Shingles, also called herpes zoster or zona, gets its name from both the Latin and French words for belt or girdle and refers to girdle-like skin eruptions that may occur on the trunk of the body. The virus that causes chickenpox
, the varicella zoster virus (VSV), can become dormant in nerve cells after an episode of chickenpox and later reemerge as shingles. Initially, red patches of rash develop into blisters. Because the virus travels along the nerve to the skin, it can damage the nerve and cause it to become inflamed. This condition can be very painful. If the pain
persists long after the rash disappears, it is known as postherpetic neuralgia
Any person who has had chickenpox can develop shingles. Approximately 500,000 cases of shingles occur every year in the United States, according to the National Institute of Allergy and Infectious Diseases (NIAID). Overall, approximately 20% of those who had chickenpox as children develop shingles at some time in their lives. People of all ages, even children, can be affected, but the incidence increases with age. Newborn infants, bone marrow and other transplant recipients, as well as indivduals with immune systems weakened by disease or drugs are also at increased risk. However, most individuals who develop shingles do not have any underlying malignancy or other immunosuppressive condition.
Causes and symptoms
Shingles erupts along the course of the affected nerve, producing lesions anywhere on the body and may cause severe nerve pain. The most common areas to be affected are the face and trunk, which correspond to the areas where the chickenpox rash is most concentrated. The disease is caused by a reactivation of the chickenpox virus that has lain dormant in certain nerves following an episode of chickenpox. Exactly how or why this reactivation occurs is not clear; however, it is believed that the reactivation is triggered when the immune system becomes weakened, either as a result of stress
, fatigue, certain medications, chemotherapy
, or diseases, such as cancer
or HIV. Further, it can be an early sign in persons with HIV that the immune system has deteriorated.
In some cases, the virus appears to be reactivated by mechanical irritation or minor surgical procedures. In one instance, the patient had an attack of shingles following liposuction
Early signs of shingles are often vague and can easily be mistaken for other illnesses. The condition may begin with fever
and malaise (a vague feeling of weakness or discomfort). Within two to four days, severe pain, itching
, and numbness/tingling (paresthesia) or extreme sensitivity to touch (hyperesthesia) can develop, usually on the trunk and occasionally on the arms and legs. Pain may be continuous or intermittent, usually lasting from one to four weeks. It may occur at the time of the eruption, but can precede the eruption by days, occasionally making the diagnosis difficult. Signs and symptoms may include the following:
- itching, tingling, or severe burning pain
- red patches that develop into blisters
- grouped, dense, deep, small blisters that ooze and crust
- swollen lymph nodes
Diagnosis is usually not possible until the skin lesions develop. Once they develop, however, the pattern and location of the blisters and the type of cell damage displayed are characteristic of the disease, allowing an accurate diagnosis primarily based upon the physical examination
Although tests are rarely necessary, they may include the following:
- viral culture of skin lesion
- microscopic examination using a Tzanck preparation. This involves staining a smear obtained from a blister. Cells infected with the herpes virus will appear very large and contain many dark cell centers or nuclei.
- complete blood count (CBC) may show an elevated white blood cell count (WBC), a nonspecific sign of infection
- Rise in antibody to the virus
- Polymerase chain reaction (PCR) analysis. PCR testing has been found to be much faster and significantly more accurate than culturing the virus.
Shingles almost always resolves spontaneously and may not require any treatment except for the relief of symptoms. In most people, the condition clears on its own in one or two weeks and seldom recurs.
Cool, wet compresses may help reduce pain. If there are blisters or crusting, applying compresses made with diluted vinegar will make the patient more comfortable. Mix one-quarter cup of white vinegar in two quarts of lukewarm water. Use the compress twice each day for 10 minutes. Stop using the compresses when the blisters have dried up.
Soothing baths and lotions such as colloidal oatmeal baths, starch baths or lotions, and calamine lotion may help to relieve itching and discomfort. Keep the skin clean, and do not re-use contaminated items. While the lesions continue to ooze, the person should be isolated to prevent infecting other susceptible individuals.
Later, when the crusts and scabs are separating, the skin may become dry, tight, and cracked. If that happens, rub on a small amount of plain petroleum jelly three or four times a day.
