Aging Begins at 30

The Shingles: Belt From Hell

Ian Maclean Smith, M.D.
Emeritus Professor
Department of Internal Medicine
University of Iowa Hospitals and Clinics
Creation Date: November 2001
Last Revision Date: November 2001
Peer Review Status: Internally Peer Reviewed

This used to be called a skin disease with neurological complications, but it is really a neurological disease with an incidental rash. It is caused by the reactivation of the virus that causes chickenpox in childhood (more than 90% of us have had it) or rarely by contact in a nursing home with another patient with shingles. The virus has been hiding in the roots of the spinal nerves and it is suddenly reactivated when the immune system is weakened by cancer, or therapy with steroid drugs or old age. The virus travels down the nerve and inflames the skin. When the rash heals without continuing pain, the virus can only be found for up to six weeks in the blood. In post herpes neuralgia victims the virus may be found in the blood for years after the skin rash is healed.

One neurologist called herpes neuralgia "a belt of roses from Hell" because the pain, called post herpetic neuralgia, can be excruciating. The pain can be steady and burning or come like sudden electric shocks. These often incapacitating pains can begin with the touch of the lightest clothing, a gentle shower or a light breeze.

Treatment has evolved from sedatives like phenobarbital, to antidepressant drugs such as amitryptyline then other anticonvulsant drugs like gabapentin primarily to relieve the pain. Treatment has entered a new era with the development of anti-viral drugs starting with acyclovir (Zovirax), which is beneficial if started in the first 3 days of the illness. It is a derivative of guanine and like an ill-fitting key kills the virus by jamming the process leading to viral DNA formation. Its disadvantages are that only 20% of the drug ends up where it is needed and antibiotic resistance can develop. The drug is excreted in the urine and caution is needed in patients with kidney disease.

As the disease shows slow spontaneous improvement it is essential in drug trials to include a population receiving a placebo or other accepted treatment. This makes trials difficult. A course of this drug costs about $200 but it is more effective and more expensive if given intravenously because higher blood levels are reached.

To try to avoid the need for IV drug, newer oral drugs such as famciclovir (Famvir 1994) 75% of which ends up where it is needed, and valaciclovir (1999) have been introduced. These reach higher blood levels and enter the nerve cell in higher amounts.

In 1867 Dr. Bowman said that the pains that follow Zoster are "sometimes so severe as to make the patient weary of existence" so it is worth hurrying to get immediate treatment.

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See related Patient Topics Brain and Nervous System, Infections, Seniors' Health or Shingles (Herpes Zoster).

See related Provider Topics Brain and Nervous System, Infections or Seniors' Health.

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