Brody MB, Chronic neuropathic pain and its control by drugs. Gabapentin for the treatment of postherpetic neuralgia. Because immunity in general tends to wane, a person is more susceptible to disease as he or she ages. A good rule — in terms of shingles and all disease — is to stay as healthy as you can. Dosing schedule and cost may be considerations. Severity of shingles. 1. Oxman MN. Current management of herpes zoster. Pieper CF, Harden N, MacFarlane BV, The incidence of herpes zoster. Racial differences in the occurrence of herpes zoster. Barbanera M, Risk factors for postherpetic neuralgia. Postherpetic neuralgia can be really severe — affecting day-to-day life — and requiring pain management techniques that could include antidepressant or anti-seizure medications. / afp Ideally, you should take antiviral medication as soon as the rash appears. Burchett BM, Lee PJ, Antiviral medicines given during the first 72 hours of the rash can reduce the chance of postherpetic neuralgia. Your California Privacy Rights / Privacy Policy. Whereas varicella is generally a disease of childhood, herpes zoster and post-herpetic neuralgia become more common with increasing age. The virus that causes shingles, the varicella-zoster virus, is the same virus that causes chickenpox. The affected area should be kept clean.Q. Choo PW, Guilbaud G. Substance P, a neuropeptide released from pain fibers in response to trauma, is also released when capsaicin is applied to the skin, producing a burning sensation. Other medicines can be prescribed to help ease the pain and improve quality of life. Ann Intern Med. et al. Tricyclic antidepressants or anticonvulsants, often given in low dosages, may help to control neuropathic pain. Based on the findings of multiple studies, acylovir (Zovirax) therapy appears to produce a moderate reduction in the development of postherpetic neuralgia.13 Other antiviral agents, specifically valacyclovir (Valtrex) and famciclovir (Famvir), appear to be at least as effective as acyclovir. Fogh H, Schmader K, He received his medical degree from the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine, Bethesda, Md., and completed two years of the combined family practice and psychiatry residency program at Eisenhower Army Medical Center. Cost to the patient will be higher, depending on prescription filling fee. Treatment is directed at pain control while waiting for the condition to resolve. A. Don't miss a single issue. Oxman MN. In addition to medications, modalities to consider include transcutaneous electric nerve stimulation (TENS), biofeedback and nerve blocks. Zoster-associated chronic pain: an overview of clinical trials with acyclovir. The virus remains latent for decades because of varicella-zoster virus–specific cell-mediated immunity acquired during the primary infection, as well as endogenous and exogenous boosting of the immune system periodically throughout life.8 Reactivation of the virus occurs following a decrease in virus-specific cell-mediated immunity. Even the slightest pressure from clothing, bedsheets or wind may elicit pain. Infect Med. Galil K, Analgesia. The dosages required for analgesia are often lower than those used in the treatment of epilepsy. There are several possibilities. 2. Ormrod D(1), Goa K. Author information: (1)Adis International Limited, Mairangi Bay, Auckland, New Zealand. Other possible risk factors for the development of post-herpetic neuralgia are ophthalmic zoster, a history of prodromal pain before the appearance of skin lesions and an immunocompromised state.6, Varicella-zoster virus is a highly contagious DNA virus. In a recent study,1 patients more than 55 years of age accounted for more than 30 percent of herpes zoster cases despite representing only 8 percent of the study population. Stress is another piece of the triggers — physical, mental or emotional — as is any assault on the immune system, be it an illness or trauma.Q. As the crusts fall off, patients are generally left with scarring and pigmentary changes. Patients should wash their hands thoroughly after applying capsaicin cream in order to prevent inadvertent contact with other areas. Neurology. Keczkes K, Developing and Communicating a Long-Term Treatment Plan for Asthma, Evaluation and Treatment of Swallowing Impairments. Ideally, therapy should be initiated within 72 hours of symptom onset. The effectiveness of antiviral agents in preventing postherpetic neuralgia is more controversial. Can anything be done to prevent shingles? 14. So there could be a rash on the right forehead, eye area or cheek, or a rash that comes around the left side of the body from the back or down one arm. Petersen CS, 20. Strauss SE. Gabapentin for the treatment of postherpetic neuralgia. Infect Dis Clin Pract. Brody MB, et al. 8(April 15, 2000) The antiviral medications are most effective when started within 72 hours after the … However treatment should be started within 72 hours of the rash appearing for the most benefit. Antiviral medications need to be started quickly, within the first 72 hours of a rash appearing, to be effective. Arch Intern Med. Whitley RJ, Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Shingles is a painful rash caused by the same virus that causes chickenpox, the varicella zoster virus. Moyer D. Choo PW, When analgesics are used, with or without a narcotic, a regular dosing schedule results in better pain control and less anxiety than “as-needed” dosing. Apply to affected area three to five times daily. 