Shingles and chickenpox (Varicella-zoster virus)
An in-depth report on the causes, diagnosis, treatment, and prevention of shingles and chickenpox.
Chicken pox; Herpes zoster; Postherpatic neuralgia
Chickenpox Vaccine Recommendations
The U.S. Centers for Disease Control and Prevention (CDC) recommends the following chickenpox (varicella) vaccination schedules for:
- Children ages 12 months - 12 years. All healthy children should receive their first chickenpox shot at age 12 - 15 months and a second shot at age 4 - 6 years (preferably before entering pre-kindergarten, kindergarten, or first grade).
- Adolescents and Adults ages 13 years and older. All healthy teenagers and adults who have never had chickenpox or the vaccine should receive 2 doses of the varicella vaccine, given 4 - 8 weeks apart.
Shingles Vaccine Recommendations
The shingles (herpes zoster) vaccine (Zostavax) is now FDA-approved for adults age 50 years and older with healthy immune systems. However, the CDC has not yet added the shingles vaccine to its list of recommended vaccines for adults ages 50 - 59, and some insurance companies will not pay for the shot for adults younger than age 60. There is no maximum age for getting the vaccine.
Home Remedies for Chickenpox Relief
Chickenpox is uncomfortable and unpleasant, but most cases are relatively mild and resolve within 7 - 10 days. In otherwise healthy people who have a low risk for complications, home remedies can help provide relief from itching and fever.
- Oatmeal baths can help relieve itching.
- Calamine lotion can help dry out blisters and soothe skin.
- Acetaminophen (Tylenol, generic) can help reduce fever.
- Antihistamines may relieve severe itching and aid sleep.
Most important, don’t scratch! Scratching the blisters can cause scarring and lead to a secondary infection.
Shingles and chickenpox are both caused by a single virus of the herpes family, known as varicella-zoster virus (VZV). The word herpes comes from the Greek word "herpein," which means "to creep," a reference to a characteristic pattern of skin eruptions. VZV causes two different illnesses:
- Varicella, or chickenpox, develops after an individual is exposed to VZV for the first time.
- Herpes zoster, or shingles, develops from reactivation of the virus later in life, usually many decades after chickenpox.
Most people get chickenpox from exposure to other people with chickenpox. The varicella virus is most often spread through sneezing, coughing, and breathing. It is so contagious that few nonimmunized people escape chickenpox when they are exposed to someone with the disease.
When people with chickenpox cough or sneeze, they expel tiny droplets that carry the varicella virus. If a person who has never had chickenpox or never been vaccinated inhales these particles, the virus enters the lungs. From here it passes into the bloodstream. When it is carried to the skin it produces the typical rash of chickenpox.
People can also catch chickenpox from direct contact with a shingles rash if they have not been immunized by vaccination or by a previous bout of chickenpox. In such cases, transmission happens during the active phase when blisters have erupted but not formed dry crusts. A person with shingles cannot transmit the virus by breathing or coughing.
Herpes Zoster (Shingles)
During a bout of chickenpox, the varicella-zoster virus travels to nerve cells called dorsal root ganglia. These are bundles of nerves that transmit sensory information from the skin to the brain. Here, the virus can hide from the immune system and remain inactive but alive for years, often for a lifetime. This period of inactivity is called latency.
If the virus becomes active after being latent, it causes the disorder known as shingles, or herpes zoster. The virus spreads in the ganglion and to the nerves connecting to it. Nerves most often affected are those in the face or the trunk. The virus can also spread to the spinal cord and into the bloodstream.
Shingles itself can develop only from a reactivation of the varicella-zoster virus in a person who has previously had chickenpox. In other words, shingles itself is never transmitted from one person to another either through the air or through direct exposure to the blisters. It is not always what triggers the virus to reactivate, but people who are older or who have weakened immune system are more vulnerable.
Other Herpes Viruses
The varicella-zoster virus belongs to a group of herpes viruses that includes eight human viruses (as well as addtional animal viruses). Herpes viruses are similar in shape and size and reproduce within the structure of a cell. The particular cell depends upon the specific virus. Human herpes viruses include herpes simplex virus 1 (HSV-1), which usually causes cold sores, and herpes simplex virus 2 (HSV-2), which usually causes genital herpes. Cytomegalovirus (CMV), which causes mononucleosis-like illness and retinitis, and Epstein-Barr Virus (EBV), the cause of classic mononucleosis, are also human herpes viruses.
