Shingles
We’ve all seen the horror movie where ...

we think the bad guy has been killed off, but he is really hiding in the basement ready to attack the girls at the sorority as soon as the cops wrap things up and head home. This is just how shingles works.

Shingles is a skin rash which commonly affects adults over 50. The rash is red, splotchy, and sometimes appears with small blisters. It usually occurs only on one side of the body in a narrow patch along the trunk, on part of an arm, or on an area of the face. The shingles rash will resolve with or without treatment in a couple of weeks. However, the most feared complication is persistent pain in the area of the rash, even after the rash has cleared up.

Shingles is caused by the varicella zoster virus, exactly the same virus which causes chickenpox in kids. Zoster is just the medical term for shingles, and varicella is chickenpox. It turns out that when you’re a kid and get chickenpox, the varicella zoster virus is never cleared totally out of your body. Like that creepy bad guy who was hiding in the basement waiting for the cops to go home, the chickenpox virus hides out in the nerves in your spine waiting for a weakness in your immune system. In general, your body’s immune system keeps that virus in check, but after many decades, your immune defenses against chickenpox begin to decline. When that happens, the virus migrates along the course of your nerves from the spine to the skin where it breaks out into a rash that looks like a localized case of chickenpox gone awfully wrong. Compared to regular chickenpox, the zoster rash has larger red blotches and fewer tiny blisters, and unlike regular chickenpox, it can hurt—a lot.

ShinglesThe nerves in your spine are organized into levels—like slices of bread in the chest and abdomen, and like long rectangular strips in your arms and legs. This is why the rash usually occurs in a narrow band; it is where that particular nerve supplies the skin. We call these narrow bands of nerve supply dermatomes (derm = skin, tome = a large book you have to read). In a healthy person, one or two adjacent dermatomes may be involved. If you have AIDS or a weakened immune system from, say, cancer or a bone marrow transplant, you can get that zoster rash, not in a single dermatome, but over much of your body. This is a condition called disseminated zoster, which is bad news.

If the rash heals up, but pain persists, we call it postherpetic neuralgia. Post means after, and neuralgia means pain from an injury to a nerve. (If you break your arm, the nerve just carries a pain message about the arm, but if you crush a nerve, it carries a pain message about itself, and that pain is usually more severe and harder to treat.) But what about the word herpetic in postherpetic neuralgia?

It turns out that chickenpox is in a family of viruses with similar biological behavior. They are all famous for “hiding out” in the body. Cold sores or herpes simplex type I, genital herpes or herpes simplex II, chickenpox, even the virus which causes mononucleosis, as well as a few others, are all “herpes” viruses. Therefore, if a 5 year old boy were brought into my office by his anxious parents with typical chickenpox, it would be scientifically correct for me to tell them that he has a total body herpes infection.

In general, the risk for postherpetic neuralgia rises with age. Patients over the age of 80 have a 25% chance of getting it if they have a case of shingles. Patients aged 60-70 have about a 7% chance. Below age 50, it is very rare.

I treat most patients who get shingles with three different drugs to speed healing and decrease the risk of postherpetic neuralgia. The first is an antiviral drug, like Valtrex or acyclovir, which prevents the virus from making copies of itself. The second is prednisone, which helps reduce inflammation of the nerve. The third is a drug like nortriptyline, which quiets down nerves and reduces pain. In randomized trials, Valtrex and prednisone help speed healing of the rash and reduce short-term pain, but it is unclear if they really prevent postherpetic neuralgia. Nortriptyline may help prevent postherpetic neuralgia, but we don’t have many studies with this particular medication.

Folks usually have only one episode of shingles in their lifetime. The recurrence of the varicella zoster virus triggers a large immune response which is then able to keep the virus in check for the rest of your life.

In the 1990s, a vaccine against chickenpox was introduced. Eventually, there will be a generation of kids coming along, most of whom don’t get chickenpox. The vaccine is about 90% effective. Kids who receive the varicella immunization should never get shingles either. One concern, however, is that after 50 or 60 years, vaccine-created immunity to chickenpox might decline, leaving older adults at risk for chickenpox but not shingles. In children, chickenpox is usually a fairly mild illness, but it can be fatal in adults. Any adult who is not certain he or she had chickenpox during childhood should have antibodies drawn, and if negative, get two doses of the kids’ chickenpox vaccine. The only death I’ve ever seen from chickenpox was in a 38-year-old man, and it was not a pretty sight, let me tell you.

Zostavax is a live vaccine, kind of an oxymoron

since viruses aren’t really alive, but

it is a weakened version of the chickenpox virus.

Since shingles represents the recurrence of chickenpox when immunity declines after many decades, it occurred to scientists and to the pharmaceutical companies to try and develop a vaccine which would boost immunity to chickenpox and prevent shingles. Instead of an outbreak of shingles serving as your “booster shot” for chickenpox immunity, why not just give patients a real booster shot? This is the strategy behind the new product: Zostavax.

Shingles

Zostavax is a live vaccine, kind of an oxymoron since viruses aren’t really alive, but it is a weakened version of the chickenpox virus. You get infected with this weaker version and this causes a boost in the immune response to keep the evil varicella zoster virus under control. In this version of the horror movie, the cops never go home and the sorority girls are not left vulnerable.

The zoster vaccine is approved for anyone 60 or older, and is obviously targeted at people who have had chickenpox as children, but have not yet had shingles. Because the vaccine contains infectious particles, it should not be given to people taking prednisone (which weakens the immune system), or to anyone with a weakened immune system for any other reason. Kids should not get the shingles vaccine. No one knows how long the vaccine will last or if a booster will be necessary.

In a study of the vaccine’s effectiveness, it reduced the chance of getting postherpetic neuralgia by 65% over a three year period. It worked partly by decreasing the chance of getting shingles in the first place, a 50% reduction, and then also by a decrease in postherpetic neuralgia in those who did get shingles. Unfortunately, three years is not a lot of follow up. I hope that longer term studies will continue to show an advantage to the zoster vaccine.

Merck, the company who makes Zostavax, also makes a vaccine for regular chickenpox. It is the same strain of weakened, but still infectious virus particles, just in a lower dose (1,350 Plaque Forming Units, a measure of infectivity, as opposed to 19,400 in the shingles vaccines).

Side effects in the studies mostly involved soreness or redness in the arm at the injection site. In clinical practice, the other side effect is a thinning of your wallet. It costs close to $200 and probably will not be covered by Medicare, at least initially.

If you’ve never had shingles, and in particular if you’ve never had postherpetic neuralgia, then this shot just seems like another hassle, something you need to do and don’t want to bother with. If a close friend or family member has had postherpetic neuralgia, you will definitely, oh most definitely, be wanting this vaccine.

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