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Shingles: causes, symptoms, and treatment – Herpes Zoster

Shingles or herpes zoster is a viral infection caused by the reactivation of the varicella-zoster virus (VZV) that produces a painful skin rash.

This infection begins with the primary infection of the varicella-zoster virus that usually occurs during childhood, called Chickenpox. Once the infection is over, the virus can remain “asleep” (inactive) in the body’s nerve cells for long periods from months to years. Then, it can reactivate for unknown reasons and produce painful skin rash lesions known as shingles.

The skin lesions begin with an itchy rash, then blisters full of liquid appear, and once dry, they form a crust. Usually, the injuries are a single strip, in the right or left side of the body, in the area of the chest, back, or face without passing the midline of the body.

This infection affects about three to five people amongst every one thousand each year in the United States. Also, around one out of three people in the United States will get shingles during their lifetime.

Therefore, any person with a previous infection of chickenpox can develop herpes zoster, but the risk increases with age due to the immune system’s wear and tear. Also, only four percent of those patients will develop a recurrent condition.

Children can get herpes zoster or shingles, but it is rare. When this happens, it usually is because the immune system is compromised by AIDS, lymphoma (cancer), other malignancies, or patients who have had bone marrow or kidney transplants.

By reading this article, you will learn leading information about Shingles, including its causes, symptoms, complications, and treatment. Please, proceed reading to get pearls on this material straight from a doctor.

What is the difference between Chickenpox and Shingles?

Chickenpox is the result of the infection from the varicella-zoster virus. It occurs in children, especially those under ten.

The virus is transmitted from person to person by inhaling respiratory droplets within the air or directly contacting an infected person’s skin lesions. Also, touching stuff that has the virus all over its surface.

Chickenpox symptoms are elevation of the body temperature (fever) and an itchy rash. This rash is in the form of pimples ten to twenty days after exposure to the virus. Then the pimples turn into fluid-filled blisters with virus particles inside them called vesicles.

Vesicles last five to ten days. They appear first on the back, abdomen, and face. After that, they extend to almost the entire body.

Chickenpox does not require medical treatment. Like several viral infections, the treatment only decreases the intensity of the symptoms, while the immune system actually defends the body against invading agents to eliminate the virus.

On the other hand, Shingles (known as Herpes zoster) is a viral skin infection caused by reactivation of the varicella zoster virus (VZV) (the same virus that causes chickenpox).

Its main symptom is the presence of a painful rash and generally affects only one side of the body. This rash turns into blisters or vesicles with liquid inside, usually displayed as a band on the skin.

File:Shingles rash, thigh. Caused by the herpes zoster virus.jpg
Shingles rash, thigh. Caused by the herpes zoster virus.
Source.

The difference between them is that for herpes zoster or shingles is necessary to have a prior infection with chickenpox.

Furthermore, Herpes zoster usually occurs in adults with a weakened immune system. The virus is inactive in the body’s nerve cells. For unknown reasons, they reactivate and produce skin lesions or neurological complications in severe cases.

What triggers a shingles outbreak?

Remember that for having shingles. You must have previously acquired the varicella-zoster virus through a chickenpox infection. 

The immune system that protects the body from infections tries to eliminate the virus during the chickenpox infection. When the infection is over, the virus particles stay in the nerve cells, specifically the ones responsible for sending sensory information from specific locations on the skin to the spinal cord.

For unknown causes, the immune system can’t eliminate the chickenpox virus. Consequently, the virus remains inactive in the spinal cord’s nerve cells. Once inside them, the immune system inhibits its replication, but it fails to contain the virus inside the nerve cells, and its reactivation occurs when the immune system is affected.

The virus can remain inactive for months or even years. After a while, it can reactivate and travel from the dorsal root ganglion to the skin producing herpes zoster. 

Although doctors don’t know what exactly causes the virus to reactivate, not everyone who has had chickenpox will have shingles, but they are susceptible to develop shingles in the future.

Reactivation usually occurs in people with compromised immune systems such as AIDS, cancers, bone marrow, or organ transplant recipients like kidney, heart, liver, and lung. Another one is the use of therapy or immunosuppressive drugs such as steroids.

Can you catch shingles from stress?