All herpes viruses share some common properties, including a pattern of active symptoms followed by latent inactive periods that can last for months, years, or even a lifetime.
Risk Factors for Chickenpox (Varicella)
Chickenpox typically strikes children under 10 years of age. Since the introduction of the chickenpox (varicella) vaccine in 1995, the number of chickenpox cases has dramatically declined. .
Chickenpox usually occurs in late winter and early spring months. It can also be transmitted from direct contact with the open blisters associated with either chickenpox or shingles. (Clothing, bedding, and other such objects do not usually spread the disease.)
A patient with chickenpox can transmit the disease from about 2 days before the appearance of the spots until the end of the blister stage. This period lasts about 5 - 7 days. Once dry scabs form, the disease is unlikely to spread.
Most schools allow children with chickenpox back 10 days after onset. Some require children to stay home until the skin has completely cleared, although this is not necessary to prevent transmission.
Recurrence of Chickenpox. Recurrence of chickenpox is possible, but uncommon. One episode of chickenpox usually means lifelong immunity against a second attack. However, people who have had mild infections may be at greater risk for a breakthrough, and more severe, infection later on particularly if the outbreak occurs in adulthood.
Risk Factors for Shingles (Herpes Zoster)
Shingles affects about 1 out of every 3 adults. Anyone who has had chickenpox has risk for shingles later in life. Certain factors increase the risk for such outbreaks.
The Aging Process. The risk for herpes zoster increases as people age. The risk for postherpetic neuralgia (PHN) also increases after age 50. PHN is persistent nerve pain and is the most common severe complication of shingles.
Immunosuppression. Medical conditions that weaken the immune system increase the risk for shingles. These conditions include:
- Cancer, especially Hodgkins disease and lymphomas, and treatments such as bone marrow transplant
- Autoimmune disorders such as rheumatoid arthritis and inflammatory bowel disorders
Sometimes, the drugs used to treat these conditions suppress the immune system and increase the risk for shingles. Drug treatments that may increase risk include:
- Immune suppressing drugs used for treating autoimmune conditions such as rheumatoid arthritis, lupus, Crohn’s disease, and ulcerative colitis. These medications include disease-modifying anti-rheumatic drugs (DMARDs), steroids, and biologic drugs such as tumor necrosis factor (TNF) inhibitors.
- Immune suppressing drugs given after organ or bone marrow transplantation
- Prednisone and other corticosteroids if they are used for extended periods of time
- Protease inhibitors used for treatment of AIDS
Note: Current guidelines recommend against herpes zoster vaccination for people with weakened immune systems. However, some recent research suggests that vaccination may be safe for people with autoimmune disorders and those who take immunosuppressant drugs.
Risk Factors for Shingles in Children. Although most common in adults, shingles occasionally develops in children. Children with immune deficiencies are at highest risk. Children with no immune problems who had chickenpox before they were 1 year old also have a higher risk for shingles.
Risk for Recurrence of Shingles. Shingles can recur, but the risk is low. Evidence suggests that a first zoster episode may boost the immune system to ward off another attack. However, people who had long-lasting shingles pain after their first episode, or patients who are immunocompromised, may be at higher risk for recurrence.
Chickenpox (varicella) rarely causes complications, but it is not always harmless. It can cause hospitalization and, in rare cases, death. The major long-term complication of varicella is the later reactivation of the herpes zoster virus and the development of shingles. Shingles occurs in about 20% of people who have had chickenpox.
Certain factors put people at higher risk for complications of the varicella-zoster virus:
- Any adult who gets chickenpox is at increased risk for complications
- Patients with impaired immune systems due to diseases (such as Hodgkin's disease) or cancer treatments (chemotherapy, bone marrow or stem cell transplants) are at higher risk for chickenpox complications. They also have increased risk for herpes zoster and its complications.
- Pregnant women who get chickenpox have an increased risk for life-threatening pneumonia. Infection during the first trimester also poses a 1 - 2% chance for infecting the developing fetus and potentially causing birth defects. If the mother contracts chickenpox during the days following birth, her newborn is at risk for developing a serious varicella infection. Shingles is extremely rare in pregnant women.
Specific Complications of Chickenpox (Varicella)
Aside from itching, the complications described below are usually rare.
