Explaining shingles, and how to avoid it

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Shingles can be a painful rash that goes away after a few weeks — or it can be hellish.

“Horrible” and “excruciating” are terms some people use to describe postherpetic neuralgia, the painful aftermath that develops after the initial rash phase in about 10 to 20 percent of shingles cases.

Postherpetic neuralgia pain is hard to predict. It can last for months, even years. Yet it can also end abruptly (and mercifully) for no apparent reason.

How shingles begins

Shingles is caused by the varicella zoster virus, the same virus that causes chickenpox. After a person experiences chickenpox, leftover varicella virus hides out in the nervous system in an inactive state, held in check there by the immune system.

If the immune system (more precisely, the T cells of the immune system) weakens, the snoozing varicella virus can come roaring back to life, replicate, and cause the havoc we experience as shingles and postherpetic neuralgia.

The pain comes from inflammation and injury to nerves, as well as changes in how pain signals are processed.

The risk of shingles increases with age because the strength of the immune system declines as we get older. Shingles starts to become more common in our 50s; half of everyone who makes it to age 85 will have experienced shingles some time along the way.

But anyone harboring the varicella virus in their nervous system, which is true of most everyone over age 40, and who has an impaired immune system is vulnerable.

This includes people with HIV/AIDS, some kinds of cancer (especially Hodgkin’s disease), and organ transplant recipients. Some studies suggest that stressful events can bring shingles on.

The classic shingles rash appears as a red band on one side of the torso. Shingles may affect nerves in other parts of the body, including those in the arms or legs, resulting in muscle weakness and wasting in the affected limbs.

Some of the worst cases involve the trigeminal nerve in the face, particularly the branches that supply the area around the eye. This can lead to inflammation in the cornea and even vision loss. It’s also more likely than other sorts of shingles attacks to develop into postherpetic neuralgia.

Treating the pain

Early treatment of shingles with antiviral drugs has been shown to cut the risk of postherpetic neuralgia substantially.

For those who miss the early treatment window, or nonetheless develop a painful case, doctors have several treatment options. Small doses of the tricyclic antidepressant medications (amitriptyline, desipramine, nortriptyline) act as pain relievers.

Antiseizure medications, such as gabapentin (Neurontin) and pregabalin (Lyrica) can be used alone or in combination with the tricyclics.

Some study results suggest that antiseizure medications are particularly good in controlling piercing, knifelike pain. Topical creams containing capsaicin (the substance that makes chili peppers spicy hot) or lidocaine (which also comes as a patch) may provide a little relief.

If all else fails, some patients benefit from injections of medications into the spinal canal.

Despite all the options, about half of the time postherpetic neuralgia patients don’t respond to any treatment.

 

Shingles can be a painful rash that goes away after a few weeks — or it can be hellish.

“Horrible” and “excruciating” are terms some people use to describe postherpetic neuralgia, the painful aftermath that develops after the initial rash phase in about 10 to 20 percent of shingles cases.

Postherpetic neuralgia pain is hard to predict. It can last for months, even years. Yet it can also end abruptly (and mercifully) for no apparent reason.

How shingles begins

Shingles is caused by the varicella zoster virus, the same virus that causes chickenpox. After a person experiences chickenpox, leftover varicella virus hides out in the nervous system in an inactive state, held in check there by the immune system.

If the immune system (more precisely, the T cells of the immune system) weakens, the snoozing varicella virus can come roaring back to life, replicate, and cause the havoc we experience as shingles and postherpetic neuralgia.

The pain comes from inflammation and injury to nerves, as well as changes in how pain signals are processed.

The risk of shingles increases with age because the strength of the immune system declines as we get older. Shingles starts to become more common in our 50s; half of everyone who makes it to age 85 will have experienced shingles some time along the way.

But anyone harboring the varicella virus in their nervous system, which is true of most everyone over age 40, and who has an impaired immune system is vulnerable.

This includes people with HIV/AIDS, some kinds of cancer (especially Hodgkin’s disease), and organ transplant recipients. Some studies suggest that stressful events can bring shingles on.

The classic shingles rash appears as a red band on one side of the torso. Shingles may affect nerves in other parts of the body, including those in the arms or legs, resulting in muscle weakness and wasting in the affected limbs.

Some of the worst cases involve the trigeminal nerve in the face, particularly the branches that supply the area around the eye. This can lead to inflammation in the cornea and even vision loss. It’s also more likely than other sorts of shingles attacks to develop into postherpetic neuralgia.

Treating the pain

Early treatment of shingles with antiviral drugs has been shown to cut the risk of postherpetic neuralgia substantially.

For those who miss the early treatment window, or nonetheless develop a painful case, doctors have several treatment options. Small doses of the tricyclic antidepressant medications (amitriptyline, desipramine, nortriptyline) act as pain relievers.

Antiseizure medications, such as gabapentin (Neurontin) and pregabalin (Lyrica) can be used alone or in combination with the tricyclics.

Some study results suggest that antiseizure medications are particularly good in controlling piercing, knifelike pain. Topical creams containing capsaicin (the substance that makes chili peppers spicy hot) or lidocaine (which also comes as a patch) may provide a little relief.

If all else fails, some patients benefit from injections of medications into the spinal canal.

Despite all the options, about half of the time postherpetic neuralgia patients don’t respond to any treatment.

Prevention is prudent

Better than treatment is prevention. There’s a shingles vaccine, sold under the name Zostavax. In the large (38,000 people), randomized trial that led to its FDA approval in 2006, the vaccine reduced the risk of shingles by half and of postherpetic neuralgia by an impressive two-thirds. And by all accounts it’s safe.

Federal vaccine officials have recommended that everyone age 60 or older with a healthy immune system be vaccinated against shingles — advice that applies to people who’ve already had a case, because shingles can recur.

Yet recent surveys indicate that less than 10 percent of the Americans who should get the vaccine have done so.

Part of the reason may be cost. The wholesale price of Zostavax is about $200 per shot, so it’s not a minor expense.

The vaccine is covered by all Part D Medicare plans (check with your carrier about copayments), but they’re set up to reimburse pharmacies, not physicians, so physicians sometimes run into difficulties billing for the shingles vaccine.

Other adult vaccines are covered by Medicare Part B, which covers physician services, but so far, legislative and lobbying efforts to move the shingles vaccine into Part B have failed.

Less than half (45 percent) of the doctors surveyed knew that shingles vaccine was reimbursed through Medicare Part D, and 12 percent said they had stopped offering the vaccine because of the cost and reimbursement issues.

But you may not need to see a doctor to get the shingles vaccine. Vaccines are also allowed to be administered at pharmacies.

Some doctors let their patients “brown bag” the vaccine: People buy it at the pharmacy and then bring it to the doctor’s office to be administered. (It must be kept cold, however, to remain effective.)

In the case of brown bagging, the cost of the vaccine itself should be covered by your Part D plan, but usually the doctor will ask you to pay the cost of administering the vaccine out of pocket. You should get a receipt and submit it to your Part D plan for reimbursement, but you probably won’t get all your money back

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