Persistent pain, called postherpetic neuralgia (PHP), is the main issue with shingles.
The pain may be burning or tingling, and the skin may be very sensitive – or painful – to even light touch. There may be reduced sensation to touch or frank numbness.
What strikes doctors who see people with shingles is just how much it can knock people about.
These are risk factors for developing PHP:
- Increasing age
- The rash is severe
- Acute shingles pain that is severe
- Symptoms occurring before the rash has started (“prodromal symptoms” like pain or headaches)
- Eye involvement
- Being on immunsuppressant medication
How to identify Shingles?
The rash occurs in a segment of the body on either the left or right side but not both, and does not cross the midline.
The rash is made up of individual lesions that may number just a few to over a hundred. Just as with chickenpox, each lesion evolves through 4 stages: red spot, blister, pustule, and finally crusting. The rash starts to settle down after around 2 weeks and goes by around 3-4 weeks.
Skin HSV (cold sores) may appear similar to shingles. A viral swab will confirm which it is.
Is Shingles Contagious?
In a word – yes. But it’s not so straightforward …
The virus is found on the lesions, particularly in the early stages when there are blisters. Remember that shingles is reactivated from past chickenpox, so you can’t pass on shingles from shingles. But shingles can spread chickenpox.
The risk of spreading chickenpox from shingles is fairly low because:
- Kids are these days vaccinated against chickenpox (the vaccination is around 98% effective).
- Around 90% of unvaccinated adults are immune to chickenpox through previous infection
- Chickenpox is usually caught via respiratory droplets whilst shingles requires some form of contact from the skin.
Nevertheless, you should take precautions and be careful to wash your hands after touching the infected skin. Lesions that have completely crusted-over should not be contagious. Cover any non-crusted lesions with a light dressing. Take extra care around people who are immunocompromised.
Gallery of Shingles
Please click on the images for details.
Six Shingles Snippets:
- It does occur in kids.
- The pain may start a few days before the rash comes out – indeed, this occurs in around half of cases with pain up to 7 days before the rash appears.
- Shingles around the buttock may look like cold sores caused by the herpes virus. A viral swab will give the diagnosis.
- Shingles near the eye can be dangerous.
- Antiviral medicaion only works if started within 3 days of the onset of the rash.
- Don’t be frightened of taking medication for postherpetic neuralgia – many people with PHP shy away from medication. Whilst understandable, remember that it can take several weeks for medication to work. In addition, persistent untreated pain often leads to depression.
- Postherpetic neuralgia is defined as pain lasting 3 months or longer
- Shingles is confined to one area of the body in most people. However, severely immunocompromised people can develop severe disease that spreads to various organs.
- Shingles can infect the ear canal and cause facial weakness with some loss of taste (Ramsay Hunt Syndrome).
Starting antiviral medication within 3 days will speed up the resolution of the rash. There has been debate about whether antiviral medication reduces the risk of developing PHP and probably it does not¹.
What treatment is available for postherpetic neuralgia?
The fact that PNP can cause real misery for people reflects in the myriad of treatment options that are available.
The following table summarises the main treatment options ².
The Shingles Vaccine
A shingles vaccine has been around for a number of years. The one-dose vaccine is licensed over the age of 50 years. National Australian guidelines recommend the vaccine in people over 60 years. In this age group, the vaccine is estimated to halve the rate of shingles, and to reduce the number of cases of PHP by 60%.
The live vaccine is relatively expensive and cost has so far been the major barrier to uptake.
Public funding for shingles vaccination of people age 70 to 79 years started in Australia from 1/11/2016.
You may have noticed that The Australian immunisation handbook (>500 pages of it) recommends the shingles vaccine in all adults over 60 years, but government funding is for adults 70 to 79. There will always be a difference between optimal recommendations and funded recommendations. Other publicly funded systems such as The UK’s NHS are also funding it for those age 70 to 79. This age group is the sweet-spot for the shingles vaccine – shingles is common and the vaccine is effective.
People age 60-69 may decide to fund the vaccine themselves. Current prices of ®Zostavax are a little over $200.
The vaccine “lasts” around 5 to 10 years. Mild injection site pain or redness occurs in half of people who have the vaccine.
Should someone with previous shingles be vaccinated?
Definitely – yes. Shingles can re-occur with some studies suggesting the risk and severity of shingles may be comparable to the risk in people without a history of shingles.
You can find more information from health direct Australia.
|Oral or Topical||Prescription? Y/N||Effectiveness||Side Effects||Doses per day||Cost for 1 month *||Notes|
|Paracetamol like ®Panadol||Oral||No Script||+||+/-||4 times daily||$10-$20||not that effective|
|Anti-Inflammatory eg. Ibuprofen||Oral||No Script||+||+||3 times daily||$10-$20||small risk of Gastrointestinal side bleeding|
|Opiate Pain killers (® Panadeine Forte)||Oral||Script||+||++||4 times daily||under $20 – short term use only||Drowsiness, potential dependence|
|Capsaicin Cream (®Zostrix HP)||Topical||No Script||++||++||4 times daily||$25-$35||Apply to healed, intact skin|
|Lidocaine Patch (®Versatis)||Topical||Script||++||+||once daily||>$100||Apply to healed, intact skin|
|Amitriptyline (®Endep)||Oral||Script||+++||+++||once daily||$10-15||Takes 4 to 8 weeks to work up to the right dose|
|Pregabalin (®Lyrica)||Oral||Script||+++||+++||twice daily||$38 *||Dose also increased slowly|
|Gabapentin (®Neurontin)||Oral||Script||+++||+++||3 times daily||$10-$20||Takes around 4 weeks to get to the right dose|
- Chen N, Li Q, Yang J, Zhou M, Zhou D, He L. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2014
- Robert W. Johnson, M.B., B.S., M.D., and Andrew S.C. Rice Postherpetic Neuralgia New Engl J Med 2014;371:1526-33.