Itching. Intense itching is the most common complication of chickenpox. It can be very distressing, particularly for small children. Many home remedies can help relieve the discomfort. It’s important not to scratch the scabs because this can lead to scarring. [See: Treatment for Chickenpox section in this report.]
Bacterial Skin Infections. In some cases, a secondary bacterial infection may develop at sites that the patient scratched. If the skin around the scab becomes red, swollen, or warm, this may be a sign of a secondary bacterial infection. These symptoms warrant a call to the doctor because in rare cases, serious bacterial complications can occur.
VaricellaPneumonia. Varicella pneumonia is an uncommon but serious complication of chickenpox. It usually develops 1 – 6 days after the chickenpox rash appears. Fever and cough may be signs of varicella pneumonia. Pregnant women, people who are immunocompromised, and smokers are at increased risk for this lung complication.
Encephalitis and Meningitis. Encephalitis and meningitis are rare but serious neurological (nervous system) complications of chickenpox. Meningitis is inflammation of the lining of the spinal cord and brain. Encephalitis is inflammation of the brain itself. Signs and symptoms include sudden fever, headache, and stiff neck as well as nausea, vomiting, sensitivity to light. In encephalitis, seizures and coma can occur. Meningitis and encephalitis are very serious conditions that require immediate medical treatment.
Reye Syndrome. Reye syndrome, a disorder that causes sudden and dangerous liver and brain damage, is a side effect of aspirin therapy in children who have chickenpox or influenza. The disease can lead to coma and is life threatening. Symptoms include rash, vomiting, and confusion beginning about a week after the onset of the disease. Children should never take aspirin when they have a viral infection or fever. Acetaminophen (Tylenol, generic) is the preferred drug for fever or pain in patients younger than age 18 years.
Disseminated Varicella. Disseminated varicella, which develops when the virus spreads to organs in the body, is extremely serious especially for patients with compromised immune systems.
Specific Complications of Shingles (Herpes Zoster)
Postherpetic Neuralgia. Postherpetic neuralgia (PHN) is pain that persists for longer than a month after the onset of herpes zoster. It is the most common severe complication of shingles. Risk factors for PHN include:
- Age. PHN affects about 25% of herpes zoster patients over 60 years old. The older a person is, the longer PHN is likely to last. It rarely occurs in people under age 50.
- Gender. Some studies suggest that women may be at slightly higher risk for PHN than men.
- Severe or complicated shingles. People who had prodromal symptoms or a severe attack (numerous blisters and severe pain) during the initial shingles episode are also at high risk for PHN. The rate is also higher in people whose eyes have been affected by zoster.
In most cases, PHN resolves within 3 months. Studies report that only about 10% of patients experience pain after a year. Unfortunately, when PHN is severe and treatments have not been very effective, the persistent pain and abnormal sensations can be profoundly frustrating for patients.
Skin Infections. If the blistered area is not kept clean and free from irritation, it may become infected with group A Streptococcus or Staphylococcus bacteria. If the infection is severe, scarring can occur.
In very rare cases, herpes zoster has been associated with Stevens-Johnson syndrome, an extensive and serious condition in which widespread blisters cover mucous membranes and large areas of the body.
Eye Infections. If shingles occurs in the face, the eyes are at risk, particularly if the path of the infection follows the side of the nose. If the eyes become involved (herpes zoster ophthalmicus), a severe infection can occur that is difficult to treat and can threaten vision. Patients with HIV/AIDS may be at particular risk for a chronic infection in the cornea of the eye.
Herpes zoster can also cause a severe infection in the retina called imminent acute retinal necrosis syndrome. In such cases, visual loss develops within weeks or months after the herpes zoster outbreak has resolved. Although this complication usually follows a herpes outbreak in the face, it can occur after an outbreak in any part of the body.
- Guillain-Barre Syndrome. Guillain-Barre syndrome is caused by inflammation of the nerves and is associated with a number of viruses, including herpes zoster. The arms and legs become weak, painful, and, sometimes, even paralyzed. The trunk and face may be affected. Symptoms vary from mild to severe enough to require hospitalization. The disorder resolves in a few weeks to months. Other herpes viruses (cytomegalovirus and Epstein-Barr), or bacteria (Campylobacter) may have a stronger association with this syndrome than herpes zoster.
