What is Shingles?

Shingles is a lay term for a medical condition known as herpes zoster (HZ).  HZ is an infection that is caused by the reactivation of chicken pox virus, otherwise known as varicella zoster virus or VZV.  Nowadays virtually all of us over the age of 40 have had regular chickenpox as a child even if we don’t remember having it.  After a person has chickenpox as a child the virus actually remains in the body hiding (from your immune system) inside nerve cells that are at the base of the brain and in groups of nerve cells (know as dorsal root ganglions) all along the spinal cord.  Later in life, for reasons that aren’t always clear, VZV reactivates in just one or two adjacent nerve roots on just one side of the body and spreads down the long arms of these nerves until it reaches the skin and causes the blistery rash that is recognized as shingles. 


Who gets Shingles?

Anyone who has ever had chickenpox can get shingles.  Since shingles is a reactivation of your own dormant chickenpox virus, you can’t get shingles from someone else.  That means shingles isn’t contagious to other people who have ever had chickenpox or to any of the young people under age 15 who have ever had the childhood vaccine that prevents chickenpox (Varivax®). Studies have shown that the older you are the more likely you are to get shingles.  So shingles is more common in people who are over 70 compared to people that are younger than say age 50.  A bout of shingles is more likely to occur when your immunity is low.  


How do people know if they have shingles?

Early on people who are coming down with shingles have one-sided pain in a distribution that matches the nerve roots that are involved.  For instance, the top nerve root is the one that corresponds to the frontal area of the scalp, the forehead, and the eye. Someone who is developing shingles involving this nerve root may have different kinds of pain, often severe, for a few days or even a week or so before any rash is present.  The pain may precede the rash of shingles for a few days or even a week.  The pain varies but is often described as sharp, shooting, boring, pressure-like, and sometimes unrelenting.  The skin over the area is hypersensitive to touch.  If the nerve root that is involved is in the thoracic (chest) area, the one-sided pain may be anywhere along the nerve root from the back to the side of the chest to the front of the chest or breast.  Depending on the nerve root and which side of the body it happens to have involved, the pain may be mistaken for arthritis pain, heart attack or gall bladder pain, or kidney stone pain.  

After a few days or even a week of this one sided pain, the rash of shingles begins to appear.  Usually the rash appears first as swollen red patches on just one side beginning close to the spine and erupting over several days around the chest, or down the arm or leg depending on which nerve roots are involved.  Within a day or two clear groups of blisters appear within the red swollen patches.  Usually the diagnosis of shingles is made only after the rash appears.  


What is the usual course of a bout of shingles?

With rare exceptions, shingles is not life-threatening and usually runs it’s course in about 4 weeks.  The blisters often turn dark and form dry scabs that eventually heal, sometimes with scarring in the skin.  The severe pain which is related to inflammation in the nerve itself can persist after the infection itself has cleared up.  Any pain that persists after the infection has cleared is known as post herpetic neuralgia or PHN.  Post is for afterwards, herpetic refers to herpes zoster (the medical term for shingles), and neuralgia refers to pain that is related to nerve injury.  PHN is notoriously difficult to treat and is best prevented (see below).  

How is Shingles treated? 

There is good evidence that early treatment of shingles with oral antiviral pills can speed healing, help with pain, and may lessen the duration of PHN.  While studies show that starting oral antiviral therapy within 72 hours of the onset of the rash of shingles has the best outcome, most doctors provide antiviral therapy to all patients who have acute shingles, even if they are past this optimum time window.  There are two similar oral agents that give the best results, valacyclovir (brand name Valtrex®) and famciclovir (brand name Famvir®). Both are available in a generic that is equally as effective as the brand name.  The dosing for valacyclovir is two 500 mg pills three times a day for one week.  The dosing for famciclovir is one 500 mg pill three times a day for one week.  There is an older antiviral drug known as acyclovir (brand name Zovirax®) which historically was used to treat shingles.  Acyclovir is not as well absorbed (10% absorption vs 40-50% for the other drugs) and there is not as much data about it’s effectiveness and therefore it is not recommended.

Recently, there have been several studies showing that adding the neuropathy drug gabapentin (brand name Neurontin®) to the antiviral regimen used to treat shingles reduces the number of people who develop PHN.   It is recommended that doctors prescribe gabapentin in addition to antiviral agents in healthy patients with acute shingles who are older than 50 years and have pain scores that are higher than 4 out of 10.  The initial gabapentin dosage is 300 mg per day taken at bedtime for one week.  The daily gabapentin dosage (300 mg per capsule) is increased each week over 4 weeks in a stepwise manner (900, 1800, 2700, 3600 mg per day divided three times a day) in accordance with patient tolerance and side effects.  The usual limiting side effects are dizziness and fatigue. Patients who have impaired kidney function, have significant immune dysfunction (e.g., active malignancy of any type, collagen vascular disease, organ transplantation recipient, severe atopic dermatitis), or who are taking immunosuppressive drugs (e.g., Imuran®, Cytoxan) should not take gabapentin. 

Prednisone can be used to reduce the acute inflammation that produces pain in acute shingles but there is no evidence that it reduces the risk of PHN.  

