Shingles is a pain – includes related information on efficacy of treatment
Shingles is a pain
New remedies offer relief from the pain that sometimes lingers on stubbornly for months, even years, following an attack of shingles.
Pain that persists after an attack of shingles is particularly troublesome in people over 60 among whom shingles most commonly occurs. Recent studies at the University of Toronto show that hot pepper ointments help some sufferers.
What is shingles?
Shingles or Herpes zoster (zoster for short) is an adult reactivation of a childhood chicken pox infection. However, the skin rash, instead of covering large parts of the body as in chicken pox, usually appears only on a small area of skin in rows like shingles on a roof. A typical shingles rash follows the path of certain nerves on one side of the body only – generally on the trunk, buttocks, neck, face or scalp – usually stopping abruptly at the midline. Shingles is common in the elderly, rare among the young. About two thirds of shingles cases occur in those over 50, afflicting both sexes equally. Most people suffer only one attack although repeat bouts occasionally occur, usually at the same site as the first eruption.
If shingles occurs on the face, the nose and cornea of the eye are often involved. This condition, known as zoster keratitis, can lead to blindness if left untreated, so anyone with shingles on the upper face no matter how mild should see a physician at once. A tingling at the tip of the nose may herald possible eye involvement. When the trigeminal facial nerve and the eyes are affected, people are more likely to experience prolonged post-shingles pain. And with advancing age, there’s an increasing chance of being left with irritating discomfort, vision impairment or severe pain after the zoster rash heals.
The main features
An attack of shingles generally begins with feverish discomfort (chills, headache, upset stomach) perhaps accompanied by a preliminary itching or burning sensation. Pain may precede the rash by a few days (occasionally mistaken for a heart attack, lung infection or back problem) but the discomfort is more commonly felt only during and/or after the rash.
The rash, typically confined to one side of the body, starts as a series of raised red spots surrounded by a swollen area that turn into clear blisters, which become cloudy, dry out and crust over. The spots may bleed and become very itchy and painful. In a few, especially the immunosuppressed, attacks are severe, the rash covering a wide area. The rash may take three to four weeks to heal and after healing may leave some whitish-silver or brown scars.
Shingles pain occasionally occurs alone, without any rash – known as zoster sine herpete. Normally, once the herpetic rash fades, the area stops hurting and full recovery follows.
What causes shingles?
The Herpes zoster virus is responsible for both chicken pox or varicella in children and shingles or zoster in adults. This virus belongs to the same family as the Herpes simplex organism responsible for cold sores. Shingles occurs almost exclusively in those who had chicken pox as children and have some but not total immunity to the virus. About 80 per cent of the Canadian population have had chicken pox, usually a mild illness, by age 10. Chicken pox is still so widespread because it’s one of the few childhood infections for which we have no vaccine as yet. While chicken pox is highly contagious, caught by inhaling infected droplets, shingles is not generally transmitted from one person to another. However, children or adults who haven’t yet had the infection may catch chicken pox if they touch wet shingles blisters.
Although childhood chicken pox almost always runs its course in a week or two, usually with full recovery, the virus isn’t fully eliminated from the body. It retreats to nerve cells, where it rests, silently hidden within nerve ganglia (centres near the spinal cord). Most of us go through life maintaining an “armed truce” with zoster viruses that linger in the body after a juvenile bout of chicken pox. If re-activated for some reason, the virus travels along affected nerve pathways causing a skin eruption as it goes.
There is some evidence, not proven, that shingles may be precipitated by excessive exposure to sunlight (ultraviolet radiation), stress, trauma (wounds, surgery or inflammation) and other events that lower immune resistance. Shingles is more common in older people because immune defences get weaker with progressing years. It is particularly frequent among the immunosuppressed such as those with Hodgkin’s disease or leukemia, transplant patients and those with AIDS, people undergoing radiation treatment or taking immunosuppressants.
