Shingles | Mate huaketo hei

If you have had chickenpox, you were infected with the varicella zoster virus. In the past, nearly every child would become infected by the time they were an adult, but now we have a vaccine that protects against chickenpox. When you recover from chickenpox, the virus ‘hides out’ in nerve cells and stays dormant (inactive).

Image credit: Dermnet NZ

You develop shingles when this dormant virus reactivates. This can happen if your immunity is lowered by getting older, during times of stress or by having cancer treatment or other conditions, eg, HIV, rheumatoid arthritis or type 2 diabetes.

Yes, but the infection spread is chickenpox, not shingles. You can catch chickenpox from somebody who has shingles if you are not already immune. Shingles is the late result of chickenpox infection.

The shingles blisters contain a live virus. If you have never had chickenpox and make direct contact with an open blister or something with the fluid on it, you can contract the virus and develop chickenpox.

A person with shingles is only infectious when the blisters appear, and until the blisters have all developed crusts. It is possible to get shingles more than once.

Shingles most commonly affects one side of the body, but it can occur on one side of the face. In rare cases (usually in people with weakened immune systems), the rash may be more widespread on the body and look similar to a chickenpox rash.

The infection usually has 3 stages.

Sometimes pain can carry on for months to years after the rash has gone – 1 in 5 people experience it for more than a year. The pain is described as burning, sharp and jabbing, or deep and aching. This is called post-herpetic neuralgia (also called nerve pain). Read more about post-herpetic neuralgia below.

Other complications from shingles infection include glaucoma, vision loss, facial weakness and hearing loss. If you experience any of these, see your GP for advice. 

Shingles typically affects older people, but it can also occur in healthy younger persons and even in children. Those whose immune systems have been weakened by cancer, HIV infection, AIDS, or treatment with certain medicines are also at increased risk of getting shingles. 

• Anyone who has had chickenpox is at risk of getting shingles later in life. About 1 in 3 people who have not been immunised against chickenpox or shingles will get shingles in their lifetime.
• Shingles usually affects older people. The older you are if you get shingles, the higher your risk of getting serious disease. People who have a weakened immune system are also at risk of getting more severe disease, even if they are young.
• Women have a higher risk of getting shingles than men.
• Most people who develop shingles have only 1 episode during their lifetime. However, you can have shingles more than once. 

An attack of shingles during pregnancy will not harm the unborn baby. The mother is already carrying the varicella zoster virus before developing shingles and there is no increase in the risk of passing it on to the fetus if shingles develops. However, an attack of chickenpox during pregnancy can be serious and requires urgent medical attention.

See your doctor as soon as you think you may have shingles. This should be within 3 days of the rash first appearing for antiviral medication to be most effective in reducing the risk of complications. The earlier that antiviral medication is given, the more effective it is – but it can be given up to 7 days after the rash appears. If it is a holiday period, go to an afterhours clinic. It is particularly important to seek medical advice if your rash is by your eyes or if you are immunosuppressed (your immune system doesn't work well).

To diagnose shingles, your doctor will ask you about your symptoms and will also do an examination. Some people may have pain with no rash or rash with no pain. In such cases, a blood test may be needed to confirm the diagnosis.

The treatment for shingles helps to reduce the severity of the rash and how long it lasts. It also helps in managing the pain associated with shingles. Antiviral medicines help to fight the virus and other medications can be used to manage the pain. There are also a few things that you can do for yourself to ease your symptoms. 

Self-care for shingles

• Keep the affected area clean and dry. Simple absorbent dressings can be used to cover the rash; this will help to prevent passing it on. Sticky (adhesive) dressings should not be used as they can slow healing and cause irritation. Antiseptics should not be used due to a lack of evidence that they are effective. A damp cool cloth on the affected area may relieve itchiness and pain.
• Wear loose clothing to reduce friction/rubbing of the blisters.
• Do not scratch the blisters – scratching can spread the virus and cause scarring. Calamine lotion is sometimes used to relieve the itch, but there is limited information about how effective it is.
• Avoid direct contact with other people, particularly immuno-compromised people (people whose immune systems don't work well), infants/pēpi aged under 1 year and pregnant women.

Antiviral medications

Your doctor may prescribe an antiviral medication, eg, valaciclovir or aciclovir, depending on your age, how long it has been since the rash started and how badly you are affected.

Antiviral medication can reduce the severity and the duration of pain associated with shingles. Antiviral treatment helps by slowing the multiplying virus. It’s best if it’s started within 3 days of the rash but may be started up to 7 days after the rash first appears. 

Medications for pain

Pain from shingles can happen during the infection (called acute pain) or may continue for months to years afterward (called post-herpetic neuralgia).

Acute pain

The choice of pain relief will depend on the severity of the pain. For mild-to-moderate pain, paracetamol or a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen, is best. If this doesn't work, or for moderate-to-severe pain, stronger pain relievers such as codeine, morphine, tricyclic antidepressants and gabapentin may be used. Read more about pain relief medications.

