Shingles (Herpes Zoster)

What is shingles?

Shingles or herpes zoster is a localized painful rash caused by a reactivation of the chickenpox (Varicella-zoster) virus in your body ^[6].

Symptoms and Signs

Early symptoms

For 1-10 days before the rash outbreak, you may experience ^[4,6]:

Malaise, headache, fatigue or, rarely, fever
Severe burning pain, tingling, numbness or itch in one body region
Swollen lymph nodes in the neck, armpit or groin on the same side

The rash stage

Few days after onset of pain, a red rash develops in a band-like pattern on one side of the body, most commonly on the trunk, neck or around the eye, but sometimes on the scalp, in the ears, nose or mouth, on the palms, buttocks or genitals (Pictures 1,2) ^[2,6].

Picture 1. Shingles with a band-like pattern
limited to one side of the body
(source: SF da Silva, MD, Dermatology Atlas)

Picture 2. Shingles on one side of
the forehead and nose
(source: SF da Silva, MD, Dermatology Atlas)

The rash develops in the following phases ^[4,5]:

Red patches, spots or bumps (erythema, macules or papules)
Blisters with clear fluid (vesicles)
Blisters with cloudy fluid (pustules)
Ulcers
Crusts

The crusts fall off spontaneously within 2-4 weeks ^[4]. The pain can disappear along with the rash or can persist for several weeks or months ^[4].

Atypical shingles

Mainly in children, shingles can appear with rash and no pain, or pain and no rash ^[2,7].

In individuals with poor immunity, shingles can appear on both sides of the body (bilateral shingles), involve large areas of the skin and internal organs (disseminated shingles) or recur several times (recurrent shingles) ^[4,7].

How does shingles develop?

When you have chickenpox, some viruses can enter the nerves in the skin and remain dormant (silent) in the nerve roots near the spinal cord. Years or decades later, a triggering event, such as stress or disease, can reactivate the viruses, which results in shingles ^[6].

Who can get shingles?

Anyone who has had chickenpox (even if passed unnoticed) or received varicella vaccine can get shingles ^[9].

About 30% of adults, especially those after the age of 50, get shingles once in their lifetime ^[8].
Children and young adults rarely get shingles ^[6].

You cannot get shingles if you previously have not had chickenpox or received varicella vaccine ^[9].

Can shingles spread to other parts of the body by touch?

Probably not.

Can you get shingles more than once?

Up to about 6% of people can get shingles twice or more times ^[2,21].

Risk Factors

Risk factors for shingles include ^[5,19,20,35]:

Old age
Genetic predisposition
Having chickenpox before 18 months of age
Poor immunity (in HIV/AIDS, blood cancer, such as lymphoma or leukemia, long-term treatment with steroids, chemotherapy or immunosuppressant therapy after organ transplantation
Diabetes mellitus type 1
Chronic lung or kidney disease
An autoimmune disease (rheumatoid arthritis, systemic lupus erythematosus or inflammatory bowel disease: Chron’s disease or ulcerative colitis)

Triggers of shingles include ^[2,34,35]:

Psychological stress, lack of sleep, depression or sexual abuse
Physical trauma, an infection, herniated disc in the spine or spinal surgery

Is shingles contagious and how is it transmitted?

Shingles is contagious but cannot be transmitted directly from one person to another. You can contract the virus from someone who has shingles in the blistering phase, but only if you have never had chickenpox or received varicella vaccine ^[1]. After contracting the virus, you can develop chickenpox, not shingles ^[7]. Once you have chickenpox, you can develop shingles later in life, though.

The transmission of the virus is by a direct skin-to-skin contact or by sharing towels or gym equipment, for example ^[29].

The Herpes zoster virus probably does not spread by air (coughing, sneezing), so it is not likely you will contract it by just being in the same room with a person with shingles ^[12]. An airborne transmission may occur between a person with widespread shingles and a person with impaired immunity, though ^[10].

A pregnant woman who gets chickenpox 21-5 days before giving birth can pass the virus to the unborn baby who can then, in infancy or early childhood, develop shingles ^[6,13]. On the other hand, a pregnant woman with shingles will unlikely pass the virus to the unborn baby ^[33].

Shingles is not related to seasons and does not occur in epidemics ^[22].

Diagnosis

A doctor can usually recognize shingles from your medical history and a physical examination. Various tests can be used in unclear cases.

Blood tests:

Varicella-zoster-specific IgM antibodies

Tests of the fluid from blisters (in decreasing order of sensitivity) ^[5,6]:

Polymerase chain reaction (PCR) testing
Direct fluorescent antibody (DFA) testing
Tzanck smear

Chart 1. Conditions Similar to Shingles
Pain AND rash	Pain WITHOUT rash
Insect bites, scabies Herpes simplex infection (cold sores, genital herpes) Acne Ingrown hair Staphylococcal folliculitis Fungal infections (ringworm, candidiasis) Eczema (allergic dermatitis) Hives (urticaria) Cellulitis Lyme disease	Acute cholecystitis Kidney stones Pleurisy Herniated disc Coronary heart disease Trigeminal neuralgia

Chart 1 references: 11

Treatment

Home remedies, lotions and creams

The rash in the blistering phase should be covered by a wet non-occlusive dressing with aluminum acetate (Burow’s solution) for 30-60 minutes few times a day to reduce itch and the spread of the infection ^[14,25]. Dressing with petroleum jelly may better protect the rash against bacterial infections ^[2].