10. Anyone who has had the chickenpox is at risk, especially if older than 50, but more commonly in folks older than 60. Pappas PG, A. No one knows for sure. Platt R. Typical dermatomal rash with hemorrhagic vesicles on the trunk of a patient with herpes zoster. Because tricyclic antidepressants do not act quickly, a clinical trial of at least three months is required to judge a patient's response. Time is of the essence, when it comes to shingles. It … Contact Approaches to management include treatment of the herpes zoster infection and associated pain, prevention of postherpetic neuralgia, and control of the neuropathic pain until the condition resolves. Platt R. Dosage recommendations are provided in Table 2. The most frequently involved cranial nerve dermatome is the ophthalmic division of the trigeminal nerve. Donahue JG, Khoo L. The pathophysiology of postherpetic neuralgia remains unclear. Your doctor may also take a tissue scraping or culture of the blisters for examination in the laboratory. Schmader K. J Infect Dis. Alliegro MB, 3. Medications are most effective when taken within 72 hours of the rash appearing. Int J Dermatol. Hamilton JD. Davies PS, 17. Lancet. Most importantly, they minimize the chance for postherpetic neuralgia — or nerve pain that continues longer than a month, even after the rash is gone. 1995;4:293–9. The prodromal phase is followed by development of the characteristic skin lesions of herpes zoster. Rowbotham M, Stacey B, These medications must be started early (up to about 24-72 hours after rash development) in the disease course to have any benefit. Keczkes K, Other illness. Galer BS. These medications shorten the course of the outbreak by preventing viral replication. I may have an outbreak every Annunziato P. Tyring S, … The pain associated with herpes zoster ranges from mild to excruciating. The skin lesions begin as a maculopapular rash that follows a dermatomal distribution, commonly referred to as a “belt-like pattern.” The maculopapular rash evolves into vesicles with an erythematous base (Figure 1). Eight patients -- 53% -- had their shingles pain scores drop by at least two points after antiviral treatment. The effects of early corticosteroid therapy on the skin eruption and pain of herpes zoster. 1997;36:667–72. Famciclovir is also a DNA polymerase inhibitor. © Gannett Co., Inc. 2020. 1987;2(8551):126–9. Acyclovir, the prototype antiviral drug, is a DNA polymerase inhibitor. Treatment of Herpes Zoster Shingles Infection. Patients with disease states that affect cell-mediated immunity, such as human immunodeficiency virus (HIV) infection and certain malignancies, are also at increased risk. Schmader K, Benson HA. Postgrad Med. Annunziato P. Galer BS. Pererslund NA, 16. A. Shingles is not contagious as shingles; however, if the blisters are not crusted over and there is skin-to-skin contact, chickenpox could be transmitted to someone who has not had chickenpox, as the blisters contain the virus. Antiviral medications are prescribed to be taken within 72 hours of diagnosis. 100 to 300 mg orally at bedtime; increase dosage until response is adequate or blood drug level is 10 to 20 μg per mL (40 to 80 μmol per L). Herpes zoster and internal malignancy. Fogh H, Primary treatment modalities include antiviral agents, corticosteroids, tricyclic antidepressants and anticonvulsants.   Occasionally, narcotics may be required. Of these patients, approximately one half manifest other neurologic or visceral involvement, and as many as one in seven with viremia may die. Copyright © 2000 by the American Academy of Family Physicians. 1997;157:1217–24. 61/No. Effective treatment of postherpetic neuralgia often requires multiple treatment approaches. Guilbaud G. Herpes zoster (commonly referred to as “shingles”) and postherpetic neuralgia result from reactivation of the varicella-zoster virus acquired during the primary varicella infection, or chickenpox. et al. Lidocaine patch: double-blind controlled study of a new treatment method for post-herpetic neuralgia. There are no specific contraindications to using anticonvulsants in combination with antidepressants or analgesics. The itchy blisters fill with fluid and then crust over.As with chickenpox, there are degrees of symptoms experienced with shingles. Shingles, also known as herpes zoster or just zoster, occurs when a virus in nerve cells becomes active again later in life and causes a skin rash. (Drug levels for clinical use are not available.). 5. 2000 Jun;59(6):1317-40. 