Shingles

Definition

Also known as herpes zoster, or zoster, shingles appears as a generally painful and blistered skin rash. It is caused by a reactivation of the varicella zoster virus (VSV) that is also the origin of chicken pox. The name of the condition, shingles is derived from the Latin word, cingulum, which means “belt” or “girdle”

and was adopted due to the way in which the rash seems to spread. The name of the virus, varicella-zoster puts the Latin term meaning “little pox” together with the Greek word for “girdle”—and thus, also, comes the derivation for the scientific name for the disease, herpes zoster. In Italy, the condition is also known as St. Anthony's Fire.

Description

Any person who has had chicken pox is subject to developing shingles. Individuals who have not had chicken pox can contract that disease by being exposed to someone with shingles. Shingles is not contagious among those who have already had chicken pox because every person who has had chicken pox already has the potential for shingles.

When the VSV is reactivated in a person with a history of chicken pox, this virus then moves through the body by way of the nerve fibers. It typically settles in one area, localized on one side of the body or another. Initially individuals experience a burning sensation and sometimes more severe pain . Within two to three days the virus reaches the skin, and a rash appears, usually with small blisters that resemble those that come during the early stages of chicken pox. The rash continues to worsen for another three to five days, at which time the blisters open. The open sores usually begin to dry out and form a crust. Another two or three weeks pass before the crust falls off. At that point the skin finally begins to heal. Once the blisters dry out, the contagious stage of the disease is ended.

The trunk is often affected with the belt-like rash that extends from the spine around one side of the chest to the breastbone.

Lesions might appear on the scalp, the neck, or on the face in those areas along the nerve (trigeminal) that is like a three-pronged branch, affecting either the forehead, middle, or lower part of the face. That part of the branch specifically involved is the location where the lesions appear. Shingles also can affect the eyes or mouth if those nerves are affected.

Herpes Zoster Ophthalmicus

If the virus does involve the eye, more serious problems can result such as the scratching of the cornea, increasing the risk of bacterial infection, or inflammation inside the eye. In severe cases, the virus might also affect the optic nerve or retina. When shingles originate in the upper ophthalmic branch of the trigeminal nerve, often a small patch of the rash will appear on the tip of the nose. Medical professionals call this Hutchinson's sign; it is an indication of herpes zoster ophthalmicus, or HZO. The eye is vulnerable to serious damage in this case, which can result in loss of vision if not treated early.

One important point to note is that this herpes virus is different from the virus that causes genital herpes, which is a sexually transmitted disease.

Demographics

Shingles is most likely to occur in people over the age of 60 who have had chicken pox; those in that age group account for more than 50 percent of the cases. In the U.S. population of those over 85, chances of getting shingles is one out of two, according to statistics determined by the National Institutes of Health, with 50 percent of all Americans suffering shingles by the time they are 80. Of those over 80, for instance, 10.9 people out of every 1,000 people are likely to get shingles as opposed to 4.6 out of every 1,000 people of those between ages 50 to 59. For those younger, the incidence rate plunges even lower.

Though the cause of the reactivation of the virus has not been clearly determined, it also occurs more frequently in people with weakened immune systems, such as the older adult population and those with autoimmune disorders such as HIV/AIDS and diabetes. Also, people who are undergoing special medical treatments might be candidates for the illness: those receiving steroid therapy, radiation, or chemotherapy ; and those who have a history of bone or lymphatic cancer .

As of 2008, there were an estimated one million cases of shingles in the United States each year. Although second and third instances have been documented, it is rare for a person to contract shingles more than once in a lifetime.

Causes and symptoms

Shingles is caused by the same virus that causes chicken pox, herpes zoster. Once individuals contract chicken pox, most often in childhood, the virus stays latent in certain nerves. When the virus reactivates, more often in older adults than in those under the age of 60, shingles occurs. Though it remains scientifically undetermined as of 2008 exactly what brings on the illness, weakened immune systems appear to be a leading predictor. The disease can begin at any time, but the older the individuals who have it, the longer it lasts.

The onset of shingles can go unheeded because the symptoms resemble those of other conditions such as allergies : itching , tingling, burning, and even more severe pain. The early stages of the illness might also include fever, a weakened appetite, and fatigue. Within a few days of the onset of these symptoms, a rash of fluid-filled blisters breaks out on the body, usually on one side of the body or face.

The pain of the condition is caused by the inflammation of the nerves. The pain may be mild to severe. In extreme cases, the skin feels like it is burning and excruciating pain comes from the lightest touch or even from air flow in fanning the area. When the pain lingers, often for months after the rash itself is healed, it is referred to as post herpetic neuralgia or PHN. This pain is both severe and chronic in some individuals. The natural course of the disease is from three to five weeks with no residual scarring.

Diagnosis

Once the outbreak of the blistered rash occurs in individuals who have had chicken pox and thus have the virus, doctors can diagnose shingles easily. The only circumstance that would slow diagnosis is in the case of individuals who are uncertain about their medical history. As the condition persists, however, in these cases, doctors would recognize the disease. Skin scrapings from the sores can also confirm the condition. In addition, in those individuals who pain without rash, the diagnosis is determined by a blood test.