Post-shingles pain can be a searing experience
Pain is often the worst part of shingles. While the rash generally vanishes leaving little or no discomfort, many, especially the elderly, continue to suffer pain long after the skin has healed. Post-zoster pain is a continuous ache, an itching, burning sensation with bouts of stabbing and shooting or lancinating pain, often set off by touching the sensitive area. Defined as unrelenting pain that persists for four or more weeks after the acute shingles phase, post-herpetic neuralgia (PHN), occurs in 10 per cent of those over 40 and one half to two thirds of those older than 60 who get shingles. About 80 per cent of those with PHN describe the pain as unpleasant but bearable. The rest find it an agonizing sensation, never letting up except perhaps during sleep, although it’s often irritating enough to hinder sleep. The pain can also upset appetite, cause lassitude and diminish sex drive. Many patients complain of allodynia (pain on contact with certain stimuli such as the touch of clothing) and hyperpathia (prolonged, radiating pain superimposed on the continuous itch). But the pain tends to fade with time, often vanishing in a year or so.
Remedies proposed for post-shingles pain
* Antidepressants help many, not because of their antidepressant effect but because the medication can relieve pain (in doses lower than those normally used for depression). It may be necessary to stay on the medication for some weeks to achieve relief.
* Transcutaneous electrical nerve stimulation (TENS) often enhances relief.
* Steroids (anti-inflammatory agents), such as triamcinolone, injected into the painful region may benefit some.
* Opioid painkillers do not usually alleviate PHN but may be helpful if all else fails.
* Early use of sympathetic nerve blockade or local anesthetics may be helpful but since these methods are elaborate and expensive, and there is little evidence of long term benefit, anesthetic remedies are not strongly supported for PHN.
* Capsaicin, the pungent element in red peppers and related vegetables (marketed as Zostrix, in a 0.025 per cent preparation), can alleviate PHN and promises relief to some sufferers. Exactly how hot pepper ointment relieves post-shingles pain is unclear but it may deplete pain pathways of substance P (a pain transmitter), thus relieving pain. Or the ointment may mimic oil of cloves as its active component is similar to eugenol in the popular toothache remedy. However, while the hot pepper ingredient may relieve PHN it can also sting because it stimulates nerve endings. A study conducted at one University of Toronto Pain Clinic found that 39 per cent of those who persevered with hot pepper treatment experienced relief by rubbing the cream onto the painful site four times a day. For over half of the subjects, relief of PHN was rated as “good to excellent.” On the down side, one-third of the subjects withdrew from the trial, unable to stand the stinging caused by the pepper cream. A preliminary U.S. study found that 12 out of 14 patients who applied Zostrix to the painful area five times a day for a week, then three times a day for the next three weeks, experienced “substantial” relief. Further studies on pepper cream are planned.(*)
(*) Volunteers are needed for future studies on hot pepper treatment of post-shingles pain. If interested, please cal (416)231-5152.
Shingles treatment varied
and of uncertain efficacy
Treatment of shingles generally includes local application of drying agents, antiseptics, compresses and perhaps anti-viral agents such as amantadine and acyclovir (the anti-herpes drug).
Cold compresses of Burow’s Solution, betadine, other antiseptics, drying agents (cornstarch or baking soda) and bandages impregnated with petroleum jelly, with or without topical antibiotics.
Application of a drying lotion containing alcohol, menthol and/or phenol may speed healing.
Splinting the area – i.e., covering it with cotton and wrapping with an elastic bandage – can help to relieve active and post-shingles pain.
Interferon (an extract of the natural defense substance present in all cells) helps some people.
Acyclovir, given by mouth or intravenous infusion, can reduce the severity of shingles and aid healing in both normal and immunosuppressed people and may, but does not necessarily, lessen post-shingles pain. Local acyclovir ointment may speed healing but cannot stop the rash from spreading nor prevent post-shingles pain.
Systemic (oral or injected) steroids are occasionally prescribed for elderly sufferers with severe or widespread infection and given within 72 hours of its start may lessen the severity of shingles, possibly reducing the likelihood of and persistence of post-shingles pain.
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