At present, it has not been determined with certainty whether stress can develop the reactivation of the VZV inside the dorsal root ganglia. More studies are still necessary to affirm or deny this.

Despite this, many studies acknowledge that stressful situations put people at a higher risk of developing shingles than those who not. Yet, for now, it does not represent a cornerstone for developing shingles as other risk factors, for example, cancer.

Moreover, stress as an individual’s response to a stressful provocation can affect the immune system; indeed, it can decrease its activity. A weakened immune system can put a person at risk for Shingles, as long as there is a previous infection of chickenpox.

What are the symptoms of Shingles?

The first symptoms of shingles are unspecific; they could be:

  • Headache
  • High temperatures as 104°F
  • Tiredness
  • Discomfort
  • Sensitivity to light (photophobia)
  • It could even start in rare cases as a stomachache (upset stomach).

When the virus reactivates, it travels from the spinal cord’s dorsal root ganglia to the skin end, producing the shingles outbreak. Then, there is a tingling sensation in the skin with burning or itching.

In this skin region, the sensitivity is controlled by a single nerve that gets to a spinal ganglion in the spinal cord. The nerve transmits the sensory information of this specific body area. This connection between the skin and the nerve receives the name of a dermatome.

File:Spinal Cord Sensory Pathways.png
Source

In herpes zoster, the lesions usually affect the nerve and the skin area innervated by one nerve. Hence, it only affects one dermatome in most cases.

File:1611 Dermatomes-02.jpg
Dermatomes
Source

The shingles pain is usually the first symptom. It can be mild or very intense. Depending on their location, it can be confused with a problem affecting the heart, lungs, or kidneys. 

When this initial pain phase passes, then a raised rash on the skin as red spots appear. This rash locates in a strip or broadband along the dermatome. Usually affects only one side of the body (left or right) and respecting the midline of the body.

The lesions are usually on the chest or back of the body. But can develop anywhere as arms, head, and face.

Next, in about three to five days, the skin rash or lesions change to vesicles (shingles blister). The contents of the vesicle firstly lighten and then begin to darken. Later the vesicle breaks and begins to dry, forms a crust, and disappears absolutely after two to four weeks.

File:Shingles on the chest.jpg
Shingles on the chest
Source

Disseminated Herpes Zoster

Less frequently, the rash may be more extensive and affect more than two dermatomes. This condition is known as disseminated herpes zoster or shingles. 

The symptoms include more than twenty skin lesions appearing outside the main affected dermatome or close to it. It mostly occurs in people with compromised or suppressed immune systems.

Then, it can also affect other organs like the liver (causing hepatitis) or the brain (producing encephalitis), compromising the person’s life.

Why do shingles appear mostly on one side or in one area of the body?

The VZV virus is inside the dorsal root ganglia. Once it reactivates, it travels in specific nerves. These nerves innervate a particular area of the body, so you will often see that the herpes zoster forms a band on one side of the body, respecting the midline. This band corresponds to the area where the nerve transmits the sensory signals. That is why the shingles rash appears on a localized part of the skin.

What complications are there from shingles?

The typical complication of herpes zoster is Postherpetic Neuralgia (PHN). This is a term doctors use with people who persist with chronic pain at the injury site, and it occurs because of nerve damage. The duration of the pain varies broadly. For example, it could take more than ninety days for the pain to disappear after the skin lesions fade. Or the pain could last for months or even years.

The risk of having PHN increases with age. It is more common in people over sixty years and rare under forty years. To prevent PHN, it is necessary to start treatment on time for shingles.

Ocular complications are common and occur when the virus infects the ophthalmic division of the trigeminal nerve. The VZV can remain inactive in the ophthalmic branch (responsible for almost all the eye’s structures). If the VZV reactivates in this nerve, it is called herpes zoster ophthalmicus.

In some people, the symptoms include painful inflammation or swelling of the different structures of the eye. It includes conjunctivitis, keratitis, uveitis, and paralysis of the optic nerve. In the most severe cases, it could cause loss of vision.

Skin lesions can also become infected with bacteria if blisters are broken by scratching. Paralysis of cranial, peripheral, and visceral nerves occurs, especially in immunosuppressed patients. In disseminated herpes zoster, there could be other complications as pneumonitis, hepatitis, and encephalitis.

