Shingles

November 24, 2021

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What is Shingles?

 

Shingles, also known as Herpes Zoster, is a viral illness caused by the same virus that triggers chickenpox- the Varicella Zoster Virus (VZV).  The virus stays dormant in our body and can manifest as shingles later in life.  

 

According to the CDC, 1 in 3 people will develop shingles at some point in their lives.  For those born before 1980, the CDC estimates that 99% of the population had a chickenpox illness regardless of whether they recall it.  

 

Shingles is a painful rash that occurs along the distribution of a nerve, called a dermatome.  The virus lays dormant in the nervous system.  Immunity likely plays a role in preventing the virus from reactivating.  When immunity is low, the virus replicates and spreads down the nerve causing pain, inflammation, blistering.  The classic description of the appearance is "dew drops on a rose petal".

 

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What is the Varicella Vaccine (chickenpox vaccine)?

 

The Varicella vaccine was released in 1995 and administered at the age of 12 months.  In 2006, a booster was recommended for those over the age of 12 years.  The vaccines contain the live attenuated virus.  The Varicella vaccine has demonstrated effectiveness in reducing both the risk for chickenpox as well as shingles.  


 

What are the risk factors for shingles? 

VZV lays dormant in the nervous system and can reactivate at any time.  The most common risk factors related to the development of shingles are:

  • Age > 50
  • Underlying Conditions that suppress the immune system such as HIV, and cancers such as myeloma and lymphoma
  • Other chronic diseases such as autoimmune conditions (rheumatoid arthritis, lupus), COPD, asthma, chronic kidney disease, type 1 diabetes, inflammatory bowel disease and  depression
  • Medications such as chemotherapy and other immunosuppressives

 
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What are the symptoms of a shingles outbreak?

 

Most patients will initially feeling a pain, tingling or itching in an area first, followed by a rash. The area is usually a region of skin innervated by a nerve root called a dermatome and can extend to the adjacent skin. It tends to stay unilateral or on one side not crossing the midline. Although most commonly found on the trunk, any region of the body can be affected. The rash that follows starts as clusters of red papules to small blisters grouped together. The classic description is the appearance of ‘dew drops on a rose petal’. There is often significant pain or discomfort associated with the area affected. This pain can persist even after the rash heals and is referred to as post herpetic neuralgia. 


Stages of Shingles

 

 Stages Symptoms Time
Pre-eruptive
  • Pain or dysesthesia (abnormal sensations) along a dermatome for up to a week
  • Posible low grade fever
  • Malaise
  • Headaches
  • Photophobia
About one week
Acute Eruption
  • Severe pain, discomfort
  • Inflammation or redness along a dermatome
  • Small red bumps that can evolve into vesicles (small blisters)
  • Contagious until scabs over
About 2 to 4 weeks
Post-eruptive
  • Persistent pain, dysesthesia with potential for post herpectic neuralgia
About 4 weeks to a year

 





If the rash is located along a facial dermatome it can result in shingles involving the eyes or ears impacting vision or hearing. 


Potential Shingles Complications

Complication Potential Risk Factors
Post Herpetic Neuralgia

Older Age

Severe immunosuppression

Diabetes

Systemic Lupus Erythematosus

Recent trauma

Ramsay Hunt Syndrome

(hearing loss, vertigo)

Shingles involving the 

vestibulocochlear nerve of the ear

Chronic ocular inflammation, Vision loss

Shingles involving the forehead, upper eyelid, orbit (ophthalmic division of the trigeminal nerve)

Nerves palsies,

Guillain Barre syndrome, etc.

 Involvement of Central Nervous System

Spread to fetus / newborn

Pregnancy

 

How is a diagnosis of shingles made?

 

When the rash is located on the trunk, it takes on such a classic appearance it is often clearly diagnosed. However, most cases that are missed or misdiagnosed tend to be in other dermatomes along the face or extremities. I have had patients believe or been told they have impetigo or acne in the scalp or on the face when the crusted papules they have are actually shingles. I’ve seen cases on the arms or legs misdiagnosed as poison ivy or cellulitis. The key to diagnosis is pattern the rash takes on and clinical history. If there is a question as to whether the diagnosis is accurate, a Tzanck smear can be obtained by scraping the base of a vesicle and applying special stains to view under the microscope. Viral cultures or biopsies can also be considered. I do not recommend this however simply because of the practical consideration that the time it takes for a result to return will lead to a delayed diagnosis and missed opportunity to treat early. 

 

How is shingles treated?

The treatment of shingles is focused on decreasing the duration of disease. Early treatment with oral antiviral medications such as valacyclovir or acyclovir is important. Consideration to the use of oral steroids is reasonable if pain is a significant component.



What is the shingles vaccine?


The shingles vaccine, known as Shingrix, is a 2 dose vaccine with doses separated by about 2 to 6 months.  The two dose series has been shown to be 90% effective at reducing the risk of shingles and post herpetic neuralgia (a persistent nerve pain that can post post infection). 
The vaccine is recommended for adults over the age of 50, regardless of whether they have had shingles or the previous vaccine Zostavax. 
 


Who should not get the shingles vaccine? 


The shingles vaccine is not recommended for those that have no immunity to varicella zoster virus.  In other words those that have never had the chickenpox or the vaccine for chickenpox.  The CDC estimates that 99% of the population born before 1980 had the chickenpox, even if they do not recall the illness.  The chickenpox vaccine (varicella vaccine) became available in 1995 for those aged 12 months or older, with a booster that became available in 2006.  This vaccine has demonstrated effectiveness in reducing the risk of both chickenpox and shingles.


If you have an allergy to any vaccine components it is important to not get the vaccine.  And, if you have a current shingles infection you should not get the vaccine right away.









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