Applying an ice pack or cold, wet cloth for 10-15 minutes several times a day or having a cool bath or colloidal oatmeal bath may temporarily reduce the pain and itch ^[27].

There is INSUFFICIENT EVIDENCE about the effectiveness of lotions containing calamine ^[14] or menthol, antiseptic lotions ^[25], or creams containing capsaicin ^[36] or aspirin ^[20] in the reduction of pain and itch in shingles.

Do not apply any home-made paste (cornstarch, baking soda) on the rash, because it may increase the risk of an infection.

Antivirals

The antiviral drugs for shingles approved in the United States include acyclovir, valacyclovir and famciclovir. They are intended to treat moderate to severe pain and rash ^[26]. The individuals with normal immunity are usually treated by oral antivirals for 7 days and those with impaired immunity by oral or intravenous antivirals for up to 21 days.

The antiviral brivudin is approved in certain European countries ^[18].

Antivirals should always be used in older individuals and those with impaired immunity and when the ophthalmic nerve (around the eye) or large skin areas are affected ^[4].

The EFFECTS of antivirals:

They decrease the severity and duration of symptoms ^[4].
They are most effective when started within 72 hours of the rash onset; they can still help when started later but before the full crusting of all lesions ^[4,5,14,20].
They only slightly decrease the risk of postherpetic neuralgia ^[16].
Valacyclovir and famciclovir may be more effective than acyclovir ^[5,14,28,37].
Topical antivirals (in creams) are not effective ^[5,26].
Pregnant women should not take antivirals.

Analgesics

For mild pain ^[5,20,25]:

Acetaminophen (paracetamol)
Ibuprofen (can increase the risk of bacterial skin infections) ^[3]
Aspirin (not for children and young adults, because it may trigger a severe liver and kidney damage – Reye’s, syndrome) ^[23]
Tramadol
Codeine

For moderate or severe acute pain, narcotics oxycodone or morphine can be used ^[5,20,26]. It is not clear if anticonvulsants gabapentin and pregabalin reduce acute pain, but they can reduce chronic pain ^[5,20,38].

Reducing pain by analgesics during the rash stage of shingles may decrease the risk of postherpetic neuralgia ^[4,5].

Antibiotics

Oral antibiotics are intended to treat secondary bacterial infection, which can develop in severe shingles ^[2]. Topical antibiotics should not be used ^[25].

Antihistamines

Antihistamines by mouth or as an ointment can help reduce severe itch ^[44].

Diet and supplements

There is no known diet to prevent or treat shingles ^[14].

While there is some weak evidence about the effectiveness of lysine supplements or foods with a high lysine/arginine ratio (milk, yogurt, cheese, papaya, beets) in the treatment of oral herpes (cold sores), there seems to be no such evidence for herpes zoster ^[30,31,39].

Some individuals with shingles have low blood vitamin C levels, but there is insufficient evidence about the effect of intravenous vitamin C on the reduction of chronic pain ^[24,32].

Even short-term moderate alcohol drinking can decrease immunity, so it reasonable to avoid alcohol during shingles ^[45].

Rest

When you have shingles, you usually do not need to rest in bed ^[14]. You should avoid activities that increase pain and those that allow the spread of the infection, such as visiting swimming pools and gym.

Therapies with insufficient evidence of effectiveness

There is INSUFFICIENT EVIDENCE about the effectiveness of the following treatments for pain or itch relief in shingles:

Steroids (clobetasol, hydrocortisone, triamcinolone) ^[2,4,18,20]
Acupuncture ^[41,42]
Wet cupping ^[43]
Zinc, colloidal silver, charcoal, table salt
Herbs: apple cider vinegar, coconut oil, lavender oil, neem, oregano, eucalyptus

Prognosis and Complications

In young and otherwise healthy persons, shingles usually heal spontaneously and without complications within a month ^[6].

In elderly, the pain often persists for several months after the rash has cleared (postherpetic neuralgia). Deep shingles may leave permanent scars and pigmentations.

In up to 15% of the individuals with weak immunity, shingles that affect the brain (encephalitis), lungs (pneumonitis), liver (hepatitis) or other internal organs may result in death ^[6].

Localized complications ^[6,40]:

Involvement of the ophthalmic nerve can result in temporary or permanent vision loss.
Involvement of the facial and acoustic nerve can result in hearing loss, vertigo and partial paralysis of the face (Ramsay-Hunt syndrome).
Damage to a sensory nerve can result in changed sensitivity, either decreased (numbness), increased (hyperesthesia) or unusual (allodynia).
Damage to a motor nerve can result in muscle weakness or limb paralysis.

Herpes zoster increases the risk of heart attack and stroke in the first year of the symptoms onset ^[17].

Some individuals with severe shingles develop chronic fatigue syndrome, fibromyalgia or complex regional pain syndrome.

References