Post-herpetic neuralgia (ongoing pain)

About 1 in every 3 people who have had shingles go on to have pain that lasts for months or years after the rash has gone. This is a type of nerve pain or neuropathic pain. Read more about post-herpetic neuralgia below.

Apps reviewed by Healthify

You may find it useful to look at some Skin care (dermatology) apps and Self-management and healthy living apps.

The best protection against shingles is vaccination.

Chickenpox vaccine should prevent you from getting the virus, and so decrease the risk of both chickenpox and shingles.

Shingles vaccine reduces the risk of getting shingles and its complications – you may still get shingles, but the symptoms are usually less severe and post-herpetic neuralgia is less likely. Shingrix® is the only brand of shingles vaccine available in Aotearoa New Zealand. Read more about the Shingrix® vaccine.

The most common complication of shingles is long-term nerve pain called postherpetic neuralgia. Long term nerve pain occurs in the areas where the shingles rash was, even after the rash clears up. It can last for months or years after the rash goes away. The pain can be very severe and can interfere with daily life. Read more about pain after shingles below.

Shingles on the face may lead to complications involving the eye, including blindness. Very rarely, it can also lead to pneumonia (lung infection), hearing problems, or brain inflammation (encephalitis).

Some people who have had shingles go on to have pain that lasts for months or years after the rash has gone. The medical term for having pain after shingles infection has cleared up is postherpetic neuralgia. 

The exact reason why some people get ongoing pain after shingles is not well understood. We know that shingles causes inflammation of the nerve and that pain can be expected while you have the rash. It is thought that postherpetic neuralgia may be related to the scar tissue next to the nerve or in the nearby part of the spinal cord that may cause pain messages to be sent to the brain. 

What are the symptoms of postherpetic neuralgia?

Postherpetic neuralgia is pain that occurs months or years after you have had shingles.

• It happens in the area of your skin where the shingles infection first occurred.
• This is most commonly in a band around your body, usually on one side of your body.
• The pain is described as burning, sharp and jabbing, or deep and aching.
• People with the condition often can't bear even the touch of clothing on the affected skin as they are sensitive to light touch.
• Sometimes postherpetic neuralgia can produce an itchy feeling or numbness.

Who is at risk of postherpetic neuralgia?

You are at greater risk of getting postherpetic neuralgia if you:

• are older than 50 years – the older you are, the more likely it is to occur
• have had shingles on your face or chest area
• had a severe rash and severe pain during the shingles infection
• have other illnesses such as diabetes
• have not had  the shingle vaccine (also called zoster vaccination) – zoster vaccination reduces the risk of developing postherpetic neuralgia following shingles. Read more about shingles vaccine 
• have not had antiviral treatment within 72 hours after your rash appeared.

Postherpetic neuralgia is rare in people aged under 50 and if it does occur it tends to be mild.

How is postherpetic neuralgia treated?

Postherpetic neuralgia is a type of nerve pain or neuropathic pain and so regular painkillers like paracetamol and ibuprofen are not likely to be helpful. Medicines may not stop the pain completely, but they can help reduce it. You may need to try a number of different types of medicine to find the one, or combination, that works best for you. The following medications have been found to be helpful:

Capsaicin cream

Capsaicin cream is rubbed onto the painful area of your skin 3–4 times a day. It is only applied on healed skin and not on blisters as it can cause a painful burning feeling. Capsaicin is thought to work by blocking nerves from sending pain messages. Read more about capsaicin cream.

Antidepressants and gabapentinoids

Some medicines used to treat depression also work for nerve pain, so you may be advised to try these. They include amitriptyline and nortriptyline. Another type of medicine, gabapentinoids (which include gabapentin and pregabalin) have been found to be helpful in relieving nerve pain. These usually ease the pain within a few days; however, it may take 2–3 weeks to ease and it can take several weeks before you have full benefit. Some people give up on their treatment too early. It is best to continue for at least 4-6 weeks to see how well the medication is working.

If the medication works, it is usual to take it for a further month after the pain has gone or eased. After this, the dose is gradually reduced and then stopped. Read more about nerve pain, amitriptyline, nortriptyline, gabapentin and pregabalin.

Self-care

• Wear comfortable clothing – cotton or silk clothing usually causes less irritation.
• Try covering the painful area with cling film or a plastic wound dressing to protect it.
• Use cold packs – for some people it helps to wrap an ice pack in a towel to apply on the affected area to cool the skin, but do not apply ice directly to the skin.

Does the pain go away?

About half of the people with postherpetic neuralgia find that the pain has gone within 6–12 months, but some have pain lasting a year or longer, especially if they have not had treatment. Some people have a slow improvement over a long period of time. A small number of people do not have any improvement over time without any treatment. If your pain is ongoing and not relieved with medicines or self care measures, you may be referred to a pain management specialist.

Living with post-herpetic neuralgia can be very difficult because it can affect your ability to carry out simple daily activities, such as dressing and bathing. It can also lead to further problems, including extreme tiredness, sleeping difficulties and depression. Speak to a healthcare professional if you need support in are of those areas.