What doctors wish patients knew about the shingles virus

If you were born before 1990 you might remember spending a week home from school with chickenpox. A sibling may have also stayed home with chickenpox at the same time. That’s because a vaccine wasn’t widely available until 1995. And if you had chickenpox as a kid, that means as an adult you’re at risk of developing shingles, which is a painful condition caused by the reactivation of the virus that causes chickenpox.

Shingles affects about one out of three people in the U.S. in their lifetime. Additionally, about 1 million people get shingles each year in this country, according to the Centers for Disease Control and Prevention (CDC).

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, AMA member Ankush Bansal, MD, a lifestyle medicine physician and hospitalist in Westlake, Florida, took time to discuss what patients need to know about shingles. Dr. Bansal is also a delegate in the AMA House of Delegates for the Florida Medical Association.

“Shingles is part of a virus called varicella zoster. So, there are two words in there—varicella and zoster—and the reason is because it describes two different conditions, but it is the same virus,” Dr. Bansal said, noting that “varicella is the fancy name for chickenpox and zoster is the scientific name for shingles.”

“What that means is that chickenpox and shingles are the same virus,” he said. “That’s why when you’re older, that’s when you get shingles and most people when they’re younger get chickenpox.”

“Now, once you recover from chickenpox, you’ve recovered from chickenpox, but the virus actually lives inside of you for your entire life,” Dr. Bansal said. “What can happen is later on in life as you get older, as your immune system starts to wane because of age or other medical conditions, that virus can reactivate in your body and then it manifests or it presents as something called shingles, which is the rash.”

“It’s the same virus as chickenpox, so it is contagious and there are two ways that you can transmit shingles,” said Dr. Bansal. “In the case of chickenpox, it is airborne. So, the way it will spread is you breathe it in if an infected person coughs and you’ll catch it by air.”

“The second and more common way is, in the early phase when you’ve got those lesions on your skin from shingles or chickenpox, there’s going to be a little bit of fluid there. That fluid is highly infectious and it’s full of virus,” he said. “So, if you touch somebody’s lesion or somebody touches your lesion, they can” spread varicella zoster virus. And if you have never had chickenpox or received the vaccine, you can get chickenpox from someone who has shingles.

“That’s why it is really important to be careful who you are around and that you practice good hygiene,” Dr. Bansal emphasized.

“The main thing with shingles is a rash. Now the rash may look initially somewhat like chickenpox where you get these little pustules and then it may crust over,” Dr. Bansal said. “But one of the other things about this is you’re going to see it in one part of the body and usually on one side of the body.”

“There is something where it can just be all over, but that’s not very common. Usually it’s going to be on your right arm or your left leg or the right side of your back,” he said. “And it’s going to be this rash that goes in a sunray pattern. So, it’ll go along certain types of nerves that are infected by the virus.”

“The rash may last several days—about a week to 10 days,” Dr. Bansal said. “But that part where it crusts over usually happens within 48 to 96 hours or an average of about 72 hours.”

“One of the other things that can happen that’s more serious is if you get shingles on the head, it can infect the eyes,” Dr. Bansal said. “And if it does infect the eyes, you need to see an ophthalmologist immediately.

“And you may have to be admitted to the hospital for medication because it can cause vision problems or even vision loss,” he added.

“What can happen after a shingles infection—which a lot of people are worried about—is that you can get what’s called postherpetic neuralgia,” Dr. Bansal said. “All that means is you have nerve pain after getting the shingles infection.”

About one in 10 people who get shingles develop nerve pain that can last for months or even years after the rash goes away.

“It’s kind of like you have a pins and needle or sharp and shooting pain in that part of the body that got the shingles rash and it just doesn’t go away,” he said. “It’s there all the time and it’s debilitating and it’s stressful.”

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“Basically, as you get older, the chance of you getting shingles increases. So, most people who get shingles are age 50 and above,” Dr. Bansal said. “And every 10 years above that, your chance of getting shingles increases.”

