Shingles: Painful and Debilitating
With no cure available, vaccination against shingles presents the best option to combat this debilitating disease.
Each year Americans make 2.1 million doctor visits because of shingles or its complications, while nearly 1 million Americans access some other form of medical care, according to the latest statistics from the Agency for Healthcare Research and Quality. Additionally, about one in five of those suffering from shingles may go on to develop postherpetic neuralgia (PHN), a debilitating pain that often affects quality of life, interrupting daily routines for months or even years.
Shingles, technically known as herpes zoster, is an acute, noncontagious infection of the nervous system, caused by the varicella-zoster virus, the same virus responsible for chickenpox. Whereas itching is the key symptom of the rash of chicken pox, pain is the overriding characteristic of shingles. PHN results from nerve damage caused by the shingles virus and is typically felt in the area of the previous shingles rash, but the size of the area of PHN pain can vary considerably. PHN pain also varies in its description but is known most commonly for its burning, aching, itching, and sharp pain.
Unfortunately, there is currently no cure for PHN, and it cannot be prevented in all patients. And because the virus is no longer present after the characteristic blisters dry up, the antiviral drugs used to treat shingles are not useful in patients with PHN. For some people, although uncommon, PHN may improve over time without treatment. Overall, shingles presents a fairly bleak outlook for patients who suffer from it.Combating Shingles
So what’s the best course of action? According to Barbara Yawn, MD, director of research at the Olmsted Medical Center in Rochester, Minn., the most important aspect of shingles treatment is prevention. “That is done with the shingles vaccine, and there is currently only one—Zostavax,” says Yawn. “Approved by the FDA in 2006 and currently recommended by the CDC [Centers for Disease Control and Prevention], Zostavax is a live attenuated virus vaccine similar to the one for chicken pox in children, only more than 10 times as potent.”
But there are stipulations. At this time, it can be given only to older adults who do not have any condition that cause problems with their immune systems. For instance, those with blood cancers such as leukemia, Hodgkin’s, or multiple myeloma and individuals who are taking chemotherapy for other types of cancers or similar types of drugs such as those used for rheumatoid arthritis are not candidates for receiving the vaccine.
The vaccine must be kept frozen and then thawed prior to administering it. “Currently the vaccine is recommended for people 60 and older,” says Yawn. “But the studies are being done to allow recommendations of the vaccine for those 50 and older.”
Yawn says there is a promise of a vaccine that does not have to be frozen and then thawed within 30 minutes of being administered, making it less complicated to handle in a physician's office and pharmacies. The new version of the vaccine, which is under study, could be kept on the shelf and would better maintain its potency, thereby increasing the possible availability to patients.
Another way to ensure greater use of the vaccine is to have your patients ask for it when they're 60 to 64 years old since most insurance companies will pay the doctor’s office directly so they will not have to pay out of pocket and be reimbursed by Medicare.
For patients who haven’t received the vaccine and end up suffering from shingles, there may be some relief with antiviral medications such as acyclovir, valacyclovir, and famciclovir—best prescribed early to stop the virus from causing more damage to the nerves—or steroids like prednisone to decrease the intensity and duration of pain associated with acute shingles.
“Some patients are candidates for an antiviral medication that can reduce the pain and length of the period of rash,” says Yawn. “It will also decrease their risk of developing postherpetic neuralgia.” The challenge to physicians is the prompt and proper diagnosis and treatment of shingles. When treated within 72 hours of eruption, the severity and duration of shingles are significantly decreased. Acute pain responds to prompt treatment, and immediate therapy reduces the duration of pain in PHN patients.
Additional relief from the pain can be found through nerve blocks; opioid medications such as morphine, oxycodone, codeine, hydromorphone, and methadone; and tricyclic antidepressants such as amitriptyline and nortriptyline. In fact, one study has shown that giving tricyclic antidepressants during the early phase of shingles can help reduce the pain and may even help reduce the chance of developing chronic PHN pain.Relief From PHN
While the possibility of reducing PHN through antiviral medications exists, there’s no proven relief. For patients who do suffer from post-shingles pain, it’s impossible to reverse the damage caused to the nerves. But there are some treatments to help manage the pain.
It’s important for all oral medications to be given initially at a low dose with dosage gradually increased until pain is relieved or side effects occur. This gradual increase is important because patients with PHN differ and individuals may respond to different doses of each medication.
For physicians or patients who prefer nondrug therapy, rehabilitation therapies and psychological therapies such as relaxation therapy and biofeedback may help with pain management. Patients may also get relief from therapies that stimulate the nerves, such as trancutaneous electrical nerve stimulation, small devices that send very small amounts of electrical current through electrodes attached to the skin. While studies have shown little relief from acupuncture, there are nonscientific reports of some patients with PHN experiencing relief with this treatment.Resources and Hope
AfterShingles.com, an online resource offering tools and information to help educate older adults about shingles and PHN, can be beneficial as well. “Relaunched by the National Council on Aging, the Web site is a consumer-focused site that offers fresh, interactive tools such as a Q & A function with a physician and a downloadable pain calendar and check list,” says Heather McKenzie, MBA, BSN, RN, senior director of clinical education and quality initiatives for the Visiting Nurse Associations of America. “This Web site will help patients talk with their healthcare providers about shingles and PHN.”
AfterShingles.com also includes a micro site for the Patchwork of Hope Network, an educational program led by the National Council on Aging and the National Pain Foundation to raise awareness of PHN. “After-shingles pain is most common among older Americans and can be emotionally distressful and isolating,” says Scott Parkin, the council’s vice president of communications. “The Patchwork of Hope Network was created to help raise awareness of this condition on a national level.”
— Jennifer Mellace is a Maryland-based freelance writer whose articles have been published in various regional and national publications.