In my practice as a general Internist I frequently encounter a debilitating condition that affects mostly my elderly patients. This condition is known as Shingles.
Shingles (Herpes Zoster) is a painful condition caused by reactivation of an old chickenpox infection which has remained dormant at the base of a sensory nerve. It usually begins as an uncomfortable or painful sensation which may vary from itching, tingling, or burning, to a very severe aching, boring, or lancinating pain. After a few days a rash consisting of small round blisters on a reddened base erupts on the skin where the nerve travels. It almost always occurs on just one side of the body. It is most common on the trunk (50%-70% of cases), and around the eye (10-15% of cases). Over a period of 7-10 days the rash progresses from red blotches to blisters, then to pustules, and finally to crusted lesions which may last for 2-3 weeks. In most people it reaches its maximal intensity during the second week and then decreases.
Shingles is much more common and severe in older individuals. Over 1 million new cases occur in the United States each year with more than 50% occurring in people over the age of 60. It is not acquired by contact with other people with Shingles, but only by reactivation of an old infection. People who live to age 85 have a 50% chance of contracting Shingles during their lifetime.
Pain and discomfort is the major complication of Shingles. Other complications may include blindness in those whose eye is affected, nerve damage, deafness, encephalitis, hepatitis, and scarring. These complications are more common in the elderly. The most common debilitating complication is pain which persists for more than 90 days after the rash is gone. This is called Postherpetic Neuralgia. It may persist for months, sometimes years and then decline with time. The pain can be severe and has resulted in suicide in some individuals.
Treatment for Shingles is available. Oral antiviral medication given within 72 hours of the appearance of the rash can significantly reduce the severity and duration of the outbreak. It may also reduce the risk of developing Postherpetic Neuralgia. The sooner this medication is started, the better. It is given for 7-10 days. Steroids can produce some improvement in the healing and the acute pain, but may also cause undesirable side effects in some individuals. Narcotic analgesics can also be prescribed to help the pain. Treatments for people who do develop Postherpetic neuralgia are complicated, not always effective, and frequently associated with adverse effects. Prevention would be much more beneficial.
In May, 2006, the FDA approved a vaccine called Zostavax for people 60 years old and older. In June of 2008 the FDA made this vaccine an official recommendation for these same people, whether they have had Shingles or not. The vaccine decreases the incidence of Shingles by 51.3%, and Postherpetic Neuralgia by 66.5%. The safety profile of this vaccine is excellent. The most common side effect is a very mild reaction (redness, pain, or swelling) at the injection site. The vaccine is given as a single dose. It is stored frozen and must be given within 30 minutes of reconstituting from the freezer. Relatively few people are unable to receive the vaccine, either due to an allergy to its components, or to an impaired immune system.
Richard J. Wilbur, M.D. is Board Certified in Internal Medicine