- Ramsay Hunt Syndrome. Ramsay Hunt syndrome occurs when herpes zoster causes facial paralysis and rash on the ear (herpes zoster oticus) or in the mouth. Symptoms include severe ear pain and hearing loss, ringing in the ear, loss of taste, nausea, vomiting, and dizziness. Ramsay Hunt syndrome may also cause a mild inflammation in the brain. The dizziness may last for a few days, or even weeks, but usually resolves. Severity of hearing loss varies from partial to total; however, this too usually goes away. Facial paralysis, on the other hand, may be permanent.
- Bell's Palsy. Bell's palsy is partial paralysis of the face. Sometimes, it is difficult to distinguish between Bell's palsy and Ramsay Hunt syndrome, particularly in the early stages. In general, Ramsay Hunt syndrome tends to be more severe than Bell's palsy.
- Meningitis and Encephalitis. Inflammation of the membrane around the brain (meningitis) or in the brain itself (encephalitis) is a rare complication in people with herpes zoster. The encephalitis is generally mild and resolves in a short period. In rare cases, particularly in patients with impaired immune systems, it can be severe and even life threatening.
- Stroke. Some research suggests that herpes zoster increases the risk for stroke in the year following a shingles outbreak.
Disseminated Herpes Zoster. As with disseminated chickenpox, disseminated herpes zoster, which spreads to other organs, can be serious to life-threatening, particularly if it affects the lungs. People with compromised immune systems are at greatest danger. It is very rare in people with healthy immune systems.
Symptoms of Chickenpox
The time between exposure to the virus and eruption of symptoms is called the incubation period. For chickenpox, this period is 10 - 20 days. The patient often develops fever, headache, swollen glands, and other flu-like symptoms before the typical rash appears. While fevers are low grade in most children, some can reach 105 °F.
These symptoms subside once the rash breaks out. One or more tiny raised red bumps appear first, most often on the face, chest, or abdomen. They become larger within a few hours and spread quickly (sprout), eventually forming small blisters on a red base. The numbers of blisters vary widely. Some patients have only a few spots, others can develop hundreds. Each blister is filled with clear fluid that becomes cloudy in several days.
It takes about 4 days for each blister to dry out and form a scab. During its course, the rash itches, sometimes severely. Usually separate crops of blisters occur over 4 - 7 days, the entire disease process lasting 7 - 10 days.
Symptoms of Shingles
Shingles nearly always occurs in adults. Usually two, and sometimes three, identifiable symptom stages occur:
Prodrome. In the prodrome phase, a cluster of warning symptoms appear 3 - 4 days before the outbreak of the infection. These symptoms range from general feelings of malaise (chills, fever, nausea, and muscle aches) to abnormal sensations such as tingling, itching, burning, or a feeling of “pins and needles” accompanied by deep pain. The skin may be unbearably sensitive to touch.
Active Infection. After prodrome, a rash appears, usually on the trunk. However, the rash can develop in other areas as well, such as legs, arms, face, or neck. The rash is typically confined to one side of the body and follows the same track of inflamed nerves as the prodrome pain.
- The rash usually starts as well-defined, small, red clear spots.
- Within 12 - 24 hours, these pimples develop into small fluid-filled blisters. The blisters grow, merge, and become pus-filled, and are extremely painful.
- Within about 7 - 10 days (as with chickenpox), the blisters form crusts and heal. In some cases it may take as long as a month before the skin clears completely.
Sometimes pain develops without a rash, a condition known as zoster sine herpete.
Postherpetic Neuralgia. Postherpetic neuralgia (PHN) is pain that persists for longer than a month after the onset of herpes zoster. Typical symptoms include:
- Pain that is described as deep aching, burning, stabbing, or like an electric shock
- Extreme sensitivity to touch or temperature changes
- The pain is persistent, but may come and go.
Both chickenpox (varicella) and shingles (zoster) can usually be diagnosed by symptoms alone. If a diagnosis is still unclear after a physical examination, laboratory diagnostic tests may be required. These tests use samples of fluid taken from the blister. They are generally used to distinguish between varicella-zoster and herpes simplex viruses.
Ruling out Other Disorders
Ruling out Disorders that Resemble Chickenpox. Chickenpox, particularly in early stages, may be confused with herpes simplex, impetigo, insect bites, or scabies.
Ruling out Disorders that Resemble Shingles. The early prodrome stage of shingles can cause severe pain on one side of the lower back, chest, or abdomen before the rash appears. It therefore may be mistaken for other disorders, such as gallstones, that cause acute pain in internal organs.
