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Shingles - All you need to know

Last updated date: 12-Jun-2022

CloudHospital

19 mins read

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Shingles is a type of viral infection also known as herpes zoster. The fundamental cause of this infection is the varicella-zoster virus, which is a similar trigger for chickenpox. Despite recovering from the chickenpox infection, the viruses can remain in the nervous system for several years. This is before they reactivate as shingles. 

Typically, shingles is associated with a red skin rash that may result in pain, inflammation, or burning. This infection also manifests as a line of blisters on a single section of the body, mainly the torso, face, and neck. Fortunately, shingles rarely develop more than once in a person and most cases clear up after two or three weeks. 

It is thought that zoster is caused by the immune system's inability to manage the virus's latent replication. The occurrence of herpes zoster is significantly linked to one's immunological condition. Individuals with a high degree of immunity are less likely to acquire shingles. The virus is not harmless and can manifest itself in a variety of ways. Even after herpes zoster has healed, many individuals experience moderate to severe pain, known as postherpetic neuralgia. 

 

Epidemiology

Herpes zoster occurs at a rate of 1.2 to 3.4 per 1000 people per year in younger, healthy people, but at a rate of 3.9 to 11.8 per 1000 people per year in patients over the age of 65. With herpes zoster, there is no seasonal fluctuation.

It is predicted that around 2 out of every 10 persons who have had chickenpox will get shingles later in life. The majority of persons who have shingles are above the age of 50. The risk of shingles increases with age because our immune systems weaken with age. Every year, over 300,000 people in Germany contract shingles.

 

Causes of Shingles 

As stated above, the primary cause of shingles is the varicella-zoster virus, which is also responsible for causing chickenpox. A person who has had chickenpox is at a higher risk of developing shingles. This is because the virus gets into the nervous system after healing from chickenpox and remains dormant for several years. 

In the long run, it tends to reactivate and move through the nerve path into the skin, resulting in shingles. However, not every person who has chickenpox gets shingles eventually.

The major reason for getting shingles is unknown. Nonetheless, medical specialists believe that low immunity and increased chance of infections due to old age are important factors. As such, shingles virus is more common among older individuals and in immunocompromised people.

A varicella-zoster virus is a form of herpes virus, which also involves viruses that lead to genital herpes and cold sores. It's for this reason that shingles are also referred to as herpes zoster. However, the virus responsible for both shingles and chickenpox is not similar to the viruses that cause cold sores or genital herpes, which is a sexually transmitted disease. 

 

Risk Factors Associated with Shingles 

Some of the risk factors that can increase the chances of developing shingles disease are; 

Over 50 years old: Medical research studies indicate that shingles are more common among individuals who are above 50. Typically, the risks of developing shingles elevate with age. 

Cancer treatment: Therapies such as chemotherapy and radiation therapy tend to minimize the body's resistance to various diseases. This increases the risk of shingles or even triggers the infection. 

Certain health conditions: Illnesses that weaken the body's immune system, including cancers and HIV/AIDS, can increase the possibility of developing shingles. 

Certain drugs: Medications that are prescribed to prevent transplanted organ rejection can sometimes increase the chances of shingles. Also, extended use of steroids, including prednisone, can trigger shingles infection. 

 

Pathophysiology

Cutaneous herpes zoster lesions induce Varicella-zoster virus-specific T-cell proliferation, whereas interferon-alfa production results in herpes zoster resolution. Specific antibodies (IgG, IgM, and IgA) develop faster and reach larger titers in immunocompetent individuals after reactivation (herpes zoster), resulting in long-lasting, increased cell-mediated protection against the varicella-zoster virus.

The dermatological involvement is centripetal and follows the path of a dermatome. In most cases, the lumbar and cervical roots are implicated, with motor involvement being uncommon. The illness is communicable to people who have never had varicella-zoster, although the rates of transmission are minimal. The virus can be spread by direct skin contact or breathing contaminated droplets.

It is critical to understand that herpes infections can occur concurrently. Herpes simplex, CMV, EBV, and human herpesviruses have all been identified in shingles patients.

 

Signs and Symptoms of Shingles

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The early signs and symptoms of shingles involve burning and pain. The pain usually affects a small part of one section of the body.

Other common signs and symptoms you are likely to notice include: 

  • A red rash that starts a few days following the pain 
  • Itching 
  • Numbness and tingling 
  • Development of fluid-filled blisters which can break open and crust 
  • Touch sensitivity 

Other individuals can also experience the following symptoms:

  • Fatigue 
  • Headache 
  • Fever and chills 
  • Sensitivity to light 
  • Muscle weakness 

For some, the pain associated with shingles can be mild or intense. However, based on pain location, it may be misdiagnosed with symptoms of kidneys, heart, or lung issues. Other people can experience pain but not develop the rash. 