Treatment

Antiviral medication is used to weaken the virus and also reduce the extent of the nerve damage. In cases that are determined early, individuals are prescribed antiviral pills and painkillers such as nonsteroidal anti-inflammatory drugs commonly known as NSAIDs. Other painkillers include acetaminophen compounds, narcotics, and steroids. If PHN continues, an anti-seizure drug known as gabapentin, pain patches, and tricyclic antidepressants can be given to combat pain.

Medical professionals recommend that individuals with shingles keep fingernails cut short in order to prevent secondary bacterial infections that might arise due to scratching the infected blisters. Short fingernails are easier to keep clean and bacteria-free, and they reduce scratching.

Bacterial infections are a serious concern in the onset of shingles, in connection to the eyes and in the threat of pneumonia . If the rash of the shingles spreads to the upper or lower eyelids, it can cause redness of the mucous membrane covering the white of the eye known as the conjunctiva. If it brings about scratches to the cornea, the risk of bacterial infection increases. In these instances, an antibiotic drug may be prescribed.

Nutrition/Dietetic concerns

Individuals suffering from shingles should avoid all foods to which they have an allergic response or which cause itching. A balanced diet with an adequate amount of fruits and vegetables is always desirable in helping to maintain a strong immune system . Since people with weakened immune systems seem more susceptible to the virus, these individuals need to bolster themselves; a balanced diet, moderate exercise , and relaxation to relieve stress aid individuals while they cope with the illness. No specific foods have been proven to help cure the disease.

Therapy

In addition to drug therapy to calm the effects of the condition, stress management techniques such as exercise and meditation might be recommended therapy while the person is healing from the disease and during the PHN that can linger for months following the outbreak and healing of the rash.

Prognosis

With proper medical treatment, though symptoms can last for several months before a person is free from pain, shingles is treatable; though the virus continues to inhabit the system, seldom does an outbreak occur twice. It is crucial to see a physician or medical professional as soon as symptoms occur in order to support an optimum outcome. Recurrence of outbreaks is more likely in the population over 85, as well as longer duration of the illness.

Prevention

In May 2006, the Federal Drug Administration (FDA) approved the vaccine, Zostavax, which was determined to help reduce the risk of getting shingles. It is recommended for any individual 60 years and older who have had chicken pox and is the only licensed vaccine in the United States the reduces the risk of reactivation of the varicella zoster virus. In those individuals over the age of 70, the FDA also determined, who received the vaccine yet still developed shingles, the use of Zostavax reduced the frequency of PHN but does not work to treat PHN. Zostavax is given by injection under the skin, preferably in the upper arm, in a single dose. As of 2008, its safety or effectiveness in people under the age of 60 had yet to be determined. The price of the vaccine is several hundred dollars; however, Medicare may cover it under the Part D prescription program.

Studies reported by the FDA in November of 2006 included approximately 38,000 people throughout the Unites States, aged 60 and older. Half of the participants received the vaccine, and half received the placebo. The participants were followed for about three years to determine if they developed shingles, and how long their pain lasted if they did. The studies concluded that the vaccine reduced the occurrence of shingles (in those 60 and older) by approximately 50 percent. The vaccine was most effective (64 percent) in people between the ages of 60 and 69; it declined to 41 percent for the 70 to 79 age group, and to 18 percent for those 80 and older. With regard to the severity and duration of the pain, the pain lasted an average of 20 days for those who received the vaccine and 22 days for those who received the placebo. Nothing indicated that the severity of the pain differed between the two.

As of publication of the study in 2006, adverse effects were still being determined in the administration of the vaccine. In the largest study conducted, however, adverse events were similar between the two groups: Those who received the vaccine and those who received the placebo were both listed at 1.4 percent. Another study within that study was conducted to examine safety aspects more closely. This smaller study showed that serious adverse effects occurred in 1.9 percent of those receiving the vaccine in contrast to 1.3 percent in those receiving the placebo. The number of deaths in each group was similar. This data did not establish, however, that these occurrences are connected to the vaccine. The manufacturer of the vaccine was set to continue a post-market study in order to ensure safety and provide further information. The reported side effects were redness, pain and tenderness, swelling at the site of the injection of the vaccine, and headache. No similar side effects occurred in those who had taken the placebo.

Zostavax should not be taken by individuals who are allergic to neomycin, or any component of that vaccine. Because it is a live vaccine, it should not be taken by people who already have a weakened immune system due to HIV/AIDS; cancer of the lymph, bone, or blood; are taking corticosteroids; or are undergoing radiation treatments. It is also not approved for pregnant women or women who might be pregnant and has not been proven safe for children. It is not a substitute for Varivax, the vaccine used to prevent chicken pox.

With the increased use of the chicken pox vaccine, available since 1995, the incidence of chicken pox has dropped about 70 to 90 percent among those vaccinated, with 95 percent having only mild symptoms. With the effectiveness of the chicken pox vaccine and fewer people developing chicken pox, fewer people will contract shingles in the future.