In the active rash stage, shingles may be confused with herpes simplex, particularly in young adults, if the blisters occur on the buttocks or around the mouth. Herpes simplex, however, does not usually generate chronic pain.
A diagnosis may be difficult if herpes zoster takes a non-typical course in the face, such as with Bell's palsy or Ramsay Hunt syndrome, or if it affects the eye or causes fever and delirium.
There are two types of varicella vaccines:
A chickenpox vaccine for vaccinating children, adolescents, and adults
A shingles vaccine for vaccinating adults age 50 years and older
The live-virus varicella vaccine (Varivax) produces persistent immunity against chickenpox. The vaccine can prevent chickenpox or reduce the severity of the illness if it is used within 3 days, and possibly up to 5 days, after exposure to the infection.
The childhood chickenpox vaccine can also be given as part of a combination vaccine (Proquad) that combines measles, mumps, rubella (together called MMR), and varicella in one product. However, the CDC advises that combining varicella and MMR vaccinations into one shot doubles the risk for febrile (fever-related) seizures in children ages 12 - 24 months compared to giving separate MMR and varicella injections. Even with the combination vaccine the risk is low, but parents should consider the lower risk associated with separate injections.
The combination varicella and MMR vaccine is usually recommended for the second dose, in children ages 4 - 6 years, as it is not associated with increased risk for febrile seizures in this age group. Children who are at higher risk for seizures due to a personal or family medical history should generally receive the MMR and varicella vaccines separately.
Recommendations for the Chickenpox Vaccine in Children
The U.S. Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends that children receive two doses of the chickenpox vaccine with:
For children who have previously received one dose of the chickenpox vaccine, the ACIP recommends that they receive a “catch-up” second dose during their regular doctor’s visit. This second dose can be given at any time as long as it is at least 3 months after the first dose. Studies indicate that the odds of developing chickenpox are 95% lower in children who receive two doses of the vaccine compared to those who receive only one.
Children most at risk for having chickenpox after having been vaccinated only one time are ages 8 - 12 years and have generally been vaccinated at least 5 years before their current chickenpox infection.
Recommendations for the Chickenpox Vaccine in Adults
The CDC recommends that every healthy adult without a known history of chickenpox be vaccinated. Adults should receive 2 doses of the vaccine, 4 - 8 weeks apart. Adults in the following groups should especially consider vaccination:
Those with high risk of exposure or transmission (hospital or day care workers, parents of young children)
People who may come in contact with those who have compromised immune systems
Nonpregnant women of childbearing age
As with other live-virus vaccines, the chickenpox vaccine is not recommended for:
Women who are pregnant or who may become pregnant within 30 days of vaccination. (Women who are pregnant and not immunized should receive the first dose of the vaccine upon completion of their pregnancy.)
People whose immune systems are compromised by disease or drugs (such as after organ transplantation).
Patients who cannot be vaccinated but who are exposed to chickenpox receive immune globulin antibodies against varicella virus. This helps prevent complications of the disease if they become infected.
Side Effects. Most side effects are mild and include pain at the injection site and low-grade fever. In rare cases, the vaccine may produce a mild rash within about a month of the vaccination, which can transmit chickenpox to others. Individuals who have recently been vaccinated should avoid close contact with anyone who might be susceptible to severe complications from chickenpox until the risk for a rash passes.
The herpes zoster (shingles) vaccine (Zostavax) is a stronger version of the chickenpox vaccine. It was originally approved in 2006 for adults age 60 years and older. In 2011, the FDA lowered the recommended age for Zostavax to 50. Because the vaccine contains live virus, it is not recommended for people with weakened immune systems.
Although the shingles vaccine is approved for adults age 50 and older, the CDC still recommends it for routine use in those age 60 and older. Many insurance companies do not pay for the shot for adults younger than age 60. However, some insurance companies are now covering the vaccine for adults in their 50s. Check with your insurance company about coverage. There is no maximum age for getting the vaccine.
A single shot of the vaccine can reduce the risk of developing shingles by 55 - 70% and may also help prevent postherpetic neuralgia and ophthalmic herpes. Is not yet clear how long immunity lasts or if patients may eventually require a booster shot. .