“The main reason for that is your immunity starts to decrease as you get older,” he said. “If you’re 60 versus 50, your immune system is weaker than when you are at age 50 and same for age 70 and 80. So, the chance of shingles increases.”

“Now there’s no guarantee. There’s nothing that says you will get shingles if you live long enough, but you have an increased risk,” Dr. Bansal said, noting that “over a million people in the U.S. get shingles and the majority of those are 50 or older.

“But overall, the CDC says about 30% of people will get shingles in their lifetime and of course there are certain factors that increase your chance of getting it,” he added. “The other part of that, which is unclear, is that women are slightly more at risk than men in getting shingles. We don’t really know why, but that just seems to be what’s happening.”

“The other risk factors are if you've had any kind of transplant—whether it's an organ transplant or even let's say a bone marrow transplant for some kind of blood disorder or blood cancer,” Dr. Bansal said. “If you are on immunosuppressant medicines for various conditions, let's say you've got Crohn's disease or rheumatoid arthritis and you're on one of these fancy biologic IV medications, it may increase your risk of getting shingles as well as other infections.”

Additionally, “if you have HIV or AIDS, that increases your risk,” he said. “Or if you have to take steroids for a long period of time or you're on a high dose, that can also increase your risk.”

“One of the other weird things that has been uncovered is that for some reason people who are older, if they get some kind of head trauma, they’re more likely to get shingles than younger people who get head trauma,” Dr. Bansal said.

“Again, it’s not guaranteed, but they’ve just seen this correlation between head trauma in older people and shingles,” he said.  

“The shingles vaccine is recommended for people 50 years of age or older, and people over age 19 if you have certain immune conditions,” Dr. Bansal said, noting it wouldn’t be recommended if “you are getting cancer treatment or it may interfere with some of the medicines you’re on like chemotherapy and that sort of thing.”

“But, generally speaking, everybody over the age of 50 is recommended to get the vaccine,” he said. “Now with all vaccines, getting a vaccine is not a guarantee that you will not get the infection, but it greatly reduces the chance of you developing shingles and if you develop shingles, it reduces the chance that it’ll be severe.”

While the exact trigger for shingles is unknown, “usually it’s some kind of stress,” Dr. Bansal said. “And that can be physical stress such as an injury. It can also be an illness, whether you developed a cancer, a really bad infection, broke a bone or experienced head trauma.”

“Any of those things can do it, but it can also be very severe mental stress from any number of things,” he added. “Because mental stress can lead to physical problems and so when you have that stress, it’ll activate certain kinds of hormones or proteins, it’ll make your immune system go down.”

A key preventative measure is to “just be cognizant of the people who you’re around. Hopefully you can trust them to tell you that they’ve had a weird rash or don’t feel well, and then stay away from them,” Dr. Bansal said. “The other thing is if you are around someone who is immunocompromised for any reason—whether it’s medication, an illness or a transplant—be very cautious about what your symptoms are so you don’t spread it to them.

“Then particularly if you’ve got any of those conditions, be careful about who you’re around and make sure that they don’t have shingles,” he added, noting that “if you develop shingles, you should stay away from pregnant women while you have the infection because you can spread it to the pregnant person and potentially cause a problem with the pregnancy or with the baby.”

It is recommended that “if you have a rash that could be shingles, or you were exposed to somebody with chickenpox or shingles, or you’re having this pain, you see your doctor to start treatment as soon as possible,” Dr. Bansal said. “Because the sooner you start, the better it’s going to be as far as reducing that duration of the infection as well as the severity of the infection.”

“The main treatment options are antiviral medications. So, interestingly, it’s very similar to if you get a herpes lesion or a cold sore,” he said. “It’s something called acyclovir, valacyclovir, or famciclovir. Those medications are at a different dose and it’s best to start that as soon as possible.”

“Any of those three medicines—depending on what your doctor recommends at the time—are used to treat the shingles,” said Dr. Bansal. “Now if you just have a rash, you can take it as a pill, but if you get a more severe infection, then you may have to get the intravenous form, which means you have to be in the hospital at least for a few days to get that treatment.”