Shingles

I wanted to share with you a story about something that happens every so often in my pain clinic.  

Here’s the scene: I get a new patient coming in for back or chest pain, and the patient tells me that they just noticed the pain out of the blue a week or so ago.  The pain is often described as burning or tingling, and my patient is wondering if maybe they pulled a muscle. Lo and behold, when I lift the patient’s shirt to examine them, I discover a rash! This isn’t a pulled muscle, this is shingles.  And the pain from shingles can be one of the most severe conditions that I treat.

Taking a step back, shingles is formally known as a herpes zoster outbreak.  This happens when the chickenpox virus (VZV), which has been hiding for years dormant in a patient’s body, decides to migrate down a nerve fiber into the skin.  This often occurs during a time of emotional or physical stress, and it can also happen when a patient’s immune system is depressed for some reason like chemotherapy.  Classically, we think of this as happening in elderly patients, but in my experience, I am seeing it often in younger patients as well.

The rash tends to appear most commonly on the chest or the legs, but it can occur anywhere on the body. It can be very serious if zoster appears on the face, especially over the eye, and these patients are often taken care of by an ophthalmologist in addition to the rest of their team.

The pain that people experience from shingles can be twofold: the pain from the actual infection/rash, and a second pain that occurs after the rash has healed, known as post-herpetic neuralgia.  Because the virus travels down the nerves, the pain is primarily a nerve pain, which can be burning, electrical, tingling and cause areas of numbness and sensitivity.

The best way to treat a herpes zoster infection is to prevent it in the first place. There is a shingles vaccine available for adults over the age of 50 to try to boost the immune response to the VZV virus and hopefully prevent a shingles outbreak before it starts.  Another important component of the treatment plan for a new zoster outbreak is starting antiviral medications early. It is possible that early treatment may prevent development of post-herpetic neuralgia, but the data are mixed about this. Patients with a new zoster outbreak are often given pain medications like anti-inflammatory medications, Tylenol, and occasionally even opioid medications if the pain is severe.

Not all patients go on to develop post-herpetic neuralgia, thankfully.  But, once this has turned into a chronic issue, a multimodal approach is often required to get patients feeling better.  One class of treatments that can be very helpful for these patients are nerve pain medications. Medications like Gabapentin, Lyrica and tricyclic antidepressants are well studied for post-herpetic neuralgia, and depending on a patient’s other medical problems, can be good options.  Topical treatments, which are treatments that go directly on the skin, are another option. Lidocaine is a numbing cream that can be applied to the area once the rash disappears. Capsaicin, which is an extract from chili peppers that interferes with pain processing, is another option in this category.  It comes in several different strengths including a high dose patch.

Finally, interventional treatment options can be considered, such as nerve blocks using an ultrasound machine, or an epidural steroid injection if the pain is in a location that can be covered by this.  Some people are exploring the use of Botox injections over the area as well.

I hope this helps to explain the pain from shingles! If you ever have a new weird burning pain, make sure you check to see if you’re developing a rash- it could be a shingles outbreak starting.  Seeing a doctor to evaluate early is key.