7. Smith JB, Italian HIV Seroconversion Study. Tyring S, Around half of all shingles cases occur in adults over 60 years old. Pezzotti P, Antiviral agents are not used in combination, and selection of an agent is based on dosage schedule and cost. Chronic corticosteroid use, chemotherapy and radiation therapy may increase the risk of developing herpes zoster. A. Friedman DJ, 8. Esmann V, What are the symptoms?A. A 10 – 12 The vesicles eventually become hemorrhagic or turbid and crust over within seven to 10 days. So yes, it is possible to get shingles more than once.According, most private insurances will cover the Zostavax, subject to the individual plans' benefit designs, co-pays, co-insurance and deductibles, and most Medicare Part D plans have Zostavax on their formularies, again subject to the plans' terms.Most children now are vaccinated against chickenpox. They slow down the progress of the rash and prevent complications. Long-term management of complications. A randomized, placebo-controlled trial. Depending on the severity of the infection, topical, oral or IV (intravenous) antibiotic medicine is used to treat the infection. Bowsher D. Magnus-Miller L. Fiddian AP. A few days after the rash appears, it will start to form painful blisters filled with fluid. Dear Dr. Roach • I am a 60-year-old woman who has been taking a 200-mg tablet of acyclovir (Zovirax) every day for HSV-2 suppression. 21. Dorrucci M, Shingles can be treated with antiviral drugs. All rights reserved. Apply to affected area every 4 to 12 hours as needed. Is shingles contagious? The vaccine also minimizes the chance for recurrence of shingles. Age. Patients with postherpetic neuralgia may require narcotics for adequate pain control. Get Permissions, Access the latest issue of American Family Physician. Montvale, N.J.: Medical Economics Data, 2000. Herpes zoster (HZ) results from reactivation of varicella-zoster virus (VZV) in the dorsal root ganglion and is the most common sensory neurologic disease in the elderly. It is in the herpes family of viruses, although not the same virus that causes genital warts or cold sores.The virus goes to rest in the dorsal root of nerves — frequently in the upper or midback or the facial trigeminal nerve.Q. Varicella zoster virus (VZV), the pathogen responsible for herpes zoster, belongs to the herpesvirus family and is sensitive to the antiviral drug aciclovir. can help recover faster and reduce the risk of complications. Unlike varicella (chickenpox), herpes zoster is a sporadic disease with an estimated lifetime incidence of 10 to 20 percent. Also, symptoms might be atypical in patients with compromised immune systems — such as caused by chemotherapy or AIDS.Sometimes the rash is preceded by a tingling or burning pain several days to a week beforehand. With postherpetic neuralgia, a complication of herpes zoster, pain may persist well after resolution of the rash and can be highly debilitating. 1995;155:1605–9.... 2. Shingles blisters may get infected with bacteria. Bowsher D. Pain medications might also be warranted. Nortriptyline and amitriptyline appear to have equal efficacy; however, nortriptyline tends to produce fewer anticholinergic effects and is therefore better tolerated. Alliegro MB, Arch Intern Med. / Vol. Lidocaine patch: double-blind controlled study of a new treatment method for post-herpetic neuralgia. What are the treatments?A. Zoster-associated chronic pain: an overview of clinical trials with acyclovir. The varicella-zoster virus genome has been identified in the trigeminal ganglia of nearly all seropositive patients.7. Management of herpes zoster in elderly patients. Forszpaniak C, Walker AM, The vesicles are generally painful, and their development is often associated with the occurrence of anxiety and flu-like symptoms. The addition of an orally administered corticosteroid can provide modest benefits in reducing the pain of herpes zoster and the incidence of postherpetic neuralgia. The views expressed herein are exclusively those of the authors and do not necessarily represent the opinions of the United States Army or Department of Defense. Varicella-zoster virus infection. Risk factors for postherpetic neuralgia. Topically administered lidocaine (Xylocaine) and nerve blocks have also been reported to be effective in reducing pain. Analgesia occurs when substance P is depleted from the nerve fibers. In certain situations, intravenous (IV) antiviral … Eaglstein WH, Fiddian AP. The incidence of herpes zoster. Blistering. ~ 40 Mulberry St., Middletown, NY 10940 ~ Do Not Sell My Personal Information ~ Cookie Policy ~ Do Not Sell My Personal Information ~ Privacy Policy ~ Terms Of Service ~ Your California Privacy Rights / Privacy Policy. The characteristic rash associated in herpes zoster infection is … Benson HA. Eat properly, exercise and get plenty of rest. Beutner KR, Geil JP, A. Antiviral medications need to be started quickly, within the first 72 hours of a rash appearing, to be effective. Valacyclovir, a prodrug of acyclovir, is administered three times daily. Who is at risk for shingles?A. Whitley RJ, 10 to 25 mg orally at bedtime; increase dosage by 25 mg every 2 to 4 weeks until response is adequate, or to maximum dosage of 125 mg per day. Weiss H, Capsaicin, lidocaine patches and nerve blocks can also be used in selected patients. When the virus breaks out, the resulting bumps and then blisters or pustules usually follow the path of the nerve it's been dormant in, often in a linear fashion. Schmader K. Burchett BM, Beutner KR, Continued Patient information: See related handout on shingles, written by the authors of this article. Studies are currently being conducted to evaluate the efficacy of the varicella-zoster vaccine in preventing or modifying herpes zoster in the elderly. 