Shingles

What are Shingles?

Shingles or Herpes Zoster is a skin condition characterized by a painful itching rash which can occur over multiple body areas. Anyone who has had a previous history of chickenpox or the immunization against the chickenpox virus can develop this disorder. Both the chickenpox virus (varicella) and the shingles virus are related. It is thought that the initial chicken pox virus remains in a dormant state for many years. With the appropriate stimulation, i.e. stress, infection, heat, cold or time, the chicken pox virus can reactivate and cause the shingles rash to occur.

Fig. 1 Swelling and early blistering around forehead and left eye- a medical emergency.

Who is affected by shingles?
 
All sexes and races are equally susceptible to shingles though this disorder occurs more commonly in those over the age of 50. It is estimated that over 20% of the total population can expect to suffer from shingles during their life span. Prior to the AIDS epidemic, approximately 300,000 to 400,000 cases of Herpes Zoster (Shingles) occurred yearly in the United States. Those who have a suppressed immune system from such factors as advanced age, Diabetes, cancer or HIV infection have a significantly higher rate of Shingles development. Some clinical studies suggest that shingles can be a marker for certain types of cancer, however, this is still under investigation and no definitive conclusions have been made as to whether this hypothesis is true.

  Fig. 2   Shingles-occurring in a dermatome or an area of the skin characterized by a nerve group. 

What are the symptoms of shingles?
 
The main symptoms of  Shingles are burning and itching. This often occurs in  a localized region of the skin that  is defined by a nerve grouping. Discomfort usually begins from one to two days before the blistering rash develops. Fever, chills, cough or headaches may accompany the initial symptoms. When the rash is full blown, it is characterized by a "clustered" group of blister. Blisters occur over a dermatome or segment of the skin which is defined by a localized group of nerve fibers. Blisters can last up to two to three weeks depending on the immune system status of the affected individual. Pus can also be noted in the blisters, however, this is only temporary because the blisters usually crust over and disappear by seven to ten days.

How intense is the pain from a shingles infection?
 
Pain can be mild or severe with a shingles eruption. Some patients may experience pain that lasts for several months or sometimes years after a shingles flare. This occurrence is referred to as  Post Herpetic Neuralgia. Dr. Harvey and Dr. Hardy can employ various pain control measures to alleviate a patient's discomfort. In extreme cases, nerve blocks or surgery may be indicated. 

Where does a shingles eruption usually occur?
 
The trunk or the chest area is the most frequently affected area of the skin followed by areas of the lower back, face, neck and buttock regions. Widespread shingles can also occur and is considered a life threatening emergency. This can be seen in infants or those with a very low immune capacity. When shingles affects the nose or the cheek, one must be concerned about the potential for eye involvement (see Fig. 1). This is because those nerves which innervate the face and nose can also send signals to the eye. For this region, Dr. Harvey and Dr. Hardy may recommend that an eye physician be consulted immediately if a group of small, clustered blisters appears on your nose or forehead. A delay in  such an evaluation may place a patient at risk for visual loss due to eye scarring.

What other complications can arise as a result of shingles?
 
Besides the risk of pain and visual loss, shingles can result in a secondary bacterial infection of the skin. In these instances, antibiotics and skin cultures may be necessary.

How is the diagnosis of shingles made?
 
The clinical exam is the most common way in which Dr. Harvey and Dr. Hardy makes the diagnosis of shingles. Sometimes blister fluid may be cultured  or sampled for its cellular makeup. Affected "shingle" cells tend to form clumps in a balloon pattern. If there still a doubt as to the diagnosis, Dr. Harvey and Dr. Hardy can biopsy the rash to determine the exact diagnosis.

Fig. 3. "Balloon like cells" seen from a microscopic evaluation of blister fluid

Is a Shingles eruption contagious?
 
Yes, but less so than the initial chicken pox infection which occurred years earlier. Newborns and those patients with a suppressed immune system are at high risk as previously mentioned. Contact with the blister fluid is necessary for viral spread so it is important to be careful not to touch a blister that has fluid in it. 

Can scarring occur with Shingles?
 
Scarring can occur in patients who have a widespread disease or whose treatment is resistant to antiviral medications. Thankfully, scarring is not a common occurrence when a shingles eruption occurs.

What are some of the treatments available for shingles?
 
Antiviral agents such as acyclovir, Valtrex^™ or Famvir^™ are first line medications for the treatment of shingles. These medications work through inhibiting viral replication. Dr. Harvey and Dr. Hardy can also prescribe topical treatments such as Denavir^™ cream, oatmeal baths or corticosteroid creams to help with symptoms of itching or burning. Finally, for those cases in which intense pain develops, anesthetic creams or nerve blocks may be employed.

Dr. Harvey and Dr. Hardy may recommend one of the following treatments

• Valtrex^™ 500mg to 1000mg three times a day.

• Acyclovir^™ 800mg 5 times a day.

• Famvir^™ 500mg three times a day.

• Elavil^™ as directed to help with pain

• Tumescent anesthesia with cortisone to help with pain and inflammation.

• Aveeno^™ oatmeal baths as directed. 

• Vicoprofen^™ to help with pain and inflammation.

• Prednisone to help with pain and inflammation.

• Avoid picking or scratching at fresh blisters as this can increase the risk of spreading a shingles infection.

• Do not take aspirin if you have shingles as flu like symptoms may occur.

• Immune globulin injections as directed by Dr. Harvey and Dr. Hardy.

• An eye exam is required for shingles which occurs on the cheek or nose.

• If you suffer from repeated bouts of shingles, a thorough physical examination is required.

• For uncontrolled pain, a neurology or pain evaluation assessment may be needed.

If you have any questions, or wish to schedule a  consultation, please call  Ponte Vedra Dermatology & Aesthetic Surgery at (904) 285-7546 or email consultation@pvderm.com.