Clinically, lesions begin as densely packed erythematous papules that quickly develop into vesicles on an erythematous and edematous base and may appear in continuous or discontinuous bands in one, two, or more adjacent dermatomes unilaterally. Thoracic (53%) cervical (20%), and trigeminal (15%) dermatomes, including ocular and lumbosacral, are the most typically implicated (11 %).

The shingle rash usually appears as a band of blisters that coils around the right or left side of the chest. Shingles can also appear around one eye or on one side of the face or neck.

Ramsay Hunt syndrome type II is another name for Shingles oticus. It is caused by the virus moving from the facial nerve to the vestibulocochlear nerve, which affects the ear and causes hearing loss and vertigo.

If the maxillary or mandibular divisions of the trigeminal nerve are damaged, a zoster can arise in the mouth. It manifests clinically as vesicles or erosions on the mucous membrane of the upper jaw (palate, gums of the upper teeth) or the lower jaw (tongue or gums of the lower teeth). Oral involvement can develop alone or in conjunction with skin lesions along with the cutaneous distribution of the same trigeminal branch.

Because of the intimate link between blood vessels and neurons, the virus can spread to include blood vessels, affecting blood flow and causing ischemia necrosis. It can lead to complications such as osteonecrosis, tooth loss, periodontitis, pulp calcification, pulp necrosis, periapical lesions, and tooth developmental abnormalities.

The most commonly implicated branch in ophthalmic zoster is the ophthalmic division of the trigeminal nerve. The skin of the brow, top eyelid, and eye orbit may be affected. It occurs in around 10% to 25% of individuals presenting with keratitis, uveitis, and optic nerve palsies.

Complications such as persistent ocular inflammation, vision loss, and incapacitating discomfort are possible. 

It is not unusual for the Central Nervous System to be involved. Because the virus lives in the sensory root ganglia, it can damage any portion of the brain, resulting in cranial nerve palsies, muscle weakness, diaphragmatic paralysis, neurogenic bladder, Guillain-Barre syndrome, and myelitis. Patients suffering from severe instances may acquire encephalitis.

 

Stages of Shingles 

The majority of shingles stages usually last for three to five weeks. When the varicella-zoster virus first reactivates, you can experience tingling, itching, burning, or numbness beneath the skin. Generally, shingles  normally appear on one side of the body, most often on the chest, back, or waist.

The three phases of the infection include:

  • The pre-eruptive stage is characterized by atypical skin sensations or discomfort within the afflicted dermatome. This stage emerges at least 48 hours before any visible lesions. At the same time, the person may suffer from headaches, general malaise, and photophobia.
  • The vesicles and symptoms found in the pre-eruptive phase distinguish the acute eruptive phase. The lesions begin as macules and swiftly evolve into painful vesicles. The vesicles frequently burst, ulcerate, and finally crust over. Patients are most infectious at this period when the lesion dries off. During this stage, pain is intense and generally resistant to conventional pain drugs. The period may last 2-4 weeks, although the pain may persist.
  • Chronic infection is recognized by recurrent pain that lasts for more than four weeks. Patients also report paresthesias, shock-like sensations, and dysesthesias in addition to pain. The agony is incapacitating and might linger for a year or more.

 

Shingles on the buttocks 

A shingle rash can sometimes appear on the buttocks. Shingles usually impact one side of the body at a time. This means you may get a rash on the right buttock and not on the left. Just like other parts of the body, shingles on the buttocks can trigger tingling, discomfort, and itching at first. A red rash and blisters can also appear after a few days. Other patients experience pain but may not have a rash.

 

Is Shingles a Contagious Infection? 

An individual with shingles can pass the varicella-zoster virus to a highly vulnerable person, hence causing chickenpox. 

Shingles can only affect a person who has had chickenpox. On the other hand, someone with shingles can pass chickenpox to an individual who is not yet immune to the varicella-zoster virus. One can develop immunity either through vaccination (chickenpox vaccine) or naturally by having the disease. 

In shingles, the reactivated varicella-zoster virus can spread through direct skin contact. This includes touching the shingle’s blisters or being in contact with a highly vulnerable person. Therefore, if you are diagnosed with shingles, it’s essential to avoid contact with people who have not had chickenpox infection, vaccine, or have a weakened immune system, such as the infants and elderly. 

