An Update from Harvard Medical School
If you’re 60 or older, it is time to get vaccinated for shingles, according to new guidelines from the Centers for Disease Control and Prevention (CDC).
Shingles, also known as herpes zoster, is characterized by a painful and itchy rash. It is caused by the same virus that causes chicken pox (varicella-zoster). Most people who have been infected with the virus never get rid of it. After an initial infection with chicken pox, the virus retreats into nerve cells near the spinal cord and brain, possibly to reemerge later in life. About two in every 10 people who have had chicken pox eventually will get shingles.
Doctors diagnose more new cases of shingles annually than any other neurological disease. About one million cases are diagnosed in the US every year, with more than half of those cases occurring in patients 60 years old and older.
MORE THAN A RASH
When the shingles virus is reactivated, it travels through nerves until it reaches the skin. Common early signs include pain, tingling and/or itching. A blistering rash typically emerges several days later and lasts up to four weeks.
The rash usually appears on just one side of the body, often as a band that extends from the midline of the back around to the breastbone. It also can appear above an eye or on the side of the face or neck.
The rash is the least important part of shingles. It’s uncomfortable but eventually will clear up on its own, with or without medical treatment.
Main risk: About 20% of patients with shingles go on to develop postherpetic neuralgia (PHN), nerve pain that can last for months or years. The pain from PHN ranges from mildly annoying to severe. Some patients experience disabling pain that is exacerbated by the slightest touch, such as the weight of a shirt.
Other risks: Some shingles patients go on to develop encephalitis (brain inflammation), retinitis (inflammation of the retina of the eye) or myelitis (swelling of the spinal cord). These complications are rare, however. Chronic postherpetic pain is the main risk.
WHO SHOULD WORRY
Anyone who has had chicken pox can develop shingles — and the virus is highly contagious. Anyone who comes into contact with the virus — usually by direct contact with the rash — potentially can be infected if he/she has not had chicken pox before. He will develop chicken pox, however, rather than shingles.
It is safe for anyone who has had chicken pox to come in contact with someone who has shingles — the shingles virus from one person cannot “reactivate” the virus in another.
Shingles outbreaks tend to occur most often in patients with weakened immune systems — due to advanced age… diseases, such as cancer or AIDS… or treatment with steroids, chemotherapy or the drugs used to prevent organ rejection after transplants.
Healthy people who get shingles are unlikely to suffer a second attack, because the emergence of the shingles virus reboosts their immunity. Decades can pass before a second attack. Since most people get their first shingles case in middle age or later, they probably won’t live long enough to get it again.
Patients with depressed immunity, however, may have subsequent or prolonged shingles.
The shingles vaccine, Zostavax, was licensed by the Food and Drug Administration (FDA) in 2006 following a study of more than 38,000 men and women ages 60 and older. Those who got the vaccine were 51% less likely to develop shingles than those in a control group. Even when the vaccine didn’t prevent shingles, the shingles attack was milder and the risk of PHN was reduced by 67%.
The CDC’s new guidelines recommending the vaccine for everyone age 60 and older were announced in May of this year, replacing a provisional recommendation made in 2006. The vaccine also is recommended for those who are currently healthy but who might experience significant immune impairments in the future. Patients with a new cancer diagnosis, for example, or someone who is anticipating a transplant procedure should ask their doctors about getting the vaccine.
Important: Patients with a blood cancer, such as multiple myeloma, and those who take immunosuppressive medications for conditions such as lupus or rheumatoid arthritis should ask their doctors if they need the vaccine.
The vaccination, given once by injection, costs about $300 (less at public health agencies) and usually is covered by insurance. Some insurance companies won’t cover the cost of the vaccine when it’s given to patients who already have had shingles, because their risk of a subsequent attack is low.
According to the CDC, the shingles vaccine should not be given to patients who are allergic to gelatin or the antibiotic neomycin… those with active, untreated tuberculosis… those with a history of bone marrow cancer or lymphatic cancer… or women who are pregnant or planning to get pregnant within three months of getting the vaccine.
IF YOU GET SHINGLES
Patients who do develop shingles often can reduce the duration and/or severity of the infection, and their risk for developing PHN, with the prompt use of antiviral drugs (within 72 hours after onset of the rash).
Three antiviral drugs — acyclovir (Zovirax), valacyclovir (Valtrex) and famciclovir (Famvir) — appear to be equally effective when taken for seven days. (Acyclovir, which has to be taken every five hours, is less expensive but less convenient than the other drugs, which are taken three times daily.) The earlier these medications are started, the more effective they appear to be at terminating a shingles outbreak.
One study found that shingles patients treated with the antiviral famciclovir were free of pain in 63 days, on average, compared with an average of 119 days in patients given a placebo. In real life, however, the drugs tend to be less effective than clinical studies suggest. Reasons: Delays in diagnosis and/or getting a prescription mean that some patients don’t start the drug until they have had the infection for more than 72 hours. Others may forget to take every dose.
Other options: Patients who combine an antiviral drug with an oral steroid (taken for three weeks in a tapering dose) may experience less pain and/or skin discomfort. The steroid/antiviral combination also may reduce the risk for developing PHN.
During the rash phase of shingles, some patients can get temporary relief by taking an over-the-counter painkiller or an anti-inflammatory, such as ibuprofen or acetaminophen. Applications of hydrocortisone cream or the use of cool, moist compresses also can help relieve pain and itching.