The antiviral drugs
acyclovir, valacyclovir, and famciclovir can be used to treat shingles. These drugs may shorten the course of the illness. Their use results in more rapid healing of the blisters when drug therapy is started within 72 hours of the onset of the rash. In fact, the earlier the drugs are administered, the better, because early cases can sometimes be stopped. If taken later, these drugs are less effective but may still lessen the pain. Antiviral drug treatment does not seem to reduce the incidence of postherpetic neuralgia, but recent studies suggest famciclovir may cut the duration of postherpetic neuralgia in half. Side effects of typical oral doses of these antiviral drugs are minor with headache
and nausea reported by 8-20 % of patients. Severely immunocompromised individuals, such as those with AIDS
, may require intravenous administration of antiviral drugs.
, such as prednisone, may be used to reduce inflammation but they do interfere with the functioning of the immune system. Corticosteroids, in combination with antiviral therapy, also are used to treat severe infections, such as those affecting the eyes, and to reduce severe pain.
Once the blisters are healed, some people continue to experience pain for months or even years (postherpetic neuralgia). This pain can be excruciating. Consequently, the doctor may prescribe tranquilizers, sedatives, or antidepressants to be taken at night. As noted above attempts to treat postherpetic neuralgia with the antiviral drug famciclovir have shown some promising results. When all else fails, severe pain may require a permanent nerve block.
A newer medication to treat postherpectic neuralgia is pregabalin, to be marketed in the United States under the trade name Lyrica. Pregabalin was approved by the Food and Drug Administration in September 2004 for the treatment of diabetic neuropathy
as well as postherpetic neuralgia. The drug has been shown to improve patients' sleep and overall quality of life as well as relieve pain. Its most common side effects are drowsiness, headache, dry mouth
, and dizziness
There are nonmedical methods of prevention and treatment that may speed recovery. For example, getting lots of rest, eating a healthy diet, exercising regularly, and minimizing stress are always helpful in preventing disease. Supplementation with vitamin B12
during the first one to two days and continued supplementation with vitamin B complex, high levels of vitamin C with bioflavenoids, and calcium, are recommended to boost the immune system. Herbal antivirals such as echinacea
can be effective in fighting infection and boosting the immune system.
Although no single alternative approach, technique, or remedy has yet been proven to reduce the pain, there are a few options which may be helpful. For example, topical applications of lemon balm (Melissa officinalis
) or licorice (Glycyrrhiza glabra
) and peppermint (Mentha piperita
) may reduce pain and blistering. Homeopathic remedies include Rhus toxicodendron
for blisters, Mezereum
and Arsenicum album
for pain, and Ranunculus
for itching. Practitioners of Eastern medicine recommend self-hypnosis, acupressure
, and acupuncture
to alleviate pain.
Shingles usually clears up in two to three weeks and rarely recurs. Involvement of the nerves that cause movement may cause a temporary or permanent nerve paralysis
. The elderly or debilitated patient may have a prolonged and difficult course. For them, the eruption is typically more extensive and inflammatory, occasionally resulting in blisters that bleed, areas where the skin actually dies, secondary bacterial infection, or extensive and permanent scarring.
Similarly, an immunocompromised patient usually has a more severe course that is frequently prolonged for weeks to months. They develop shingles frequently and the infection can spread to the skin, lungs, liver, gastrointestinal tract, brain, or other vital organs. Cases of chronic shingles have been reported in patients infected with AIDS, especially when they have a decreased number of one particular kind of immune cell, called CD4 lymphocytes. Depletion of CD4 lymphocytes is associated with more severe, chronic, and recurrent varicella-zoster virus infections. These lesions are typical at the onset but may turn into ulcers that do not heal.
Potentially serious complications can result from herpes zoster. Many individuals continue to experience persistent pain long after the blisters heal. This pain, called postherpetic neuralgia or PHN, can be severe and debilitating. Postherpetic neuralgia can persist for months or years after the lesions have disappeared. The incidence of postherpetic neuralgia increases with age, and episodes in older individuals tend to be of longer duration. Most patients under 30 years of age experience no persistent pain. By age 40, the risk of prolonged pain lasting longer than one month increases to 33%. By age 70, the risk increases to 74%. The pain can adversely affect quality of life, but it does usually diminish over time. Another risk factor for PHN is female sex.
