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 gives physicians a platform to share what they want patients to understand about today’s health care headlines and how to take charge of their health through preventive care.
In this installment, two AMA member physicians took time to discuss what patients need to know about the shingles virus and vaccination. They are:
- Sherryl Ann Ashberg, MD, a family physician with Conviva Senior Primary Care in Jupiter, Florida.
- Ankush K. Bansal, MD, a lifestyle medicine physician and hospitalist in Westlake, Florida. Dr. Bansal is also a member of the AMA Council on Science & Public Health.
Conviva Senior Primary Care—part of Humana—is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Chickenpox is the same virus as shingles
“When I have a conversation with my patients about shingles, I always start with chickenpox because most patients remember having had chickenpox as a kid,” said Dr. Ashberg. “They remember that itchy, full body rash very well. When I transition the discussion to shingles, I find that a lot of them are really confused about shingles. They don’t realize there is a connection between the two.”
“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.”
“When you have chickenpox and the rash finally goes away, what happens is that varicella zoster virus … then goes along the nerves to the dorsal root ganglion,” said Dr. Ashberg. The dorsal root ganglion is a cluster of sensory neuron cell bodies located next to the spinal cord that act as a relay station for pain, touch, temperature and vibration signals from your body to your brain.
“It lies dormant and at some point in our lives, if we’re the one in three who are unlucky enough to wake up that dormant chickenpox virus, then it comes back out along that nerve root and causes shingles,” she said.
There are two ways to spread shingles
“I am often asked if patients can spread shingles and how contagious it is, and that has a two-part answer,” Dr. Ashberg said. “Although you cannot give somebody else shingles, if you expose them to your shingles—which is the varicella virus—you can give someone who has never had chickenpox, the chickenpox. This is why you should avoid babies, people who are unvaccinated and pregnant women when you have shingles.”
“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.
A rash is the primary symptom of shingles
“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.”
Many patients may first feel an itchy sensation
“Because the virus is coming out along a particular nerve, most of the time you don't get the rash initially,” said Dr. Ashberg. “Most patients come in with an itchy sensation, a burning sensation, prickliness along that particular nerve pathway called a dermatome.”
“Sometimes it's really severe and sometimes because the rash hasn't developed, we may miss the diagnosis initially depending on where that sensation is coming from,” she explained. “If it's on the chest, we might think that the patient's having a heart attack or if it's coming along the side of the abdomen we might think it's gallstones or kidney stones. But when the rash comes out a day or two later, then it's an easy ‘Aha!’ diagnosis.”
Shingles on the head is serious
“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.
Nerve pain can follow shingles
“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.”
Shingles treatment starts with pain management
“When you get shingles, because that virus is coming back along that nerve, the nerve is very inflamed and the nerve pain can be very severe,” Dr. Ashberg said, noting that “some patients tell me it feels like a hot acid burn along where that rash is, so part of the treatment is dealing with the pain.”
“Depending on the pain level, we recommend acetaminophen, ibuprofen, topical medications such as lidocaine or capsaicin to deal with the topical pain,” she said. “There are oral medications for pain as well, such as gabapentin, and your doctor will help you with that part of treatment for shingles.”
“We also give patients antiviral medications, which are most effective if started within 72 hours of the appearance of the rash,” said Dr. Ashberg. “The reason we give antiviral medications and nerve pain medications is, No. 1, to help with the symptoms. And No. 2, we can help to minimize or hopefully prevent the complications that can happen due to the nerve inflammation and nerve damage from the shingles virus.”
As you age, your risk increases
“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.”
“While the risk does go up as we age, it’s not only a disease of older people. Plenty of young people have gotten shingles, such as Justin Bieber who had it a couple of years ago at 28 years old,” said Dr. Ashberg, adding “he also got facial paralysis after his shingles, so that’s another potential complication.”
There are other risk factors at play
“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, “certain conditions—HIV, cancers, leukemia, any condition that reduces your immune system—will increase our odds of getting shingles as well as certain prescriptions that we take can increase our risk of shingles,” Dr. Ashberg. “For example, if we take prescriptions that also decrease our immune function, such as steroids, chemotherapy or antirejection drugs, those medications decrease our immune system and that can increase our risk of getting shingles at any age.”
Head trauma impacts shingles 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.
Get vaccinated against shingles
“The shingles vaccine is recommended for people 50 years 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 do develop shingles, it reduces the chance that it’ll be severe.”
“The shingles vaccine is a two-dose vaccine, and you space it out two to six months apart and it is covered by most insurances at the age of 50,” said Dr. Ashberg. “Even if you have had shingles, the CDC still recommends that if you’re of age, once your shingles clears up that you do go get your shingles vaccine.”
There are side effects to the shingles vaccine
“The shingles vaccine does potentially have side effects,” said Dr. Ashberg. “The most common side effects are fatigue, muscle ache, injection site pain and general malaise or generally not feeling well for a couple of days.”
“But when you take shingles into consideration, those side effects are minor when compared to the pain and the complications and the potential for chronic pain from shingles,” she said. “When you weigh the risks of the side effects of having the vaccine versus the complications of having shingles, one or two days of not feeling well pales in comparison to how bad you can feel when you have shingles.”
Stress can trigger shingles
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.”
Stay away from others until shingles rash is gone
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.”
“I see an older population and they often will ask, ‘Can I still play with my grandkids?’ And I say, ‘It really depends on if they’ve had chickenpox or not,’” said Dr. Ashberg. “Most likely they’ve had the chickenpox vaccine, then that’s fine, you’re not going to give them chickenpox. But in an unvaccinated person, you want to stay away from them.”
That is why it is important for “people with shingles to stay away from young children, unvaccinated people and pregnant women until the rash goes away, which usually takes about 10 days,” Dr. Ashberg said.
Seek treatment immediately
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.”
You can get shingles more than once
“A lot of my patients say, ‘Well, I had shingles before, so I'm fine.’ And that is just not true,” said Dr. Ashberg. “There are many cases of patients who unfortunately get recurrent shingles.”
“You can get shingles either in the same area where you had it before or you can get it in a completely new area,” she said, emphasizing that “having had shingles once is not the same as having had chickenpox where you'll never get chickenpox again.”
Contact your doctor right away
“If you think you have shingles,” said Dr. Ashberg, “the best thing to do is to call your doctor right away because we want to get you on the antiviral medication and also the nerve pain medication as soon as possible within the first 72 hours.
“That’s really to try to minimize the chances of having those complications from shingles, such as the postherpetic neuralgia,” she added.