 

Shingles and pregnancy

Shingles in pregnancy may not seem to trigger birth abnormalities or complications to the infant in the uterus. However, when an expectant woman gets chickenpox 21 to 5 days before giving birth, the baby may develop the infection at birth or after a few days. The baby has a small chance of developing shingles within the first five years of life. This is because the immune system may not maintain the varicella-zoster virus latent following the previous chickenpox infection. 

 

Shingles diagnosis

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Shingles diagnosis usually depends on the rash, type or nature of pain, and other associated signs. Also, in the absence of a rash, the extent of pain, as well as other skin feelings, can be sufficient to give a diagnosis. Sometimes, the doctor can scrape a piece of the skin or collect a sample of blister fluid for lab testing. If the results prove that it’s shingles, then the varicella-zoster virus may be present. 

If you notice any shingle symptoms, then do not wait for a rash to develop before contacting the healthcare provider. This is because not everybody with shingles gets a rash. So, the earlier you start shingles treatment, the lower the chances of having a more serious infection or complications.

Tests for the varicella-zoster virus include the following:

  • Tzanck smears of vesicular fluid reveal multinucleated large cells. Its sensitivity and specificity are lower than those of direct fluorescent antibody (DFA) or polymerase chain reaction (PCR) (PCR).
  • Varicella-zoster virus-specific IgM antibody is identified in blood during active chickenpox or shingles infection but not when the virus is latent.
  • When there is ocular involvement, direct fluorescent antibody testing of vesicular fluid or corneal fluid can be performed.
  • In cases of eye involvement or widespread infection, PCR testing of vesicular fluid, a corneal lesion, or blood is performed.

Molecular biology tests that use in vitro nucleic acid amplification (PCR tests) are now thought to be the most trustworthy. The nested PCR test has a high sensitivity but is prone to contamination, resulting in false-positive findings. The most recent real-time PCR techniques are fast, simple to use, as sensitive as nested PCR, have a decreased chance of contamination, and are more sensitive than viral cultures.

 

Treatment of Shingles Infection 

Shingles treatment options tend to vary depending on the patient's age, nature of the infection, and other medical conditions. The treatment aims at relieving the discomfort and pain that come with shingles episodes. It also helps prevent additional complications from occurring. 

Generally, there is no specific cure for shingle infections. However, some of the available shingles medications that can help address the condition include:

Antiviral medications:

Shingle’s antiviral drugs can help reduce the seriousness and duration of the infection. These medications can also minimize the chances of postherpetic neuralgia, a chronic complication associated with shingles.   

Antiviral medications are usually effective from 72 hours after developing shingles' signs and symptoms. They include acyclovir, valacyclovir, and famciclovir. 

Antiviral medications are not recommended for everyone who has shingles. In general, patients who experience shingles should take the antiviral medication if they fall into one of the following categories: 

Over 50 years old: As a person gets older, they become more vulnerable to getting serious shingles and associated complications. Hence, the possibility of recovering faster after the treatment. 

Any age bracket and have one or more of the following; 

  • Shingles in the eye or ear
  • A compromised or poorly functioning immune system
  • Shingles affect any area of the body other than the trunk. This includes shingles on the legshingles on the scalp, shingles on the arm, and shingles around the genitals
  • Mild or severe shingle rash 
  • Moderate or chronic pain

 

Pain medication:

Pain relievers such as paracetamol or co-codamol (combination of paracetamol and codeine) and anti-inflammatory drugs like ibuprofen can provide relief. In certain circumstances, potent painkillers, including tramadol and oxycodone, may be required. 

Certain pain relievers are particularly beneficial for shingles nerve pain. If the shingles pain is serious, or if you have postherpetic neuralgia, the doctor might recommend you to take the following medications:

  • An antidepressant medication in the tricyclic category. This medication is not used to relieve depression in this case. Tricyclic antidepressants, including amitriptyline, nortriptyline, and imipramine, alleviate nerve pain (neuralgia) in addition to their antidepressant function. 
  • An anticonvulsant medication, including pregabalin or gabapentin. In addition to controlling convulsions, they alleviate neuralgic discomfort. 

When an anticonvulsant or antidepressant is recommended, you need to take it on a daily basis according to the prescription. It could take two or three weeks for it to be completely effective in relieving pain. They can help to avoid postherpetic neuralgia in addition to relieving pain during a shingles episode. 

 

Steroidal drugs:

Steroids aid in minimizing swelling and inflammation. In addition to the antiviral drugs, a short course of steroid tablets known as prednisolone can be considered. This could help to alleviate discomfort and hasten the shingle’s healing process. Nonetheless, the use of such steroids drugs in the treatment of shingles is somewhat controversial. Due to this, your medical provider will give you some advice on this form of medication. You should, however, note that steroids do not protect against postherpetic neuralgia. 

