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May 10, 2010

Shingles: Painful and Debilitating
By Jennifer Mellace
For The Record
Vol. 22 No. 9 P. 24

With no cure available, vaccination is often the best option to combat this destructive 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 chicken pox. Whereas itching is the key symptom of the chicken pox rashs, 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 sharpness.

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, the antiviral drugs used to treat shingles are not useful in patients with PHN. Although uncommon, for some people, PHN may improve over time without treatment. Overall, shingles presents a fairly bleak outlook for its sufferers.

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.”

However, there are stipulations to receiving the vaccine. At this time, it can be given only to older adults who do not have any conditions 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 undergoing chemotherapy for other types of cancer or taking similar types of drugs such as those used for rheumatoid arthritis are not candidates for the vaccine.

“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.”

The vaccine must be kept frozen and then thawed prior to administration. Yawn says there is 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, which is under study, could be kept on the shelf and would better maintain its potency, thereby increasing the availability to patients.

Another way to ensure greater use of the vaccine is to have patients aged 60 to 64 request a shot because 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 such as prednisone to decrease the intensity and duration of pain.

“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 for 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 pain relief 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 postshingles pain, it’s impossible to reverse the resulting nerve damage. But there are some treatments to help manage the pain.

It’s important for all oral medications to initially be given at a low dose with the dosage gradually increased until pain is relieved or side effects occur. This gradual increase is important because PHN patients may react differently to different doses of each medication.

For physicians or patients who prefer nonpharmaceutical therapy, rehabilitation therapies and psychological tactics such as relaxation therapy and biofeedback may help with pain management. Patients may also get relief from therapies that stimulate the nerves, such as transcutaneous electrical nerve stimulation, or tiny devices that send 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 PHN patients feeling more comfortable following such treatment.

Resources and Hope
AfterShingles.com, an online resource offering tools and information to help educate older adults about shingles and PHN, can help alleviate patient fears about what lies ahead. “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 checklist,” 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 PHN awareness. “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.


Chicken Pox Vaccine Lowers Shingles Risk for Black Children
Black children are less likely than white or Asian children to develop shingles (herpes zoster) after receiving the varicella vaccine to prevent chicken pox, according to a study in the March issue of The Pediatric Infectious Disease Journal.

The results are consistent with previous studies showing lower rates of herpes zoster in black vs. white adults. “It is possible that genetic variation may explain some portion of varicella-zoster virus reactivation,” according to the study led by Hung Fu Tseng, PhD, MPH, of Kaiser Permanente in Pasadena, Calif.

Using records from a large Kaiser Permanente health plan, Tseng and colleagues identified 122 children aged 12 or younger who developed herpes zoster after receiving the chicken pox (varicella) vaccine. Sometimes called shingles, herpes zoster is a painful, blistering rash that occurs when the varicella-zoster virus (VZV), which causes chicken pox, becomes reactivated in the body.

Herpes zoster is much more common in adults than children, particularly children who have received the varicella vaccine. However, like natural VZV, the virus used in the varicella vaccine can become reactivated, causing shingles to later occur.

The children with herpes zoster were matched for race, age, and sex to a group of vaccinated children who did not develop herpes zoster. Possible risk factors were analyzed.

The results suggest black children had a significantly lower risk of developing herpes zoster. With adjustment for other factors, including the time since varicella vaccination, herpes zoster risk was 60% lower in black children compared with white children and 70% lower compared with Asian children.

No children with herpes zoster had a serious illness requiring hospitalization. Another recent study in the journal from December 2009 found that children receiving the varicella vaccine are much less likely to develop herpes zoster than those with natural chicken pox and that, when the condition does occur, it is less severe.

The lower risk in black children is consistent with previous studies showing rates of herpes zoster are lower in black than white adults. Those studies suggest several possible explanations for the lower risk of shingles in black adults, such as more infections or increased exposure to people with chicken pox.

However, none of these would account for a reduced risk of shingles in black children. Racial differences in access to healthcare are also unlikely in this case, since all of the children in the study were enrolled in an insurance plan providing equal access to care.

Having eliminated these possibilities, Tseng and the study coauthors believe a genetic explanation is most likely. “The lower risk of herpes zoster found in both black children and adults suggests the potential of an underlying genetic factor that modifies the risk of VZV reactivation,” they wrote. Further studies to understand the reasons for this racial difference could also lend important clues as to how VZV becomes reactivated to cause herpes zoster.

— Source: Wolters Kluwer Health: Lippincott Williams & Wilkins