus in the nervous system inactive. This age group develops shingles more often, although shingles can develop at any age. After an attack of shingles, a person may be immune for the rest of his or her life.

Most people recover from the disease without any problems. However, in older patients, the pain may last for months or years after the blisters have healed. This is called postherpetic neuralgia (post-her-PET-ik noo-RAL-je-ah).

What Other Diseases Can Herpes Zoster Cause?

The herpes zoster virus can cause several other diseases:

• Chickenpox is usually a mild disease that causes a rash and fever. It is very contagious.
• Herpes zoster oticus, also called Ramsay Hunt syndrome and viral neuronitis, causes ear pain, hearing loss, vertigo (a spinning sensation), and may paralyze a part of the face.
• Ophthalmic herpes zoster involves the eyelid and sometimes the eye itself. It can be serious if the eye is involved.

See also

Resources

Oldstone, Michael. Viruses, Plagues, and History. New York: Oxford University Press, 1998.

Schwarz, Richard H. “When You Get a Childhood Illness.” American Baby, February 1999, p. 22.

The U.S. Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, N.E., Atlanta, GA 30333. The United States government authority for information about infectious and other diseases, the CDC posts information about shingles at its website.

http://cdc.gov/ncidod/srp/varicella.htm

shin·gles / ˈshinggəlz/ • pl. n. [treated as sing.] Med. an acute, painful inflammation of the nerve ganglia, with a skin eruption often forming a girdle around the middle of the body. It is caused by the same virus as chicken pox. Also called herpes zoster.

herpes Infectious disease caused by one of the herpes viruses. Herpes simplex 1 infects the skin and causes cold sores. Herpes zoster attacks nerve ganglia, causing shingles. The same virus is responsible for chickenpox.

shingles (herpes zoster) Acute viral infection of sensory nerves. Groups of small blisters appear along the course of the affected nerves, and the condition can be very painful.

her·pes zos·ter / ˈzästər/ • n. medical name for shingles. ∎  a herpesvirus that causes shingles and chicken pox.

shingles eruptive disease often extending round the middle of the body. XIV. Late ME. schingles, cingules, sengles — medL. use of L. cingulus, var. of cingulum girdle.

shingles (shing-ŭlz) n. see herpes (zoster).

shingles see herpes zoster .