How is shingles diagnosed?

Your doctor will first ask you about your medical history looking for evidence about previous chickenpox infection.

After that, the doctor will ask about symptoms and look through the physical examination typical findings of shingles. This mostly includes the location and appearance of skin injuries like rashes or ulcerations.

Most of the time, just by these three simple elements, it is possible to diagnose the disease and start treatment right away. However, laboratory tests can be useful in patients who do not have a typical presentation of this infection as in people who have their immune system compromised or diminished.

Laboratory tests

For most people, confirming the diagnosis through laboratory tests is not generally useful. Most of the tests just consume time or fail to give accurate results.

The polymerase chain reaction (PCR) is the first option. It detects the genetic material of the virus in a fluid sample from the blister or vesicle. In the absence of vesicle fluid, there are many other acceptable samples for this procedure.

Plasma DNA can also be identified, allowing early recognition of VZV infection in immunosuppressed individuals. Also, the direct immunofluorescence assay (DFA) can be an alternative to PCR in some cases.

The Tzanck smear under a microscope is one of the most economical and simple methods. It can detect changes that are typical of herpes infections. However, it cannot distinguish between VZV and other herpes viruses. Therefore, it is very inconclusive, and it could also fail to recognize the disease.

What is the treatment for shingles?

Nowadays, there is no cure or way to eliminate herpes zoster. Treatment involves reducing the pain (most debilitating symptom), shortening the virus impact, and preventing complications.

Antiviral medication does not completely eliminate the virus and is not a cure, but prevents the virus from multiplying and reduces pain, the duration of symptoms, and the prevention of complications like postherpetic neuralgia.

In general, the most widely used antiviral medicines include acyclovir, famciclovir, and valacyclovir. The treatment should start no later than seventy-two hours after the rash onset to avoid possible complications or severe symptoms.

Painkillers

For pain management, it depends on the intensity of the pain. People with mild pain can treat it with non-steroidal agents (AINES). For people with more severe pain and who don’t respond to analgesics, there are other options available like opioids that can relieve the pain.

Systemic corticosteroids

Corticosteroids help to relieve acute pain. Corticosteroid therapy is only beneficial when combined with an antiviral drug.

Topical treatments

We find topical creams like 5% acyclovir, calamine, capsaicin, and lidocaine regarding the topical treatment available. It will depend on the specific case, but people can put the cream on the rash or blisters to calm the pain.

Anticonvulsants

Oral anticonvulsants such as gabapentin can reduce chronic pain in patients with PHN.

How do you dry out shingles blisters?

The skin rash will have its own course depending on the underlying conditions the patient has plus if the patients start treatment or not. By now, oral antiviral treatment taken early, before seventy-two hours, helps patients cope with symptoms and causes the skin rash to wane earlier than without treatment.

The pain caused by herpes zoster blisters can significantly reduce functional status and quality of life, so it is important to treat them early. In addition to antiviral drugs, there are topical complementary treatments to relieve the pain caused by these lesions. 

The lesions on the skin must always be clean and dry. Clean or sterile dressings that are not occlusive or adherent can help to cover and protect the blisters. It decreases the pain or itching and prevents bacterial infection secondary to scratching.

Within the topical treatment used to soothe the pain and protect the infected skin, there is:

  • Acyclovir 5%
  • Calamine
  • Lidocaine
  • Capsaicin

Is there a vaccine available to prevent shingles?

There is currently two shingles vaccine available in the United States to reduce the probability of developing the disease and its complications through shingles vaccination.

Zostavax® is an available zoster vaccine since 2006. It is beneficial for adults 60 years and older to prevent herpes zoster and post-herpetic neuralgia.

Shingrix® is another zoster vaccine available since 2017. It is more than ninety percent effective in preventing herpes zoster and post-herpetic neuralgia. It also maintains its effectiveness for at least four years. Its administration is a two-dose injection, the second dose two to six months after receiving the first one.

It is a strong suggestion to give the vaccine to all persons over or equal to fifty years of age, including those who received the Zostavax® more than two months previously. As you may imagine, you can get both of them, but it would be better to receive Shingrix®.