Short term use of analgesics (pain pills) not only helps relieve the often severe and unrelenting pain of shingles but also studies suggest that those who try to “tough it out” may be at more risk of long term PHN.    


Can Shingles be prevented?  

In 2006 the FDA approved ZostavaxⓇ, the first vaccine for shingles.  ZostavaxⓇ is a live virus vaccine which means it cannot be given to people who are immunocompromised either because of drugs (e.g., HumiraⓇ, chemotherapy or organ transplant rejection drugs) or because of a medical condition (immune cancer such as chronic leukemia or an infection like HIV).  ZostavaxⓇ overall reduces the risk of getting shingles by 51%.  It was less effective in older people. ZostavaxⓇ showed a 64% reduction of herpes zoster in people aged 60 to 69, a 41% reduction in the 70-to-79 age range and an 18% reduction for those 80 and older. ZostavaxⓇ has recently been shown to have completely lost it’s effectiveness five years after administration.  Many people still had an episode of shingles despite receiving ZostavaxⓇ although it was more likely to be milder.  Overall Zostavax reduces the risk of post herpetic neuralgia by 66% during a study period of 5 years.  

On October 20, 2017, the FDA approved a new vaccine to prevent shingles called ShingrixⓇ.  ShingrixⓇ will be available for use in early 2018.  ShingrixⓇ is better in every way than ZostavaxⓇ and will completely replace ZostavaxⓇ.  ShingrixⓇ is not a live virus vaccine so just like the pneumonia vaccines ShingrixⓇ can be given to just about anyone who is at risk of getting shingles, regardless of advanced age or immune status.  It is vastly more effective and durable in all age groups compared to ZostavaxⓇ.  ShingrixⓇ is well over 90% effective in people in their 50’s, 60’s, 70’s, and 80’s.  Four years after administration it is still 88% effective.  ShingrixⓇ is approved for anyone over 50 years of age.  

To get this unprecedented  level of protection, ShingrixⓇ requires two doses that are given 2 months apart.  Twelve per cent of people receiving ShingrixⓇ (compared to 2% of people getting placebo) reported local or systemic side effects that were severe enough to interfere with normal daily activity.  This was most commonly muscle aches and the average duration was one day.  No one developed shingles because of the vaccine.  


FAQ’s about Shingrix


I already received Zostavax.  Should I get Shingrix?  Yes.  This is especially true if you are over 70 or if it’s been over 3 years since you received Zostavax.  Even if you recently received Zostavax, ShingrixⓇ offers vastly more protection.


I was told I couldn’t get Zostavax.  Can I get Shingrix?  That depends.  Because it is not a live virus ShingrixⓇ is safe to give to just about anyone.  It may not offer the same level of protection to those who do not have normal immune systems but it should definitely reduce the risk of shingles.  If you are currently receiving chemotherapy it may be more effective to wait until you have completed it before receiving ShingrixⓇ.  There are lots of examples of non-live vaccines (e.g., flu shot, pneumonia vaccine) that are given to almost everyone at risk regardless of age or immune status.  All of my patients who are on biologic drugs such as EnbrelⓇ, HumiraⓇ, RemicadeⓇ, StelaraⓇ, CosentyxⓇ, TaltzⓇ, and TremfyaⓇ and all of my patients on immunosuppressive drugs like CellCeptⓇ (mycophenolate mofetil), methotrexate, or ImuranⓇ (azathioprine) who were not allowed to get ZostavaxⓇ, can and should get ShingrixⓇ at the earliest opportunity.


I just had an episode of shingles.  Should I get Shingrix?  That depends.  People with intact immune systems that have an episode of shingles are very unlikely to get shingles again for at least 3 and some people say 5 years.  So delaying ShingrixⓇ in these people is probably quite reasonable.  If it’s been 5 years since an episode of shingles or your immune system is not in great shape, you should strongly consider getting ShingrixⓇ.   It can only reduce your risk.


Where should I go to get Shingrix®?  If you are a military veteran you should get SnhingrixⓇ through the VA as there will be no out of pocket expense.  Once it has been distributed (probably late January 2018) ShingrixⓇ will be given by primary care physicians, most pharmacies, and my office.  All established patients of mine who are over 50 years old can get ShingrixⓇ.  They will not be charged an office visit.  An appointment is not required to get ShingrixⓇ so any established patient may get ShingrixⓇ between 7 am and 12 noon and between 1:20 pm and 4:30 pm Monday through Thursday.  In case there are shortages of ShingrixⓇ it might be best to call ahead to assure it is in stock and available.  As with any office procedure patients may be responsible for copays and/or deductibles.  For those who do not have insurance or for those who are denied coverage by their insurance carrier, I will provide ShingrixⓇ to any established patient at my cost.   At this time the cost of ShingrixⓇ is not known.  


What if I might be out of town two months after the first dose and have to delay the second dose?  ShingrixⓇ is ultimately just as effective if there is a delay of up to 6 months receiving the second dose.  One dose alone is not as protective as the standard two doses although the exact protection and duration of protection from a single dose is not known.


Can ShingrixⓇ be given at the same time as the flu shot (influenza vaccine)?  Yes. The flu shot may be given with either dose of Shingrix® and it is just as effective and just as well tolerated.   


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