QUESTIONS TO ASK YOUR DOCTOR

• How will the illness and treatment affect my lifestyle?
• Given my other health concerns or conditions, are there any contraindications with other medicines I am taking or treatments I am receiving?
• Will the blisters scar me?
• Should I stay away from my children or grandchildren during the outbreak of shingles?

Alternative treatment

In April 2007, the National Center for Complementary and Alternative Medicine (NCCAM), a division o the NIH, reported another preventative measures in an article in the Journal of the American Geriatrics Society.. In a study conducted by Michael Irwin at the University of California, Los Angeles (UCLA), 112 healthy adults ages 59 to 86 took part in a 16-week program of either tai chi , a traditional form of Chinese exercise that combines aerobic activity, relaxation, and meditation, or health education with 120 minutes of instruction weekly. Both groups of people had received a single dose of the chicken pox vaccine, Varivax, and blood tests were done to determine immunity at the completion compared with the beginning levels at the beginning of the study. Tai chi alone was found to increase the participants' immunity to the varicella virus, and the use of the vaccine with the exercise created a significantly higher level of immunity: about 40 percent, double the immunity of the health education group.

Attention to diet and exercise is known to help strengthen the immune system. Those precautions, along with the vaccine, seem to be a significant help in lowering the likelihood of developing shingles.

Caregiver concerns

When caring for older persons with shingles, caregivers need be cautious on various levels, both physical and emotional. Caregivers must maintain contact with a physician or healthcare professional, alerting them to any complications that may arise. Proper bathing, even when the sores are still in their early stages, can be crucial to eliminating or reducing the potential for bacterial infections. Maintaining a hygienic environment is also vital. Creating a calm and stress-free environment can also help reduce the patients' stress in coping with the illness.

KEY TERMS

Herpes zoster —The virus that causes shingles.

Herpes Zoster Ophthalmicus (HZO) —The condition indicating that shingles has affected a person's eyes.

Post-herpetic neuralgia (PHN) —The pain that continues or recurs after the shingles rash has healed. PHN is generally defined as pain that lingers more than five weeks past the appearance of the first rash.

Trigeminal nerve —The cranial (head) nerve with three branches, which serves one side of the face.

Varicella —The virus that causes chicken pox and remains in a person's system, eventually causing shingles to occur.

Resources

PERIODICALS

“AAFP to Support Immunizing Elderly Against Shingles: Payment under Medicare Remains Murky.” Family Practice News (November 15, 2006): 1.

“Augmenting Immune Responses to Varicella Zoster Virus in Older Adults: A Randomized, Controlled Trial of Tai Chi.” Journal of the American Geriatrics Society (April 2007).

“Chicken Pox Vaccine Cuts Deaths but Raises Questions on Shingles.” New York Times (February 3, 2005).

“Shingles' Fiscal and Physical Burden Is Steep.” Skin & Allergy News (October 2006): 37.

“Shingles: More Tools Now; Elderly Patients Are at Greatest Risk for Debilitating Post-herpetic Neuralgia, but Antiviral Therapies Ease the Pain and Shorten Its Duration, and a New Vaccine Offers Hope of Prevention.” Cortlandt Forum (November 2006): 40.

“Visual Clues to the Diagnosis of Infectious Disease: Skin Disorders in Elderly Persons: Identifying Viral Infections.” Infections in Medicine (November 1, 2007): 479.

other

Elliott, Victoria Stagg. “Immunization Panel Endorses Shingles Vaccine.” Amednews.com November 13, 2006 [cited April 9, 2008]. http://www.ama-assn.org/amednews/2006/11/13/hlsc1113.htm

“Herpes Zoster.” American Academy of Dermatology [cited April 9, 2008]. http://www.aad.org/public

“Herpes Zoster (Shingles) Eye Infections.” Steen-Hall Eye Institute [cited April 9, 2008]. http://www.steen-hall.com/zoster.html

“International Survey Reveals Need for Greater Understanding of Shingles.” Medical News Today June 4, 2005 [cited April 9, 2008]. http://www.medicalnewstoday.com/articles/25590.php

“Zostavax.” U.S. Food and Drug Administration May 26, 2006 [cited April 9, 2008]. http://www.fda.govcdc.gov/products/zosmer052506qa.htm

organizations

American Academy of Dermatology, 1350 I Street NW, #870, Washington, DC, 20005-4355, (202) 842-3555, (202) 843-4355, http://www.aad.org.

American Chronic Pain Association, PO Box 850, Rocklin, CA, 95677-0850, (800) 533-3231, (916) 632-0922, (916) 632-3208, http://www.theacpa.org.

American Diabetes Association, 1701 Beauregard Street, Alexandria, VA, 22311, (800) 342-2383, http://www.ada.org.

Mayo Clinic, 200 First Street NW, Rochester, MN, 55905, (507) 284-2511, http://www.mayoclinic.com.

National Institute on Aging, National Institutes of Health, Building 31, Room 5C27, 31 Center Drive, Bethesda, MD, 20892, http://www.nia.nih.org.

VZV Research Foundation (For Research on Varicella Zoster), 21 East Sixty-fourth Street, 5th floor, New York, NY, 10021, (212) 371-7280, (212) 838-0380, [email protected], http://www.vzvfoundation.org.

Jane Elizabeth Spear