Important Questions About Shingles

What is shingles?

Shingles is an infection caused by the chickenpox (herpes zoster) virus. After a chickenpox infection, the virus remains dormant in the body’s nerves for years or even decades without causing symptoms.[1] If the virus reactivates, it causes the painful condition known as shingles.

Shingles typically develops on one side of the face or body, often beginning as pain before manifesting as a rash over the painful area one to five days later.[2] The rash consists of blisters that usually scab over in seven to 10 days, and it typically clears up completely, even without treatment, within two to four weeks.[3]

How likely am I to get shingles?

Shingles is very common: Nearly one-third of people will get shingles at least once in their lives.[4] Elderly adults are particularly vulnerable to infection, with half of all cases occurring in those 60 and older.[5] While shingles typically occurs only once in a person’s lifetime, repeat episodes are possible.[6]

Is shingles contagious?[7]

A person with an active shingles rash can spread the virus to another person through direct contact with the blister fluid, but the virus can cause only a chickenpox infection in those who have not yet had one; it does not transmit the shingles rash to another person. The shingles virus is contagious only when blisters are present and stops being transmissible once the blisters have scabbed over.

How do I avoid spreading the shingles virus?[8]

Cover your rash with clothing or dry bandages while blisters are present, try not to touch or scratch your blisters, and wash your hands often. While blisters are present, avoid people who are particularly vulnerable to serious complications from infection with herpes zoster. This includes pregnant women who have never had chickenpox; premature or low-birth-weight babies; and people with weak immune systems, such as those with HIV infection, patients on chemotherapy or other immunesuppressing medications, or anyone who has recently received an organ transplant.

What are the possible complications of shingles?

The most common complication of shingles is persistent pain. When the pain continues for more than three months after the rash disappears, the condition is known as post-herpetic neuralgia (PHN).[9] About one in five patients report PHN three months after a shingles rash, and 15 percent still have pain two years after the rash.[10] The pain of PHN can be severe, taking a physical and emotional toll.

In 10 to 20 percent of shingles cases, the virus affects the nerves near the eye.[11] This is considered a medical emergency that requires prompt treatment by an ophthalmologist to prevent permanent vision loss and other complications.[12]

Should I get the shingles vaccine?

The shingles vaccine is effective in preventing the shingles rash. The vaccine was tested in a very large clinical trial enrolling more than 38,000 people aged 60 and older.[13] In this study, the vaccine reduced the chance of getting shingles within three years by more than half.

The Centers for Disease Control and Prevention (CDC) recommends one dose of the shingles vaccine for all people 60 and older.[14] The CDC notes that the effectiveness of the vaccine beyond five years is uncertain, as the body’s immune response to the vaccine begins to wane within that time.[15] However, the agency has, to date, not made any recommendations for repeat vaccination.[16]

The shingles vaccine is very safe and was not associated with an increased risk of death, hospitalization or serious side effects in the large trial mentioned above.[17] However, you should not get the vaccine if you have a confirmed fever; have ever had a life-threatening allergic reaction to gelatin, the antibiotic neomycin or any other component of the shingles vaccine; are pregnant or might be pregnant; or have AIDS or any other condition that has weakened your immune system.[18]

In extremely rare cases, as with all vaccines, the shingles vaccine can cause an immediate and life-threatening allergic reaction. More commonly, it can cause redness, soreness, swelling or itching at the injection site.[19]

How effective are shingles treatments?

To treat the virus, antiviral medications are given at the first sign of a shingles infection. The following antivirals are approved by the Food and Drug Administration (FDA) to treat active shingles infections, but the treatments have been shown to be effective only when given within three days of the onset of symptoms: acyclovir (ZOVIRAX),[20] famciclovir (FAMVIR)[21] and valacyclovir (VALTREX).[22],[23] Famciclovir may reduce pain more quickly than valacyclovir,[24] and both of these drugs seem to be more effective for pain than acyclovir.[25]

All three antiviral drugs can cause kidney failure, while valacyclovir has been associated with agitation, hallucinations, seizures, confusion and, in HIV patients and transplant recipients, a life-threatening blood condition.[26]

Painkillers, including prescription painkillers for severe cases, also can relieve pain during an active shingles infection.[27]

Unfortunately, studies have not found effective medications for preventing PHN. Two reviews of clinical trials found that neither antivirals[28] nor corticosteroids[29] were effective in preventing PHN in the months following an infection. And the shingles vaccine does not reduce the risk of PHN in patients who get shingles despite having received the vaccine.[30]

Finally, for patients with PHN, many different medications are effective in treating pain.[31] Various forms of the drug gabapentin (NEURONTIN, among other brands) are the only oral drugs approved by the FDA specifically for PHN, while lidocaine (LIDODERM) and capsaicin (QUTENZA) are two prescription skin patches approved for the condition.[32] Opioid drugs also are approved for treating pain.

So how should I treat shingles?

If you get shingles, you should see your doctor immediately to make sure that the infection is not affecting the nerves near your eyes. If it is not, the infection will likely pass without treatment within a few weeks, so if your pain and rash are mild, treatment is not necessary.

If your symptoms are more severe and began less than three days previously, you can take antiviral drugs. For your pain, you should first use over-the-counter acetaminophen (TYLENOL) or ibuprofen (ADVIL), and if those do not help, you can ask your doctor for a prescription painkiller.