22. How the virus enters the sensory dorsal root ganglia and whether it resides in neurons or supporting cells are not completely understood. Br J Dermatol. 19. 1991;80:62–8. Kroon S, Wright A, Ocular herpes zoster is treated with orally administered antiviral agents and corticosteroids, the same as involvement elsewhere. … A recent double-blind, placebo-controlled study showed gabapentin to be effective in treating the pain of postherpetic neuralgia, as well as the often associated sleep disturbance.23. The pain can be significant, and, without the rash, a doctor might first suspect the heart or gallbladder as the culprit.Q. Mertz GJ, 4. Shingles is a viral infection that affects approximately 1 in 3 adults in the United States. Pererslund NA, The treatment of herpes zoster has three major objectives: (1) treatment of the acute viral infection, (2) treatment of the acute pain associated with herpes zoster and (3) prevention of postherpetic neuralgia. Patients with mild to moderate pain may respond to over-the-counter analgesics. Eaglstein WH, However, there are variables, such as mild cases of chickenpox with symptoms that aren't even noted, and the fact that we've now learned that the immunity offered from vaccines wanes over time. Italian HIV Seroconversion Study. Given the theoretic risk of immunosuppression with corticosteroids, some investigators believe that these agents should be used only in patients more than 50 years of age because they are at greater risk of developing postherpetic neuralgia.15  The recommended dosage for prednisone is given in Table 1. Original content available for non-commercial use under a Creative Commons license, except where noted. Pappas PG, 1995;171:701–4. Several antiviral medicines—acyclovir, valacyclovir, and famciclovir—are available to treat shingles and shorten the length and severity of the illness. 1. Acyclovir may be given orally or intravenously. Treatment with tricyclic antidepressants can occasionally lead to cardiac conduction abnormalities or liver toxicity. Geil JP, Crooks RJ, Antivirals should be started while you’re still developing new lesions, which is usually within 72 hours of your first symptom. Andersen PL, Katz R, Other antiviral medications include famciclovir and valacyclovir. Herpes zoster is usually treated with orally administered acyclovir. Crooks RJ, Herpes zoster and progression to AIDS in a cohort of individuals who seroconverted to human immunodeficiency virus. Brown JA. Reprints are not available from the authors. Patches containing lidocaine have also been used to treat postherpetic neuralgia. Antivirals. Pezzotti P, The most common adverse effects are nausea, headache, vomiting, dizziness and abdominal pain. Shingles is usually diagnosed based on the history of pain on one side of your body, along with the telltale rash and blisters. Pain therapy may include multiple interventions, such as topical medications, over-the-counter analgesics, tricyclic antidepressants, anticonvulsants and a number of nonmedical modalities. 1997;102(1):187–94. Indeed, patients may have insomnia because of the pain.10 Although any vertebral dermatome may be involved, T5 and T6 are most commonly affected. Reprints are not available from the authors, The views expressed herein are exclusively those of the authors and do not necessarily represent the opinions of the United States Army or Department of Defense. Bottom Line. These drugs are best tolerated when they are started in a low dosage and given at bedtime. Intravenously administered acyclovir is generally used only in patients who are severely immunocompromised or who are unable to take medications orally. 1994;35(suppl):S4–8. You're older than 50. When herpes zoster involves the eyes, ophthalmologic consultation is usually recommended. Therefore, it is very important to get an early diagnosis from the GP as soon as shingles is suspected. 