You might think it’s “just a rash,” but fluid-filled blisters are the mildest of symptoms that can include debilitating, never-ending pain.
Dr. Jan Patterson. Published in Wise & Well
Dr. Bill Nichols, a friend of mine, recently went through a horrible, preventable ordeal, suffering a severe case of shingles that left him wishing he had gotten the shingles vaccine.
“Anytime I have an opportunity, I tell people to get the Shingrix shot,” Nichols said. “I’ve survived therapy for three different cancers, and I’ve had a stroke. But I can tell you when I had shingles around and inside my eye, it was the most frightening thing I’ve ever experienced. If I’d had the vaccine, I could have avoided 11 hospital days, difficult medications, misery, fear, and potential life-long painful effects. Don’t take a chance.”
In addition to seeing severe cases of shingles in the hospital that required intravenous therapy, I’ve personally known many other people who have endured shingles. One of my friends had recurrent shingles (before Shingrix was available) in the ear, which resulted in hearing loss, and she now requires a hearing aid. My mother had it on her forehead and was left with long-lasting pain in the area.
Anyone who has had chickenpox, which is more than 90% of people born in the United States before 1980, is at risk for shingles. One in three unvaccinated people over 50 years old will get shingles. Half of unvaccinated people over 85 years old will get it.
Blisters, itching, and sometimes extreme pain
In a typical presentation of shingles, the nerve involvement initially causes pain, tingling or itching in the distribution of the nerve. After the pain, over the next few days, a skin rash begins with small red spots. These spots progress to small, fluid-filled blisters that contain the virus. The nerve pain usually becomes severe at this stage. The pain is extreme for many people. On a pain scale of one to 10, patients say the pain ranges from six to 10.
After about seven to 10 days, the blisters drain, and a scab is formed. Typically, the rash becomes very itchy at this stage. In most cases, scabs heal in a couple of weeks, although it is possible for the rash to become infected with skin bacteria at the scab stage, requiring anti-bacterial antibiotics.
In about 10–18% of people, the nerve pain remains after the rash is gone. This so-called post-herpetic neuralgia can last for weeks, months, or years and be debilitating. It is more common in older adults. With this neuralgia pain, even the feeling of clothing can be painful. It can significantly limit daily activities, and cause insomnia, depression, anxiety, and weight loss.
If the rash occurs around the eye or the ear, vision or hearing can be affected. When the infection affects the ear and/or the nerve on the side of the face, it is called Ramsay Hunt syndrome and can cause loss of hearing or partial paralysis of the face.
Also, shingles can disseminate to other parts of the body, including the lungs and other organs, in immunosuppressed people. Intravenous antiviral therapy is usually required if vision or hearing is threatened, or if there is a suppressed immune system. In milder cases, oral antiviral therapy may be used, if started early.
Rarely, shingles can occur without the rash. This is known as zoster sine herpete in the medical world or may also be called internal shingles. This presents as pain or burning along the distribution of the affected nerve.
Also, a study (done before an effective vaccine) showed that shingles can increase your risk of heart attack or stroke. The risk is highest in the first year after you have shingles and decreases over time.
Let’s look at what chickenpox has to do with shingles.
What causes shingles?
It helps to understand the virus that causes shingles. This is herpes zoster, or varicella virus. It is the same virus that causes chickenpox, called varicella by those in medicine. Chickenpox, easily recognized because of the characteristic rash appearing like small blisters on the torso, legs, and arms, is a mild illness in most people. It typically occurred in young children in the U.S.
While it is a mild disease in most children, some children would get a serious bacterial infection of the blisters and die of overwhelming infection. Also, pregnant women or immunosuppressed people who have not previously had chickenpox can become seriously ill with it.
This is why the varicella vaccine was developed for children and released in 1995. Since the use of the vaccine in children, chickenpox is much less common. Those who have had the varicella vaccine also have much less risk of getting shingles.
After the chickenpox blisters scab over, the skin typically heals and there are no more signs of chickenpox. (Unless you are like me. Despite my mother’s admonitions, I scratched the blister on my temple so much it left a small scar.)
However, the varicella (herpes zoster) virus has not gone away in people who’ve had chickenpox. It lives in the nerve roots of the body and is present but not visible—latent, in medical terms. As people age and immunity wanes with time, the virus can activate along a nerve root. Instead of a rash all over the body as with chickenpox, the shingles rash occurs along the distribution of the affected nerve.
