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Shingles is caused by the varicella-zoster virus (VZV). This is the same virus that causes Chickenpox. After a person has Chickenpox, the virus does not go away; it goes into latency or ‘hibernation’ in the dorsal root ganglia (DRG).
The DRG (figure 1) is a group of nerves that lie just outside of the spinal canal. A person who has had Chickenpox may then go on to develop Herpes Zoster (Shingles) years to decades later when the Varicella Virus (VZV) reactivates or ‘wakes up.’
The VZV then spreads from the DRG to peripheral nerves (smaller nerves) and to the skin, causing pain and unilateral (figure 1a) vesicular (blisters) rashes in a dermatomal, or stripe-like, distribution; this is Zoster (Shingles). (figure 2)
Here are some facts about Shingles:
- 1 million cases occur annually in the U.S. (CDC data).
- About 1 in 3 (1/3) of all adults will develop Zoster.
- Most common locations are: Thoracic > Cervical > Face > Lumbar. (figures 3, 4, and 5)
- Fully resolves within 3 weeks in the majority (70-75%) of individuals.
- Occasionally rash never develops, though patients may still go on to suffer from PHN (see below).
Post Herpetic Neuralgia (PHN) is a complication of Shingles that occurs and represents longer term damage (chronic inflammation) to both the spinal nerves (DRG) and the peripheral nerves that results in a neuropathic pain syndrome (nerve damage or altered sensitivity of nerves).
Here are some facts about PHN:
- Pain persists after 4 weeks (28 days).
- Occurs in 25-30% of all Zoster cases.
- May last weeks, months, years, or the rest of a patient’s life.
- Can disrupt sleep, mood, work, and recreational activities, possibly leading to depression.
- Risk factors for PHN include age over 50, severe pain before/after rash, and extensive rash.
- Complications, in addition to lifelong pain, include nerve damage, infections, and permanent skin scarring.
- It is impossible to predict who will develop PHN.
Treatment options for PHN include a variety of medications and possibly injections. The goal of treatment is twofold. The first goal is to provide immediate relief for the patient in pain; while the second, more pressing goal, is to reduce or eliminate the chance of that patient developing lifelong pain and nerve damage with PHN. The key determinant of success is timely onset of treatment from the first outbreak. The sooner a patient is treated, the better the chance of resolving the pain and preventing the development of lifelong PHN.
This often involves a combination of one or more of the families of drugs listed below. Frequently medications approved for one use (i.e. anticonvulsants) have been found to be very effective in the treatment of PHN.
- Nonsteriodal Anti-inflammatory Drugs (NSAIDs)
- Anticonvulsants (seizure medications)
- Analgesics (pain medication)
This consists primarily of Cervical Epidural or Thoracic/ Lumbar Epidural Injections. These treatments often allow for rapid decrease in pain via fluoroscopically (x-ray) guided administration of steroids to the inflamed and infected nerves. These injections are often performed in a series over a span of several weeks. The goal is the administration of the steroid (anti-inflammatory) to the injured nerves with hope of minimizing the chance of long-term scarring and damage.
- CALL Now! Time is of the essence in this potentially debilitating and life altering disease process.
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