However, sadly, not everyone can receive Zostavax or Shingrix vaccine. There are situations in which the two of them cannot be given. Please consult your doctor before any health-related decision.

What can be done for recurrent shingles?

Constant reactivation of varicella zoster is very rare. If you already had herpes zoster before, it is not very likely for you to have the infection again. The estimations are that 5% or less will have shingles again in the future.

However, Recurrent shingles usually occur in people who have a severely weakened immune system. These high-risk people comprise the ones with an underlying disease such as cancer, lymphoma, HIV, and those over fifty years old when they first had shingles. Also, people taking treatments that suppress their immune system are at greater risk.

It has been shown that people who have had shingles and persistent pain for more than thirty days (postherpetic neuralgia) are at greater risk of developing other episodes of shingles.

In recurrent reactivation, VZV viral replication persists, and it is out of control, causing herpes zoster symptoms to remain for several months.

Recurrent shingles cannot be prevented, but it is possible to reduce the risk of getting it by having the vaccine. Even people who have already had the first episode of shingles can receive the vaccine to prevent the virus’s reactivation. 

In addition to vaccination, the best way to avoid complications is antiviral treatment during the first 72 hours after the first injury and receiving pain relief medication.

How long should you stay at home with shingles?

During the acute or eruptive phase, persons are highly infectious and contagious to other people. When the vesicles begin to appear with liquid content inside them until the last of them dry out and form a crust, which takes about two to four weeks to do so. Then, in that precise moment of a crust formation in the last skin lesion, that person is not spreading the virus anymore. Neither before having the blisters nor after having the last crust you can transmit VZV. 

During that time, you should avoid contact with:

  • Pregnant women who have never had chickenpox or who have not had the chickenpox vaccine.
  • Babies that are born with a lower weight, or newborn children.
  • Babies born before thirty-seven weeks of pregnancy (a normal pregnancy lasts between 37 to 42 weeks).
  • Overall children.
  • People who have a compromised immune system such as people with human immunodeficiency virus (HIV) or AIDS, cancer, and so on. 
  • It would be best to avoid contact with all people who do not have the chickenpox vaccine or previous infection with chickenpox.

People with shingle injuries must cover them up and avoid contact with susceptible people (without chickenpox vaccine or past-chickenpox infection).

Can you catch it from someone?

You cannot get shingles from someone with herpes zoster. But if you had never had chickenpox or the chickenpox vaccine, you can get the chickenpox from someone who has shingles.

Therefore, it is the same because later, after you had chickenpox. Then, you could develop shingles in the long run.

What can be mistaken for shingles?

Herpes simplex can be mistaken for Shingles due to the distribution of lesions in the dermatome that resemble herpes zoster, requiring laboratory tests to confirm the diagnosis.

The main difference is that herpes simplex presents blisters around the oral cavity and the genitals; these are known as oral and genital herpes, respectively. In herpes zoster, lesions are in the form of a strip affecting one dermatome on the chest, back, and even the face.

It can also be mistaken for additional affections like eczema, psoriasis, contact dermatitis, among others.

Do you have symptoms of this infection?

This is a Shingles Symptoms Checker. It gathers the most important signs, symptoms, and risk factors for this infection. Therefore, the tool will tell anybody who uses it the likelihood of their symptoms because of shingles. Using this tool is free and would only take a few minutes.

What do you think?

Written by Dr. Esteban Kosak

Doctor of Medicine - MD Recently Graduated from Medical School and inspired to aid the global population during this situation. I think that we shall no longer be waiting to see a doctor when we feel sick. Several times we feel disease searches in Google drive us to a rabbit hole and come out thinking that we may die of cancer or something very serious, given that symptoms may seem to fit a wide variety of illnesses. Since I recently graduated from medical school. I have all the medical information fresh in my mind. My thorough experience as an expert researcher allows me to very-well known the different diseases and conditions that affect human bodies. Empowered by the United Nations 17 Sustainable Development Goals (SGDs). I think that we all can provide a grain of sand to help humanity. That's why we created Symptoms.Care a place where you can come and screen your symptoms and find what different illnesses can be related to them. Armed with the right information you can instantly, discretely, secure and from the comfort of your home talk with a Doctor that can Evaluate your Symptoms and help you seek the right treatment.

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