 

Treating Postherpetic Neuralgia 

Postherpetic neuralgia treatment comprises creams and lotions, including capsaicin or lidocaine and other medicines not particularly intended for pain. They include epilepsy medications or antidepressants. Ordinary pain killers are normally ineffective in dealing with this form of pain.

Certain treatments, including steroid shots or nerve blockers at the region where the nerves leave the spine, can be sought if the discomfort does not subside. For intense, persistent pain that fails to respond to other therapies, implantable nerve stimulator devices are an alternative.

 

Home Remedies for addressing Shingles 

Comprehensive shingles self-care at homes involves the following; 

  • Applying calamine lotion and other essential creams to ease discomfort and soothe the skin 
  • Gently clean the shingle rash area to avoid bacterial infection.
  • Applying cool compresses to the shingles blisters to help reduce discomfort and speed up healing. 
  • Regularly taking water and other nutritious beverages.
  • Resting more often. You can consult the doctor for the pain medication prescription if you cannot sleep because of the pain. 
  • Minimizing shingles stress by taking walks each day and consuming healthy foods. 

 

Shingles vaccine

There are two main vaccines available to help lower the risk of contracting shingles as well as postherpetic neuralgia. Zostavax, one of the vaccines, has been available since 2006. Shingrix, the other vaccine, has been available since 2017. The Food and Drug Administration (FDA) recommends Shingrix as the alternative vaccine.

Shingrix, also called recombinant zoster vaccine, is usually administered as a two-dose upper arm injection. The second dose (injection) should be administered two to six months after the first shot. Typically, Shingrix has been proven to be more than 90 percent successful and effective in postherpetic neuralgia and shingles prevention. Its efficacy has been over 85 percent for four years following the vaccine administration.

However, it should be noted that shingles vaccination does not assure you that you will not develop shingles. Nonetheless, this vaccine is expected to shorten the shingles duration and seriousness. It also helps lower the possibility of postherpetic neuralgia. 

In addition, the shingles vaccine is only beneficial as a preventative measure. It is not meant to treat patients who are still infected with the disease. Consult the doctor to determine which alternative is best for you. 

 

Who Can Receive The Shingrix Vaccine? 

FDA approves the Shingrix vaccine for people aged 50 and over and are in great health. Also, you can have the Shingrix vaccine regardless of the following; 

  • If you have already developed shingles 
  • If you recently received Zostavax, a zoster vaccine. You should, however, wait for about eight weeks before receiving the Shingrix vaccine. 
  • If you are not certain whether or not you’ve had chickenpox before

On the contrary, one should not get the Shingrix vaccine if they; 

  • Are pregnant or breastfeeding 
  • Have had a chronic allergic reaction to the vaccine or a particular ingredient 
  • Have shingles at the moment 
  • Are slightly sick or severely ill and experiencing high fever 
  • Test negative for being immune to shingles zoster virus 

 

Side Effects Associated with Shingrix Vaccine 

Intense shingles shot side effects are very rare. But in case you develop any of the following symptoms within minutes or hours of getting Shingrix, go to the nearest healthcare facility right away; 

  • Facial or throat swelling 
  • Hives 
  • Breathing difficulty 
  • Increased heart rate 
  • Lightheadedness, dizziness, and fatigue

 

Complications of Shingles 

Some of the possible complications of shingles are; 

Postherpetic neuralgia: This is a common complication of shingles. It’s a condition in which the shingle’s pains persist for an extended period even after the blisters clear. It occurs if the damaged nerve fibers transmit exaggerated and confused signals of pain to the brain from the skin. 

Vision problems: Shingles around the eye can lead to inflammation within the front part of the eye. If the condition becomes intense, it could result in inflammation of the entire eye, and this could cause vision loss. 

Skin infection: Occasionally, the shingles rash gets infected with bacteria or germs. As a result, the nearby skin turns red and warm. In case this happens, you might require a course of antibiotics. 

Weakness: Occasionally, the affected nerve can be a motor nerve that controls and regulates muscles rather than the normal sensory nerve responsible for touch. This can cause weakness or palsy in the muscles that the nerve supplies.

Neurological issues: Based on the affected nerves, shingles can sometimes lead to encephalitis (brain inflammation), balancing and hearing problems, and facial paralysis. 