Varicella-Zoster Immune Globulin
Varicella-zoster immune globulin (VariZIG) is a substance that mimics the normal immune response against the varicella-zoster virus. It is used to protect high-risk patients who are exposed to chickenpox. Such groups include:
- Pregnant women with no history of chickenpox who have not been previously immunized
- Newborn infants whose mothers had signs or symptoms of chickenpox around the time of delivery (5 days before to 2 days after)
- Premature infants
- Immunocompromised children and adults with no antibodies to VZV
- Recipients of bone-marrow transplants (even if they have had chickenpox)
- Patients with a debilitating disease (even if they have had chickenpox)
For these patients, VariZIG should be given within 96 hours of exposure to someone with chickenpox. (Note: VariZIG is a new formulation of an older drug called VZIG, which is no longer produced.)
Treatment for Chickenpox
Home Treatments for Chickenpox
Acetaminophen. Patients with chickenpox do not have to stay in bed unless fever and flu symptoms are severe. To relieve discomfort, a child can take acetaminophen (Tylenol, generic), with doses determined by the doctor. A child should never be given aspirin, or medications containing aspirin, as aspirin increases the risk for a dangerous condition called Reye syndrome.
Soothing Baths. Frequent baths are particularly helpful in relieving itching, when used with preparations of finely ground (colloidal) oatmeal. Commercial preparations (Aveeno) are available in drugstores, or one can be made at home by grinding or blending dry oatmeal into a fine powder. Use about 2 cups per bath. The oatmeal will not dissolve, and the water will have a scum. Adding baking soda (1/2 - 1 cup) to a bath may also help.
Lotions. Patients can apply calamine lotion and similar over-the-counter preparations to the blisters to help dry them out and soothe the skin.
Antihistamines. For severe itching, diphenhydramine (Benadryl, generic) is useful and may help children sleep.
Preventing Scratching. Small children may have to wear mittens so that they don't scratch the blisters and cause a secondary infection. All patients with varicella, including adults, should have their nails trimmed short.
Acyclovir for Chickenpox
Acyclovir is an antiviral drug that may be used in adult varicella patients or those of any age with a high risk for complications and severe forms of chickenpox. The drug may also benefit smokers with chickenpox, who are at higher than normal risk for pneumonia. Some doctors recommend its use for children who catch chickenpox from other family members because such patients are at risk for more serious cases. To be effective, oral acyclovir must be taken within 24 hours of the onset of the rash. Early intravenous administration of acyclovir is an essential treatment for chickenpox pneumonia.
Treatment for Shingles
The treatment goals for an acute attack of herpes zoster include:
- Reduce pain
- Reduce discomfort
- Hasten healing of blisters
- Prevent the disease from spreading
Over-the-counter (OTC) remedies are often effective in reducing the pain of an attack. Antiviral drugs (acyclovir and others), oral corticosteroids, or both are sometimes given to patients with severe symptoms, particularly if they are older and at risk for postherpetic neuralgia (PHN).
Home Treatments for Shingles
Applied Cold. Cold compresses soaked in Burrow's solution (an over-the-counter powder that is dissolved in water) and cool baths may help relieve the blisters. It is important not to break blisters as this can cause infection. Doctors advise against warm treatments, which can intensify itching. Patients should wear loose clothing and use clean loose gauze coverings over the affected areas.
Itch Relief. In general, to prevent or reduce itching, home treatments are similar to those used for chickenpox. Patients can try antihistamines (particularly Benadryl), oatmeal baths, and calamine lotion.
Over-the-Counter Pain Relievers. For an acute shingles attack, patients may take over-the-counter pain relievers:
- Children should take acetaminophen. (Shingles is very rare in children.)
- Adults may take aspirin or other nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, other brands, generic). These remedies, however, are not very effective for postherpetic neuralgia.
Antiviral drugs do not cure shingles, but they can reduce the severity of the attack, hasten healing, and reduce the duration. They may also reduce the risk of postherpetic neuralgia.
Antiviral drugs approved for treatment of shingles include:
- Acyclovir (Zovirax, generic) is the oldest, most studied of these drugs
- Famciclovir (Famvir, generic) and valacyclovir (Valtrex, generic) are now preferred to treat herpes zoster in most patients because they require fewer daily doses than acyclovir.
These anti-viral drugs are usually taken for 7 days. To be effective, they should be started within 72 hours of the onset of infection. The earlier they are given the more effective these drugs are. Side effects may include stomach cramps, nausea, diarrhea, headache, and dizziness. Acyclovir may have more side effects than the other two drugs. People who have kidney problems or weakened immune systems may need to take a lower dose of these medications.