Other complications include a secondary bacterial infection, and rarely, potentially fatal inflammation of the brain (encephalitis
) and the spread of an infection throughout the body. These rare, but extremely serious, complications are more likely to occur in those individuals who have weakened immune systems (immunocompromised).
Strengthening the immune system by making lifestyle changes is thought to help prevent the development of shingles. A lifestyle designed to strengthen the immune system and maintain good overall health includes eating a well-balanced diet rich in essential vitamins
, getting enough sleep, exercising regularly, and reducing stress.
— An antiviral drug that is available under the trade name Zovirax, in oral, intravenous, and topical forms. The drug blocks the replication of the varicella zoster virus.
— A specific protein produced by the immune system in response to a specific foreign protein or particle called an antigen.
— A steroid that has similar properties to the steroid hormone produced by the adrenal cortex. It is used to alter immune responses to shingles.
— An oral antiviral drug that is available under the trade name Famvir. The drug blocks the replication of the varicella zoster virus.
— A state in which the immune system is suppressed or not functioning properly.
— Procedure in which skin cells from a blister are stained and examined under the microscope. Visualization of large skin cells with many cell centers or nuclei indicates a positive diagnosis of herpes zoster when combined with results from a physical examination.
— An oral antiviral drug that is available under the trade name Valtrex. The drug blocks the replication of the varicella zoster virus.
Beers, Mark H., MD, and Robert Berkow, MD., editors. "Herpesvirus Infections." Section 13, Chapter 162 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
Andrews, T. R., G. Perdikis, and R. B. Shack. "Herpes Zoster as a Rare Complication of Liposuction." Plastic and Reconstructive Surgery 113 (May 2004): 1838–1840.
Feder, H. M. Jr., and D. M. Hoss. "Herpes Zoster in Otherwise Healthy Children." Pediatric Infectious Disease Journal 451-457.
Jung, B. F., R. W. Johnson, D. R. Griffin, and R. H. Dworkin. "Risk Factors for Postherpetic Neuralgia in Patients with Herpes Zoster." Neurology 62 (May 11, 2004): 1545–1551.
Sabatowski, R., R. Galvez, D. Cherry, et al. "Pregabalin Reduces Pain and Improves Sleep and Mood Disturbances in Patients with Postherpetic Neuralgia: Results of a Randomised, Placebo-Controlled Clinical Trial." Pain 109 (May 2004): 26-35.
Stranska, R., R. Schuurman, M. de Vos, and A. M. van Loon. "Routine Use of a Highly Automated and Internally Controlled Real-Time PCR Assay for the Diagnosis of Herpes Simplex and Varicella-Zoster Virus Infections." Journal of Clinical Virology 30 (May 2004): 39-44.
American Academy of Dermatology. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-0230. Fax: (847) 330-0050. http://www.aad.org.
National Institute of Allergy and Infectious Diseases (NIAID). Office of Communications and Public Liaison, 6610 Rockledge Drive, MSC 6612, Bethesda, MD 20892-6612. http://www.niaid.nih.gov.
any inflammatory skin disease caused by a herpesvirus
and characterized by formation of small vesicles in clusters. When used alone the term may refer to either herpes simplex
or herpes zoster
herpes cor´neae herpetic inflammation involving the cornea.
a variety of herpes simplex
usually found on or around the lips and nostrils but occasionally on other mucoid tissues. It is generally caused by human herpesvirus
1, although occasionally it may be caused by human herpesvirus
2. It is usually a concomitant of fever, but may also develop in situations of other stresses without fever or prior illness. The virus is carried by most people but usually lies quiescent. There is no cure for the condition, but some medications increase comfort. Antiviral medications used in this way include acyclovir
. Called also fever blisters
and cold sores
) herpes simplex
of the genitals, a common sexually transmitted disease
, usually caused by human herpesvirus
2 but occasionally by human herpesvirus
1. If it is present at term in the pregnant female, it may lead to infection of the neonate (see maternal herpes
The incidence of active genital herpes is difficult to determine precisely because many cases present mild symptoms, are self-limiting, and are not called to the attention of health care personnel. However, it is clear that the disease has reached epidemic proportions in the United States. It is highly contagious and is transmitted by direct person-to-person contact (not limited to sexual contact). Autoinoculation via the hands is possible; for example, from a lip ulcer to the genital area or from the lip or genitals to the eye. Once the virus gains access to the body it enters the nervous system and invades nerve cells located near the site of infection, such as in the sacral ganglia. The virus lies dormant in nerve cells and can remain there indefinitely, predisposing the person to recurrent outbreaks. Factors contributing to recurrent genital herpes are not well understood. Some infected persons experience no recurrences while others have frequent and severe outbreaks. Many patients are aware of a correlation between the appearance of lesions and precipitating factors such as exposure to sunlight, local trauma, fever, or emotional stress. Hormonal changes preceding menses have been associated with recurrences in women.
