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 | Shingles
By Michael Spilane, MD
Shingles is an unfortunately common and nasty problem. It is more than a simple skin rash. The virus that is responsible for the eruption also infects the nerves beneath the skin, resulting in a rash that hurts. Not just itches, but hurts. It is the pain that makes shingles miserable for the patient and challenging for the physician.
Along with pain, the other characteristic feature of a shingles rash is its one-sided regional distribution on the body. The eruption and the pain are on one side of the chest, one side of the face or on one flank. The most common location flows from the mid-back, along the lower ribs, to the belly button. The wrap-around distribution of the eruption explains the origin of the word shingles--it comes from the Latin term meaning "girdle." The medical name is herpes zoster, but even physicians are likely to call it shingles.
In a typical case of shingles the pain comes first, often accompanied by a sense of ill being and a slight fever. The eruption that follows a day or two later is characterized by patches of involved skin separated by areas of normal skin. The patches vary in size but are similar in appearance to cold sores of the lips (a condition caused by a related virus). Initially the rash contains small water blisters, but these quickly evolve to a crusted stage. The lesions heal over a period of several weeks, but often leave pigmented scars. Pain usually eases after about a week and disappears soon after the rash is entirely healed, but for some the pain does not always go away so quickly. In about fifteen percent of cases the pain lasts for months or years, and sometimes it never goes away. Shingles is responsible for some of the most severe persisting pain experienced by humans.
Although shingles most commonly attacks the lower chest or flank, it can appear on almost any part of the skin. Serious eye complications can develop if the rash is present on the forehead or face, and bladder dysfunction can result if the rash affects the groin region.
Shingles is primarily an ailment of older people. It is uncommon under the age of fifty-five, unless a pre-existing disease has impaired the immune system. The older a person is when the ailment strikes, the more likely that complications such as persisting pain will develop. Recurrences are possible but are not likely.
The eruption is caused by the chicken pox virus, a member of the herpes family of germs. Virtually every older person has had chicken pox; an illness that comes on early in life, lasts a week and is soon forgotten. But the pox virus is not eliminated from the body. It lives dormant and harmless in nerve cells of the spinal column. Eventually the virus awakens, replicates itself a few million times, and uses a peripheral nerve to journey from the spinal column to the skin. Involvement of the nerve explains the pain and the highly localized distribution of the skin eruption.
Shingles seldom presents a diagnostic problem for a physician--the burning pain and unilateral distribution of the lesions are highly characteristic. Treatment is another matter. Significant progress has been made in developing antibiotics that attack the shingles virus, but existing drugs are only partially effective and need to be started within a day or two of the initial eruption. And they are not cheap. Fortunately, the body itself does a good job of eradicating the virus. The rash can be soothed with calamine lotion or Burrows solution, and prayers can be said in hope that damage to the nerve does not result in persistent pain.
A person with an active shingles eruption can communicate the chicken pox virus to others, but the likelihood is low. Only those who lack immunity from a previous chicken pox infection (almost always young children) are at risk. It is best for the afflicted person to avoid direct touching contact with susceptible individuals until the rash is well crusted and is subsiding. A susceptible exposed person will develop chicken pox and not shingles.
About thirty percent of persons living to older age have the misfortune of experiencing shingles. For most it is tolerable and passes with little more than memory of some distressful days, but for a few it brings serious and lasting complications. Effective treatment remains a future hope.
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