 

Differential Diagnosis

Herpes zoster cutaneous lesions must be distinguished from herpes simplex, dermatitis herpetiformis, impetigo, contact dermatitis, candidiasis, medication responses, and insect bites. Herpes zoster pain preceded by no skin lesions differs from cholecystitis and biliary colic, renal colic, trigeminal neuralgia, or any tooth infection.

Herpes zoster is distinguished from other oral blistering disorders by its tendency to afflict only one side of the mouth cavity. It begins in the mouth as vesicles that break down fast, leaving ulcers that heal in 10 to 14 days. The pain before the rash may be misdiagnosed as a toothache, resulting in unneeded dental treatment.

 

Shingles Vs. Poor Immune System 

People who develop shingles and have a weakened immune system (immune suppression or immune deficiency) should see the doctor immediately. Regardless of your age, you will receive antiviral drugs and will be closely observed for complications. 

Individuals with a weakened immune system are those who:

  • Use strong doses of steroids. This refers to people who take 40 mg prednisolone, the steroid tablets daily for more than a week for the past three months. Alternatively, children who have used steroids in the past three months, equal to prednisolone 2 mg/kg each day for a week or 1 mg/kg daily for at least a month. 
  • Use low doses of steroids combined with certain immune suppressant drugs. 
  • Take anti-arthritis drugs that can impact the bone marrow.
  • Have undergone an organ transplant and is currently under immunosuppressive therapy.
  • Are undergoing generalized radiation therapy and chemotherapy treatment, or have been receiving these therapies for the past 6 months. 
  • Have an impaired body defense system
  • Are immunosuppressed due to the HIV infection.

 

Shingles VS Hives 

In case you develop shingles, a disease triggered by the varicella-zoster virus, you are likely to have a sore and itchy red rash on one part of the body with liquid-filled blisters. Nonetheless, you can only have shingles if you have had chickenpox before.

Generally, shingles are not similar to hives which are characterized by raised and itchy welts on the skin. Usually, hives occur due to an allergic reaction from food, medicines, or certain environmental aspects. 

 

What to Expect If You Develop Shingles?

Shingles are painful and can cause extreme discomfort. If you suspect that you have shingles, contact the medical provider as soon as possible. You should start taking antiviral drugs right away to alleviate your pain and shorten the period of the associated symptoms.

A good solution to shingles is taking precautions and doing everything possible to reduce the chances of acquiring them. If you've never developed shingles or if you've had shingles in the past, consult the doctor about having the shingles vaccine. Also, if you have never developed chickenpox, discuss with the doctor about receiving the chickenpox vaccine.

 

When should you consult a physician?

In case you notice any related signs or suspect shingles, consult your doctor right away. This is especially if you have any of the following issues:

  • Pain, discomfort, and rash appear around the eye. This form of infection, if not treated, will cause permanent damage to the eye. 
  • You are 50 years old or above. This is because age raises the chances of complications dramatically. 
  • You or a member of your family has a compromised immune system. It can be due to cancer, a particular chronic disease, or certain medications. 
  • The shingles rash is extremely painful and widespread.

 

Conclusion  

Shingle is typically a viral infection that results in an outbreak of a painful rash and blisters on the skin. The varicella-zoster virus is the primary cause of both shingles and chickenpox. The shingles rash mostly develops as a band of blisters or rashes on a single side of the body. 

Being above the age of 50 and having a compromised immune system increases the risk of developing shingles. As such, it’s always essential to discuss with your doctor, especially if you are at a higher risk of the infection. You can as well consider vaccination against the disease to ensure that you have less chance of getting shingles.

Anyone who has had chickenpox in the past might develop shingles later in life. Both are caused by the same virus, varicella-zoster virus. After a chickenpox infection, this virus becomes latent (inactive) in the body. However, it can reactivate years later and produce shingles (herpes zoster): a rash with blisters that often forms a band across the skin and is frequently incredibly painful. Normally, the rash only affects one side of the body.

Although there is no treatment for the disorder, it can be averted in the majority of people with immunization. When the eyes are involved, patients must be sent to an ophthalmologist as soon as possible. Healthcare personnel such as the primary care physician, nurse practitioner, internist, and pharmacist should educate the patient about the vaccine's advantages. 

If at all possible, avoid scratching the blisters: The fluid contained within them is infectious, and blisters that have been ripped apart can leave scars. People with shingles should avoid direct contact with others if they don't know if the other people are immune to chickenpox for as long as it's contagious – that is, until the very last blisters have gone away – if they don't know whether the other people are immune to chickenpox.

This is especially crucial for those with compromised immune systems and pregnant women. Covering the blisters with a bandage can help prevent shingles from spreading.

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