Diagnosis and Symptomatology. Diagnosis is most often based on the patient's history and symptoms, which are easily recognized by an experienced clinician. Clinical and serological findings help establish whether the patient's complaints are manifestations of a primary infection or an initial phase of a recurrent episode. At the primary or first exposure to the virus, the typical cutaneous lesions may or may not be present and no antibodies to the virus are found in the patient's serum. The presence of such antibodies at the time of an initial episode indicates a previous herpes infection. Since the virus dwells in the lesions and nerve cells and not in the blood, antibody titers, smears, and cultures taken from the lesions can be helpful in identifying the stage of the disease.
Typically, recurrent episodes become milder and less frequent; however, some patients may experience weekly or monthly outbreaks that are severe and painful. Those with recurrent herpes usually have high antibody titers. Paradoxically, it has been noted that the higher the antibody titer the more severe the symptoms and the more frequent the recurrences. Thus, it is apparent that the body's immune system is not effective in providing protection against herpes infection or in mitigating its effects.
A genital rash and mild itching usually are the earliest signs of infection. Eventually vesicles on the surface of the skin form, and then enlarge, break open, and ulcerate. The lesions are painful, especially during coitus, and can cause intense itching, and, if the urethra is involved, painful urination. The disease affects both sexes. In the male, vesicles are found principally on the glans penis, shaft of the penis, and prepuce, and may extend to the scrotum and inner thighs. In the female, vesicular eruptions usually involve the vulva, vagina, and cervix, and may extend to the perineum, inner thighs, and buttocks. Lesions of the cervix can vary from small superficial ulcers with diffuse inflammation to a single, large, necrotic ulcer. Other symptoms include malaise, fever, and anorexia. There also can be involvement of neural structures and the manifestation of neurologic symptoms. The characteristic lesions usually last from one to three weeks in either the initial stage or during periodic outbreaks.
. At the present time there is no cure for genital herpes. (A vaccine to prevent the development of herpes is under active development.) Antivirals such as acyclovir
help shorten episodes during the initial phase of infection, but do not cure it. Palliative treatment consists of measures to keep lesions clean and dry, to control pain with an analgesic, to promote healing with frequent sitz baths, and to prevent secondary bacterial infections.
Complications and Sequelae
. A primary herpetic infection usually is self-limiting, and, barring secondary infection and neurologic damage, immediate complications are rare. In some instances the infection may be complicated by urethral stricture, meningoencephalitis
, labial fusion, or lymphatic suppuration. Although there is no conclusive evidence that herpesvirus infection actually leads to cervical cancer, women with genital herpes are eight times more likely to develop carcinoma in situ than are those whose serum lacks antibodies to the virus.
. Probably the greatest needs of patients with herpes are accurate information and support and counseling to help them cope with the emotional impact and fears about the disease and its effects. The palliative treatments presented above can provide symptomatic relief. In addition, the patient should be told to try to keep the lesions clean and dry. Loose cotton clothing avoids trapping moisture in the genital area. The person should not use perfumed soaps or sprays, and women should not use feminine deodorants or douches. Management of stress can be important in controlling symptoms; ineffective or harmful coping mechanisms can aggravate the condition and delay healing. The emotional impact of genital herpes often is overwhelming to persons who learn they have the disease. Since there currently is no cure, preventive medication, or vaccine and the infection can be transmitted by intimate contact, patients often feel anger, guilt, fear, or anxiety.