Foscarnet (Foscavir) is an injectable antiviral drug that can be used to treat cases of varicella-zoster infection resistant to acyclovir and similar drugs. It is rarely necessary.
Treatment for Postherpetic Neuralgia
Postherpetic neuralgia (PHN) is difficult to treat. Once PHN develops, a patient may need a multidisciplinary approach that involves a pain specialist, primary care physician, and other health care providers.
The American Academy of Neurology (AAN) treatment guidelines for postherpetic neuralgia recommend:
Tricyclic antidepressants (amitriptyline, nortriptyline, desipramine, maprotiline)
Anticonvulsants (gabapentin and pregabalin)
Lidocaine skin patches
Opioids (oxycodone, methadone, morphine)
Topical Treatments for Postherpetic Neuralgia
Creams, patches, or gels containing various substances can provide some pain relief:
- Lidocaine. A patch that contains the anesthetic lidocaine (Lidoderm, generic) is approved specifically for postherpetic neuralgia (PHN). One to four patches can be applied over the course of 24 hours. Another patch (EMLA) contains both lidocaine and prilocaine, a second anesthetic. The most common side effects are skin redness or rash.
- Capsaicin. Capsaicin is a chemical compound found in hot chili peppers. A prescription capsaicin skin patch (Qutenza) is approved for pain relief of PHN. The patch must be applied by a health care professional, as placement of the patch can be painful. Because the patch may increase blood pressure, the patient should be monitored for at least 1 hour after the patch is applied. A lower-concentration ointment form of capsaicin (Zostrix) is available over the counter, but its benefits may be limited.
- Topical Aspirin. Topical aspirin, known chemically as triethanolamine salicylate (Aspercreme, generic), may bring relief.
- Menthol-Containing Preparations. Topical gels containing menthol, such as high-strength Flexall 454, may be helpful.
Tricyclic antidepressants may help relieve PHN pain. Nortriptyline (Pamelor, generic), amitriptyline (Elavil, generic), and desipramine (Norpramin, generic) are the standard tricyclic drugs used for treating PHN.
It may take several weeks for the drugs to become fully effective. They do not work as well in patients who have burning pain or allodynia (pain that occurs with normally non-painful stimulus, such as a light touch or wind).
Unfortunately, tricyclics have side effects that are particularly severe in the elderly, who are also more likely to have PHN. Desipramine and nortriptyline have fewer side effects than amitriptyline and are preferred for older patients. Side effects include dry mouth, blurred vision, constipation, dizziness, difficulty urinating, disturbances in heart rhythms, and an abrupt drop in blood pressure when standing up.
Anticonvulsant (Anti-Seizure) Drugs
Certain anticonvulsant drugs have effects that may be helpful for PHN. (Anticonvulsant drugs are also known as anti-seizure drugs.) Gabapentin (Neurontin, generic) and pregabalin (Lyrica) are approved for treatment of PHN. Side effects may include dizziness, sleepiness, blurry vision, weight gain, trouble concentrating, and swelling of hands and feet. Anticonvulsant medications can increase the risk of suicidal thoughts and behavior.
Opioids and Opioid-like Drugs
Opioids. Patients with severe pain that does not respond to tricyclic antidepressants or anticonvulsants may need powerful painkilling opioid drugs. The use of narcotics is controversial as these drugs can be addictive. These drugs may be taken by mouth or delivered through a skin patch. Oxycodone is the standard opioid for PHN. It is available in different formulations (Percocet, Percodan, Oxycontin, generic.) Morphine may also be used. Constipation, drowsiness, and dry mouth are common side effects of opioids.
Tramadol. Tramadol (Ultram, generic) is a pain reliever that is used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) Side effects are similar to opoids.
Pain Management Techniques
A number of relaxation and stress-reduction techniques may be helpful for managing chronic pain. They include meditation, deep breathing exercises, biofeedback, self-hypnosis, and muscle relaxation. Psychotherapy approaches such as cognitive behavioral therapy may help patients learn how to cope with and manage their responses to pain.
Certain surgical techniques in the brain or spinal cord attempt to block nerve centers associated with postherpetic neuralgia. These methods carry risk for permanent damage, however, and should be used only as a last resort when all other methods have failed and the pain is intolerable. Most studies indicate that surgery does not relieve PHN pain.
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- Last reviewed on 6/22/2013
- Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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