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Pain Management

Shingles – Symptoms and Treatment Options

Shingles is a viral infection that causes a painful rash, usually in a stripe pattern around one side of your chest or back. This infection is caused by the varicella-zoster virus, the virus that causes chickenpox. Over 95% of people are infected, with the virus remaining silent inside their nerve cells. An estimated one in three people may eventually develop shingles in their lifetime, when the virus becomes active again.

Shingles is common in people whose immune systems are weakened by stress, a disease, or advanced age. Ideally, these people receive booster vaccinations in order to minimize the risk for shingles. However, a vaccine does not always prevent outbreaks.

If prevention of shingles through vaccination is not possible, early treatment is your next best option. Your primary care or emergency room doctor is likely to start treatment with antiviral medications and light analgesics. However, this may not adequately control your pain. You will benefit by continuing your treatments with a pain specialist. A pain specialist can treat postherpetic neuralgia, a common and disabling type of pain that can last for months after a shingles outbreak.

Why does shingles hurt?

Anyone who’s had chickenpox and recovered from it, still harbors the virus deep in their nerves, close to the spinal cord. In this regard, chickenpox resembles the viruses that cause cold sores and genital herpes. Although chickenpox is not the same as sexually transmitted herpes, it is in the same family and it is therefore named herpes zoster.

Your immune system keeps the herpes zoster virus in check until you experience some stress. This allows the virus to multiply and travel along the entire length of the nerve, all the way to the skin. On the skin, it creates painful blisters that can readily ooze, allowing the virus to infect its next victim. You are highly infectious at this point and should avoid contact with people who aren’t vaccinated.

Symptoms

Pain is usually the first symptom before a shingles outbreak. It usually affects only a certain part of your body. After a couple of days, the painful area becomes covered in red, itchy, pus-filled blisters.

Shingles symptoms:

  • Pain, burning, numbness, tingling, itching
  • Your skin is sensitive to touch
  • A red rash over some part of your body, on the right or left side
  • Fluid-filled blisters that break open and crust over
  • General symptoms such as fever, headache, sensitivity to light

Where on the body does shingles appear?

Some people experience shingles pain without ever developing the rash. However, this is rare and most people have a rash.

  • Chest and back     A common shingles pattern is a stripe of blisters that wraps around either the left or right side of your torso. This pattern is often confused with a heart problem, lung pain, or kidney pain. 
  • Around the eye    The rash can start around one eye. You should seek treatment immediately for this, as it can harm your vision.
  • Scalp    The rash can appear on one side of your head, under your hair.
  • Neck and face    Shingles may break out over one side of the neck or face. 

A decrease in quality of life in people with shingles

A 2010 Canadian study looked at the impact of herpes zoster on people’s quality of life. It followed 261 persons with shingles, aged 50 years or older, over a period of six months. The study found that pain interfered with sleep in 64% of the participants; it interfered with the enjoyment of life in 58% of the participants and prevented general activities in 53%. Pain usually lasted 32 days. 

However, the pain lasted much longer (over 90 days) in people who developed postherpetic neuralgia. This is a severe, burning pain that affected one in four people with shingles. In fact, the largest changes in the enjoyment of life, mood, and sleep were seen in people who suffered from postherpetic neuralgia. 

The study supported a need for early treatment of herpes zoster and adequate pain control in people with postherpetic neuralgia.

Factors that lead to a shingles outbreak

Factors that increase your risk of having shingles include:

  • A chickenpox outbreak in your childhood  –  Older adults in the United States may have had a full-blown chickenpox infection when they were children. In recent years, due to routine childhood vaccinations, childhood chickenpox outbreaks are less and less common.
  • Advanced age  –  Shingles is most common in people older than 50, due to a weakened immune system. Some experts estimate that half the people age 80 and older will have shingles.
  • Having certain diseases  –  Diseases that weaken your immune system, such as HIV/AIDS and cancer, can increase the risk for shingles.
  • Cancer treatments  –  Radiation or chemotherapy can lower your resistance to diseases and trigger shingles.
  • Certain medications  –  Drugs taken in order to prevent rejection of transplanted organs can increase your risk of shingles. Prolonged use of steroids, such as prednisone, can lead to shingles.