Support groups can provide patients opportunities to ventilate their anger and talk about their guilt. In a group of persons with similar problems, they can learn that there are others who have had much the same feelings and have managed to work through them and develop a more positive attitude. The American Social Health Association (ASHA) sponsors self-help groups and provides educational materials; their address is P.O. Box 13827, Research Triangle Park, NC 27709.
Fear of cancer is very real in these patients; females are encouraged to have a Pap smear every six months. Early detection is almost guaranteed with such frequent examinations, and the cure rate in these cases is 100 per cent. Another source of anxiety for female patients is the effect of herpes on fertility and the welfare of infants born of mothers with herpes (see maternal herpes
herpes labia´lis herpes febrilis
affecting the vermilion boder of the lips.
active genital herpes
during pregnancy and the perinatal period. Herpes infection during early pregnancy can result in a viral septicemia
and spontaneous abortion
. Infants born of mothers with active herpes during which there is shedding of the virus at the time of delivery are likely to become infected during a vaginal delivery. Of those who contract herpes from their mothers, about 50 per cent will not survive. Of the ones who do survive, half will suffer from permanent neurological or visual damage.
Protective measures such as cesarean section for delivery improve the chances of avoiding infection in the newborn. During the last trimester it is best if the woman abstains from sexual intercourse if there is any history of either partner having herpes. When there is such a history, it is recommended that frequent cervical viral cultures be done to determine whether vaginal delivery is safe.
With early diagnosis and cesarean section many infants can be protected from infection, but only if the membranes are intact or have been ruptured no more than 4 to 6 hours before the operation. After that length of time it is assumed that an ascending infection has reached the fetus. Mothers who have no active lesions at the time of birth and two negative cervical smears for the virus within a week of delivery can safely deliver their newborns vaginally.
Wound and skin precautions are followed in the care of the mother if she has recurrent herpes (see above). An isolation nursery and wound/skin precautions are recommended for newborns delivered (whether vaginally or by cesarean section) to women with active genital herpes. Some authorities recommend isolation precautions the entire time the newborn is in the hospital and until the incubation period of 21 days has passed.
an acute viral disease caused by a herpesvirus
and marked by groups of vesicles on the skin, each about 3 to 6 mm in diameter. Type 1 herpes simplex,
or herpes labialis
, is usually found on the borders of the lips or nostrils and has been nicknamed “kissing herpes.” It may accompany fever (herpes febrilis
or fever blisters
), although there may also be other precipitating factors, such as the common cold, sunburn, skin abrasions, and emotional disturbances. Type 2 herpes simplex,
or genital herpes
, is usually found on or around the genital area. Infection of the newborn from a mother with the condition (see maternal herpes
) has a fatality rate of 50 per cent and many survivors have significant neurological or ocular sequelae.
traumatic herpes (wrestler's herpes) a self-limiting cutaneous herpesvirus infection following trauma, the virus entering through burns or other wounds; the temperature rises moderately, and vesicles appear around the wound.
an acute viral disease caused by a herpesvirus (the same virus that causes chickenpox
); characteristics include inflammation of spinal ganglia and a vesicular eruption along the area of distribution of a sensory nerve. Called also shingles
. It may appear in persons who have been exposed to chickenpox, and it sometimes accompanies other diseases such as pneumonia, tuberculosis, and lymphoma or is triggered by trauma or injection of certain drugs. In some cases it appears without any apparent reason for activation.
Treatment is symptomatic and is aimed at relieving the pain and itching of the blisters. Local applications of calamine lotion or other lotions to dry the blisters may help. Herpes zoster is a very exhausting disease, especially for elderly people, because the constant itching and pain are difficult to control, even with systemic analgesics in some cases.
Herpes zoster affecting the eye causes severe conjunctivitis and possible ulceration and scarring of the cornea if not treated successfully.
Herpes zoster is a communicable disease and therefore requires some type of isolation, the specific precautions depending on whether the disease is localized or disseminated and also on the condition of the patient. Localized lesions in immunocompromised patients often become disseminated. Persons susceptible to varicella-zoster (chickenpox) should stay out of the patient's room. This includes hospital personnel as well as other patients. If there is any question as to the proper procedures for prevention of the spread of herpes zoster, the CDC Guidelines for Infection Control in Hospital Personnel
should be consulted.