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An Unwelcome Encore


Updated June 10, 2014

Doctor examining patient, using stethoscope
Thomas Northcut/Digital Vision/Getty Images
In Italy, shingles also is called St. Anthony's fire, a fitting name for a disease that has bedeviled saints and sinners throughout the ages. Caused by the same varicella-zoster virus that causes chickenpox, shingles (also called herpes zoster) most commonly occurs in older people. Treatment was once limited to wet compresses and aspirin. Today's treatments provide a variety of ways to shorten the duration of a shingles outbreak and to control the associated pain. Sometimes, however, shingles leads to a chronic painful condition called post-herpetic neuralgia (PHN) that can be difficult to treat.

Initial Symptoms

After an attack of chickenpox, the varicella-zoster virus retreats to nerve cells in the body, where it may lie dormant for decades. But under certain conditions, usually related to aging or disease, the virus can reactivate and begin to reproduce. Once activated, the virus travels along the path of a nerve to the skin's surface, where it causes shingles.

Shingles' symptoms may be vague and nonspecific at first. People with shingles may experience numbness, tingling, itching, or pain before the classic rash appears. In the pre-eruption stage, diagnosis may be difficult, and the pain can be so severe that it may be mistaken for pleurisy, kidney stones, gallstones, appendicitis, or even a heart attack, depending on the location of the affected nerve.

The Outbreak

Pain may come first, but when the migrating virus finally reaches the skin, usually the second to the fifth day after the first symptoms, the rash tells all. The virus infects the skin cells and creates a painful, red rash that resembles chickenpox.

Doctors can distinguish shingles from chickenpox (or dermatitis or poison ivy) by the way the spots are distributed. Since shingles occurs in an area of the skin that is supplied by sensory fibers of a single nerve, called a dermatome, the rash usually appears in a well-defined band on one side of the body, typically the torso; or on one side of the face, around the nose and eyes. (Shingles' peculiar name derives from the Latin cingulum, which means girdle or belt.) If a diagnosis is in doubt, lab tests can confirm the presence of the virus.

The rash usually begins as clusters of small bumps that soon develop into fluid-filled blisters (vesicles). In turn, the blisters fill with pus (pustules), break open, and form crusty scabs. In about four or five weeks, the disease runs its course, the scabs drop off, the skin heals, and the pain fades. Most healthy individuals make an uneventful, if not particularly pleasant, recovery.

Not everyone sails through without incident, however. Although it's difficult to resist scratching the itchy rash, it's better to keep hands off, as the damaged skin may develop a bacterial infection requiring antibiotic treatment. After such an infection, the skin may be left with significant scarring, some of it serious enough to require plastic surgery.

Another complication called the Ramsay Hunt syndrome occurs when the varicella-zoster virus spreads to the facial nerve, causing intense ear pain. The rash can appear on the outer ear, inside the ear canal, on the soft palate (part of the roof of the mouth), around the mouth and on the face, neck and scalp. The hearing loss, vertigo and facial paralysis that may result are usually, but not always, temporary.

Occasionally, the rash will appear as a single spot or cluster of spots on the tip of the nose, called Hutchinson's sign. This is not good news. It means that the ophthalmic nerve is probably involved and the eye may become affected, possibly causing temporary or permanent blindness.

"My husband was undergoing chemotherapy treatment for prostate cancer," says Julia Hershfield, of Kensington, Md., "when he developed shingles in his right eye. The pain was so bad, that he lost all will to live. Shingles finished him." In people whose immune systems are extremely weakened, the shingles virus can also spread to the internal organs and affect the lungs, central nervous system and the brain, sometimes causing death.

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