Dear Dr. Pat:
I am a 65-year-old woman. My sister developed a severe case of shingles two months ago. It took her GP more than one visit to diagnose the problem, since she did not have the typical “blisters,” she was told. She had intense pain on just one side of her face, and she continues to have the pain.
After she told me about the diagnosis, I did some research on the Internet and found that there is a shingles vaccine. When I went to my GP to ask about having the shot, he told me that I could not have it because I take a medicine for rheumatoid arthritis that suppresses my immune system. Another friend has been unable to get a vaccination for shingles because her doctor cannot find any of the vaccine. Would you discuss these troubling issues with your readers? Should patients who develop symptoms like shingles be treated with any medication?
This is a question that gynecologists are frequently asked. The shingles vaccine has been available since 2006 for people over 60 who have had chickenpox, and since 2011 for people at least 50 who’ve had chickenpox. As a part of preventive care, all primary care doctors should be prepared to discuss the benefits and risks of this vaccine. I have asked Dr. Jason Kendler, a specialist in infectious disease and a new member of the WVFC Medical Advisory Board, to discuss this important issue. Thanks for sending in the question.
DR. KENDLER RESPONDS:
Your excellent questions about shingles bring up some very import issues regarding the diagnosis, treatment, and prevention of this illness—which is, unfortunately, quite common.
Shingles occurs only in people who have had chickenpox in the distant past. It occurs when the chickenpox virus reactivates, or “wakes up,” after years in a dormant or quiet state. Shingles causes a rash that can resemble chickenpox, but the rash does not always have the same appearance—which is why even experienced doctors may not always recognize it when they see it.
One defining characteristic of the rash of shingles is that it occurs on only one half of the body (left side or right side, without crossing the middle of the body) in a special pattern, called a dermatomal pattern, that follows the course of the nerve that is involved. Because nerves are infected as well as skin, patients with shingles often experience pain, which can sometimes start before the rash is visible. The most common location of shingles is the chest, but any part of the body can be involved—including the face, as in your sister.
A troublesome complication of shingles is called postherpetic neuralgia—prolonged pain that can last after the rash has resolved. This pain can last weeks or months, sometimes even longer. Patients may require strong painkillers to get relief from this pain.
There are currently three medicines available that can be used to treat shingles. They are acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex). In order to be most effective, these medicines must be started early in the course of shingles. A prompt diagnosis is therefore crucial. In certain circumstances, doctors may choose to treat with steroids in addition to one of these medicines. Pain medications are often prescribed for the pain, which can vary in intensity from mild to very severe.
As with many other diseases, prevention is optimal. A shingles vaccine called Zostavax (made by Merck) has, since 2011, been approved for patients at least 50 years old. Because it is a “live” vaccine (it is a weakened version of the chickenpox virus), it cannot be given to patients who have a weakened immune system as a result of medication (in your case), infection (such as HIV), or cancer. The vaccine also should not be given to pregnant women.
The shingles vaccine is given once. It lowers the risk of getting shingles by about half. The main reason why the vaccine is given, though, is that it lowers the risk of getting the severe pain that can follow shingles (postherpetic neuralgia) by about two-thirds.
There have been shortages of the vaccine in the recent past, but it is generally available at this time. The most common side effect of the vaccine is a rash or pain at the site of injection, but more severe reactions can occur.
Patients who are interested in getting the vaccine should have a discussion of the risks and benefits with their doctor. The cost of this vaccine is high, so anyone interested in getting it should shop around for the best price.
—Jason S. Kendler, M.D.
Clinical Associate Professor of Medicine
Weill Medical College of Cornell University