If you get PHN, you should discuss the best treatment option with your doctor. If over-the-counter pain relievers do not work, you can try gabapentin, lidocaine or capsaicin. If your pain is still severe, you can consider opioids, but these should be a last resort, as they are highly addictive. We recommend against taking pregabalin (LYRICA), another drug approved by the FDA for PHN, because its risks far exceed any benefit.[33] Although the American Academy of Neurology recommends tricyclic antidepressants as treatments for PHN,[34] we recommend against using these drugs, as they are not approved for PHN and have dangerous side effects.[35]

References

[1] Centers for Disease Control and Prevention. Shingles (Herpes Zoster). http://www.cdc.gov/shingles/about/overview.html. Accessed March 20, 2016.

[2] Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Signs & Symptoms. http://www.cdc.gov/shingles/about/symptoms.html. Accessed March 20, 2016.

[3] Ibid.

[4] Centers for Disease Control and Prevention. Shingles (Herpes Zoster). http://www.cdc.gov/shingles/about/overview.html. Accessed March 20, 2016.

[5] Ibid.

[6] Ibid.

[7] Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Transmission. http://www.cdc.gov/shingles/about/transmission.html. Accessed March 20, 2016.

[8] Ibid.

[9] Johnson RW, Rice AS. Clinical practice. Postherpetic neuralgia. N Engl J Med. 2014;371(16):1526-1533. http://www.nejm.org/doi/full/10.1056/NEJMcp1403062. Accessed March 20, 2016.

[10] Ibid.

[11] Johnson JL, Amzat R, Martin N. Herpes Zoster Ophthalmicus. Prim Care. 2015;42(3):285-303.

[12] Ibid.

[13] Gagliardi AM, Andriolo BN, Torloni MR, Soares BG. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev. 2016;3:CD008858.

[14] Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Prevention and Treatment. http://www.cdc.gov/shingles/about/prevention-treatment.html. Accessed March 20, 2016.

[15] Hales CM, Harpaz R, Ortega-Sanchez I, Bialek SR; Centers for Disease Control and Prevention (CDC). Update on recommendations for use of herpes zoster vaccine. MMWR Morb Mortal Wkly Rep. 2014;63(33):729-31. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6333a3.htm. Accessed March 20, 2016.

[16] Ibid.

[17] Gagliardi AM, Andriolo BN, Torloni MR, Soares BG. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev. 2016;3:CD008858.

[18] Centers for Disease Control and Prevention. Shingles: Vaccine information statement. http://www.cdc.gov/vaccines/hcp/vis/vis-statements/shingles.html. Accessed March 21, 2016

[19] Ibid.

[20] National Institutes of Health. DailyMed. Zovirax (updated February 2014). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6fe0ab86-9d81-461e-9c84-6ba724a91318. Accessed March 21, 2016.

[21] DailyMed. Famvir (updated April 2013). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3c6194c0-ba69-4b16-b882-caf736a02348. Accessed March 21, 2016.

[22] DailyMed. Valtrex (updated December 2013). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f8e0d8f8-cb73-4206-a484-88f5c4fbd719. Accessed March 21, 2016.

[23] We confirmed that no other antivirals seem to be approved for shingles, based on a search of the following website: Food and Drug Administration. FDA Approved Drug Products. https://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm. Accessed March 21, 2016.

[24] Ono F, Yasumoto S, Furumura M, et al. Comparison between famciclovir and valacyclovir for acute pain in adult Japanese immunocompetent patients with herpes zoster. J Dermatol. 2012;39(11):902-908.

[25] McDonald EM, de Kock J, Ram FS. Antivirals for management of herpes zoster including ophthalmicus: a systematic review of high-quality randomized controlled trials. Antivir Ther. 2012;17(2):255-264.

[26] DailyMed. Zovirax (updated February 2014). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6fe0ab86-9d81-461e-9c84-6ba724a91318; Famvir (updated April 2013). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3c6194c0-ba69-4b16-b882-caf736a02348; Valtrex (updated December 2013). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f8e0d8f8-cb73-4206-a484-88f5c4fbd719. All links accessed March 21, 2016.

[27] American Academy of Dermatology. Shingles: Diagnosis and treatment. https://www.aad.org/public/diseases/contagious-skin-diseases/shingles. Accessed March 21, 2016.

[28] Chen N, Li Q, Yang J, et al. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2014;2:CD006866.

[29] Han Y, Zhang J, Chen N, et al. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2013;3:CD005582.

[30] Chen N, Li Q, Zhang Y, et al. Vaccination for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2011;(3):CD007795.

[31] Snedecor SJ, Sudharshan L, Cappelleri JC, et al. Systematic review and meta-analysis of pharmacological therapies for pain associated with postherpetic neuralgia and less common neuropathic conditions. Int J Clin Pract. 2014;68(7):900-918.

[32] Massengill JS, Kittredge JL. Practical considerations in the pharmacological treatment of postherpetic neuralgia for the primary care provider. J Pain Res. 2014;7:125-132.

[33] Pregabalin (LYRICA). WorstPills.org. /monographs/view/312. Accessed March 21, 2016.

[34] Dubinsky RM, Kabbani H, El-Chami Z, et al. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004;63(6):959-65.

[35] DailyMed. https://dailymed.nlm.nih.gov/dailymed/. Accessed March 21, 2016.