For more information on shingles, click here.

When to see a pain specialist

Chances are that once you develop shingles, you will rush to your primary care physician (PCP) or the emergency room (ER) for treatment. Your physician usually recognizes a shingles outbreak due to the tell-tale rash. Testing is not necessary but can be done.

There is no cure for shingles. However, starting treatment early on, can speed the healing process. Your PCP or ER doctor might start you on light pain medications and antiviral drugs such as Acyclovir (Zovirax) or Valacyclovir (Valtrex). However, this treatment is not strong enough to prevent post-herpetic neuralgia.

Treatment for shingles pain, including postherpetic neuralgia

There is no cure for shingles. However, starting treatment with antiviral drugs early on, can speed the healing process. A pain specialist will treat you if you are experiencing a long lasting type of shingles pain, known as post-herpetic neuralgia. Postherpetic neuralgia is nerve pain. It feels like burning, tingling, or stinging over the area of the outbreak. It may last for weeks or months after the rash has disappeared.

Treatment options:

  • Antidepressants.  Medications like Amytriptilene (Elavil) decrease nerve pain in many conditions, including post-herpetic neuralgia.
  • Medications that prevent seizures (anticonvulsants). These medications also decrease nerve pain. Examples include Gabapentin (Neurontin).
  • Creams that calm nerve pain.  Creams with Lidocaine act directly on the painful nerves, to block pain signals. Other treatments such as Capsaicin, a cream made from hot peppers, can gradually de-sensitize you from feeling pain. It gets you accustomed to feeling a stinging sensation, until the pain no longer bothers you.
  • Nerve Blocks.  Your pain specialist can treat your pain by injecting numbing medicine directly on the painful nerve. This is a very efficient treatment since the Herpes Zoster virus lives inside that particular nerve. If you suffer from a shingles outbreak in the eye area, a supraorbital nerve block can relieve your pain. Cervical paravertebral nerve blocks can be used for a shingles outbreak on your arm. Shingles on your chest or back can be treated with a paravertebral nerve block.
  • Epidurals. During an epidural, your pain specialist injects numbing medicine and/or steroid very close to the spinal cord. This allows the medicine to reach the nerve cell body, where the virus hides between outbreaks. An epidural reduces some of the nerve inflammation and also numbs the skin pain. Relief can last anywhere from several weeks to months.

A scientific study – Epidurals for pain prevention

Scientists searched for the best treatment to prevent postherpetic neuralgia, the severe pain that one in four patients develops after a shingles outbreak.

They compared two treatments.

  1. Treatment 1 included an anti-virus medication (Acyclovir) given directly in the bloodstream (intravenously), for increased efficacy. Some patients also received steroid pills, while others did not.
  2. Treatment 2 was an epidural with local anesthetics (numbing medicine). Some patients also had steroids placed in the epidural, while others did not.

The scientists found that after one year 22.2% of the patients who completed Treatment 1 (51 patients of 230) still had pain.

Significantly better results were found after Treatment 2 where only 1.6% (4 patients of 255) still had pain one year after the outbreak.

Epidurals with local anesthetic and steroid were found to be very effective in preventing (post-herpetic neuralgia) long-term pain after shingles.

General information

  • Early treatment for pain is key    After a shingles outbreak, treatment should start early (in the first week). You should be taking a combination of medications (i.e. Valacyclovir, Neurontin) and get an epidural from a pain specialist.
  • Prevention with shingles vaccines    There are two options. Zostavax is a live vaccine that protects against shingles for about five years. Shingrix is the preferred alternative to Zostavax, since it offers protection against shingles beyond five years. It’s a nonliving vaccine, given twice, six months apart. The shingles vaccine doesn’t guarantee you won’t get shingles but reduces the severity of the disease.
  • Home remedies    The following help: cool compresses, calamine lotion, wearing loose cotton clothes, oatmeal baths.

Pain specialists offer unique treatments that other physicians, such as urgent care providers and PCPs cannot provide. A pain specialist can offer you a Nerve Block or an Epidural. Both treatments can have dramatic and significant pain relief effects and decrease your risk of long-lasting pain after shingles. 

Our pain specialists at National Spine and Pain Centers are here to help you. Click here for an appointment.