The affected nerves are usually the ones on the torso that run parallel to the ribs, as in the red lines on the illustration below. It also commonly occurs on the scalp and areas around the eye and ear, in the area within the red lines on the illustration. But shingles can affect any nerve.
Who Is at risk for getting shingles?
The biggest risk factor is older age, especially over 50 years old. Other significant risk factors are immunosuppression, cancer, family history of shingles, and physical trauma. Some significant but lesser risks are psychological stress, female sex, and medical illnesses including diabetes, rheumatoid arthritis, heart disease, inflammatory bowel disease. In some studies, Black people are at lower risk of getting shingles, for reasons unknown.
The shingles vaccine for adults is different from the varicella vaccine used in children.
The first shingles vaccine, Zostavax, was released in 2006 for people over 60 years old. It was only about 50% protective against developing shingles but was 70% protective against neuralgia. This vaccine was also limited because it used a live virus, which could cause a disseminated infection if administered to immunosuppressed persons. Zostavax is no longer available in the United States.
An effective and safe vaccine?
In 2017, a more effective shingles vaccine, Shingrix, was released for people over 50 years old. It has several advantages over the previous vaccine. It is more than 90% effective against shingles. A preliminary study even shows that Shingrix might decrease the risk of dementia–another potential benefit.
It is not a live vaccine, but a recombinant vaccine, which means that only the part of the virus that gives immunity is replicated in the laboratory and used.
Shingrix vaccine is given in two doses. The second dose is two to six months after the first dose. Most people get the second dose at six months, but an immunosuppressed person may get it at two months, depending on the physician’s recommendation.
Are there side effects from the vaccine?
The most common side effects are pain, redness, and swelling at the injection site. It is not uncommon to get muscle pain, tiredness, upset stomach and fever — like a mild case of the flu — after the second dose.
After the vaccine was marketed, the FDA noted that there was a small (3 cases in 1 million) increased risk of Guillain-Barre syndrome. In this rare disorder, the immune system attacks the nerves and results in severe muscle weakness. Treatment for the syndrome includes intravenous immunoglobulin which contains healthy antibodies. Most people make a full recovery within a year. About 20% of people may have some long-term residual effects. It is more common for Guillain-Barre Syndrome to occur after some bacterial or viral infections than after the vaccine.
Despite the effectiveness of Shingrix, only about 25–30% of eligible persons have been vaccinated. Many people are not aware of the severe complications of shingles that can include persistent pain, loss of hearing, or effect on vision. Some are not aware there is a vaccine for shingles. People may also be hesitant to get vaccines due to the misinformation and politics around the Covid vaccine.
Take action to prevent shingles
Don’t take the risk of persistent pain, loss of vision or hearing when there is an effective vaccine to avoid these complications. The side effects from Shingrix are usually mild and may include some flu-like symptoms. For this reason, I’d suggest not getting the vaccine right before a trip, or a few days before some big weekend plans. Regarding Guillain-Barre Syndrome, it is very rare and your chances of getting a complication from shingles is much higher.
Are there other things you can do to prevent shingles?
“Don’t age” would be helpful advice, were it practical. Looking at the risks outlined above, controllable factors to decrease the risk could be avoiding psychological stress and staying healthy to avoid diabetes and heart disease. Children who get varicella vaccine are much less likely to get shingles because most avoid chickenpox.
There is usually no out-of-pocket cost for Shingrix vaccine in most of those eligible. Medicare Part D covers it, as do most private insurance plans.
Where can you get Shingrix? Check with your healthcare provider or nearby pharmacy to see if they have it. If not, there is a Shingrix vaccine locator to help you find a pharmacy or provider near you that has it.
If you’re not yet 50 years old, you may have some loved ones who are, so you can let them know about the vaccine, and how they can lower their risk of getting shingles.
If you’re eligible, make your plans to get the vaccine. Don’t take the risk of getting one of the most common, annoying, and painful conditions that is almost 100% preventable.
This information is intended to provide useful information on the topic discussed. It is not intended to diagnose or treat any medical condition. Please be sure to discuss any conditions regarding your health with your own healthcare professional.
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