1998;15:709–13. Start patients on oral antiviral medication (acyclovir, valacyclovir or famciclovir) within 72 hours of the onset of symptoms to reduce the risk of long-term sequelae, including postherpetic neuralgia. Bacterial infection. Mertz GJ, What exactly is shingles?A. Patients may also complain of pain in response to non-noxious stimuli. *—Estimated cost to the pharmacist based on average wholesale prices (rounded to the nearest dollar), for seven days of therapy, in Red book. Most treatment is aimed at reducing the initial pain and rash. To achieve this response, capsaicin cream must be applied to the affected area three to five times daily. The condition involves continued pain long after the rash from shingles clears up. Because some cases are very mild, not everyone knows for sure whether they've had the chickenpox.Generally, I've been treating about 10-20 cases a year; the youngest has been about 18 and the oldest in his late 70s.Q. 4. Antinociceptive effects of acute and ‘chronic’ injections of tricyclic antidepressant drugs in a new model of mononeuropathy in rats. Khoo L. Neurology. Rezza G, Stacey B, Other medicines can be prescribed to help ease the pain and improve quality of life. Donahue JG, Some patients may have prodromal symptoms without developing the characteristic rash. Reactivation of latent varicella-zoster virus from dorsal root ganglia is responsible for the classic dermatomal rash and pain that occur with herpes zoster. Forszpaniak C, No, but the CDC estimates that about 32 percent of those who have had chickenpox will experience shingles. Sinicco A, Do corticosteroids prevent post-herpetic neuralgia? Platt R. Although postherpetic neuralgia is generally a self-limited condition, it can last indefinitely. Rowbotham MC, Nurmikko T. You have a chronic disease, such as diabetes. Anyone with diabetes should make every attempt to keep their sugar under control. Chronic neuropathic pain and its control by drugs. Postherpetic neuralgia is generally a self-limited disease. So treating shingles in a timely fashion to lessen this possibility is crucial.Shingles can also lead to skin infections, and in rare cases, can pose a risk to sight. In diabetics, for example, the shingles recurrence rate is at least 4 percent. In theory, this will translate into fewer Americans who suffer from shingles in the future. Factors that decrease immune function, such as human immunodeficiency virus infection, chemotherapy, malignancies and chronic corticosteroid use, may also increase the risk of developing herpes zoster. George LK, Magnus-Miller L. Clinical features and pathophysiologic mechanisms of postherpetic neuralgia. *—Estimated cost to the pharmacist based on average wholesale prices (rounded to the nearest dollar), for seven days of therapy, in Red book. 1970;211:1681–3. 23. The most troublesome symptom of HZ is pain, which occurs in m… Hamilton JD. Shingles location. The tricyclic antidepressants share common side effects, such as sedation, dry mouth, postural hypotension, blurred vision and urinary retention. Antiviral medications, such as acyclovir , valacyclovir , and famciclovir , can decrease the duration of skin rash and pain, including the pain of PHN. Although the diagnosis of the conditions is generally straightforward, treatment can be frustrating for the patient and physician. Orally administered corticosteroids are commonly used in the treatment of herpes zoster, even though clinical trials have shown variable results. Antiviral therapy should be initiated within 72 hours of onset of the rash in patients with acute herpes zoster to increase the rate of healing and decrease pain. Spiegelman D, The potential for these problems should be considered in elderly patients and patients with cardiac or liver disease. Less than one quarter of patients still experience pain at six months after the herpes zoster eruption, and fewer than one in 20 has pain at one year. 11. Although the disease can occur at any age, in the otherwise immunocompetent individual the risk of developing HZ substantially increases over the age of 50 years: it has been estimated that 50% of persons who reach the age of 85 years will have suffered at least one attack of HZ [1]. Antiviral drugs, such as Aciclovir tablets are safe and may shorten the duration, but work best if they are given within the first three days (72 hours) of onset of the outbreak. Antimicrob Agents Chemother. However, the risk of side effects increases when multiple medications are used. Wood MJ. DEBORAH PACKER, MAJ, MC, USA, is staff family physician and predoctoral program coordinator at Eisenhower Army Medical Center. What Everyone Should Know about the Shingles Vaccine (Shingrix) Shingles vaccination is the only way to protect against shingles and postherpetic neuralgia (PHN), the most common complication from shingles. 1. Strauss SE. Ocular complications occur in approximately one half of patients with involvement of the ophthalmic division of the trigeminal nerve. Lotions containing calamine (e.g., Caladryl) may be used on open lesions to reduce pain and pruritus. Esmann V, These complications include mucopurulent conjunctivitis, episcleritis, keratitis and anterior uveitis. Shingles rash and blisters can cause severe pain and may not reduce … Pain. These medicines may slow down the progress of the shingles rash, especially if you take them within the first 72 hours … If the use of orally administered prednisone is not contraindicated, adjunctive treatment with this agent is justified on the basis of its effects in reducing pain, despite questionable evidence for its benefits in decreasing the incidence of postherpetic neuralgia. Smith JB, Pieper CF, The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Certainly, age is a factor. Will everyone who has had the chickenpox get shingles?