Anyone who has already had chickenpox is at risk of developing shingles later on. Both are caused by the same virus, the varicella-zoster virus. This virus stays dormant (inactive) in the body after a chickenpox infection. But it can become active again years later and cause shingles (herpes zoster): a rash with blisters that usually forms a band across the skin and is often very painful. The rash normally only affects one side of the body.
People who have been vaccinated against chickenpox can still get shingles. But this is thought to be less common than developing it after having chickenpox.
Shingles is particularly common in older people. Although it can be very unpleasant, it’s usually over in about two to four weeks if there are no complications.
Shingles is contagious, but only for people who have never had chickenpox. In that case the infection only causes chickenpox, and not shingles.
Before the rash breaks out you usually feel tired and run-down. You may also have a slight fever and tingling sensations under your skin. Two or three days later the typical symptoms of shingles start: stinging or burning pain in the affected area, followed by slightly reddish patches of skin with small bumps. The pain is usually moderate to severe. In just a few hours the bumps turn into small blisters that may be itchy. This stage can last up to five days. After that the blisters dry up in two to ten days, leaving behind yellowish scabs. It takes a total of two to four weeks for these skin symptoms to clear up completely.
The shingles rash generally affects only one side of the body, and typically forms a band across the skin.
Sometimes larger patches of skin are affected, or the blisters may appear outside of the area that was originally affected.
Shingles: Typical rash on one side of the body only
Shingles most commonly affects the torso or chest. But it can develop just about anywhere, like on your face or arms, or on your head. Sometimes it can also affect your eyes or ears.
After people have recovered from chickenpox, the varicella-zoster viruses settle undetected in the nerve roots near the spinal cord or at the base of the skull. Although you usually don't notice it, they remain there for the rest of your life.
If your immune system is weakened – for instance, as a result of a cold, extreme stress or old age – the viruses may start to multiply again and move along the affected nerve, eventually reaching the skin. When the viruses multiply in skin cells, they cause inflammation and the typical shingles rash. The inflammation in the nerve is what causes the pain.
Nerve infected by the virus, and inflamed area of skin
People who have never had chickenpox can be infected with the varicella-zoster virus by coming into contact with the fluid from inside shingles blisters. In this case the infection causes chickenpox, and not shingles. You are no longer contagious once all of the blisters have dried up and all of the scabs have fallen off.
It is estimated that about 2 out of 10 people who have had chickenpox develop shingles sometime later in life. Most people who get shingles are over 50. The risk of shingles increases with age because our immune systems weaken as we grow older. About 400,000 people get shingles in Germany every year.
In normal cases, without complications, it usually takes about two to four weeks for adults to completely recover from shingles. Children and younger people generally have milder cases. People usually only get shingles once in a lifetime.
In very rare cases the blisters spread to neighboring areas of skin or even over the whole body. This may happen if the immune system is very weak, possibly because of a serious disease like cancer or AIDS. Under those circumstances, shingles can be life-threatening.
Breaking the itchy blisters open by scratching them may cause a bacterial infection in the skin and leave scars. Other longer-term effects of shingles include overly sensitive skin or changes in skin pigmentation – leaving it darker or lighter than the surrounding skin.
Shingles in the face area can spread to the eye too, causing inflammation of the cornea. If auditory (hearing) nerves or facial nerves are involved, shingles may also lead to hearing loss or paralysis in the face. This usually goes away once the shingles infection has cleared up.
About 10 to 20 out of 100 people still have quite severe pain from nerve damage even after the rash has gone away. This pain is referred to as "post-herpetic neuralgia" and can last anywhere from a few weeks or months up to several years.
People with a very weak immune system are at greater risk of developing serious complications, including a lung infection (pneumonia), inflammation of the cerebral membranes (meningitis) or a liver inflammation (hepatitis).
Unlike chickenpox, shingles is not dangerous for unborn children during pregnancy.
Many people who have shingles first think that it might be a non-contagious skin condition, like eczema. This may delay a diagnosis because they might think that they don’t need to see a doctor about it.
Shingles can also be difficult to diagnose in the early stages because the characteristic rash often only appears after the pain starts. Depending on what part of your body is affected, you might suspect another cause at first, like appendicitis or cholecystitis (inflamed appendix or gall bladder), a slipped disk or even a heart attack.
Doctors usually diagnosis shingles based on its characteristic one-sided rash and the accompanying pain or abnormal sensations. If they aren’t sure whether it’s shingles, the fluid inside the blisters can be tested to see whether it contains the virus. Doctors can also check if the blood has more than the usual numbers of antibodies needed to fight the varicella-zoster virus.
As of December 2018, the German Standing Committee on Vaccination (STIKO) recommends that everyone over the age of 60 have the inactivated zoster vaccine. “Inactivated” means that the vaccine only has parts of dead viruses in it, not weakened live viruses. People who have a weak immune system or chronic diseases (such as diabetes or rheumatoid arthritis) are advised to already have this vaccine from the age of 50. Studies have shown that the vaccine clearly lowers the risk of healthy people getting shingles. But it’s hard to tell whether the protection against shingles lasts longer than four years because the inactivated vaccine is still quite new. The vaccination may cause side effects, including reddened skin and rashes, pain where the vaccine was injected, or swelling.
The costs are covered by all of the statutory health insurers in Germany.
Pain and fever can be relieved with medication such as acetaminophen (paracetamol) or acetylsalicylic acid (the drug in medicines like Aspirin). Prescription painkillers are sometimes used to relieve more severe pain.
Thorough skin care is recommended if you have shingles. Antiseptic or anti-itch lotions, gels and powders are often used to relieve the itching and dry out the blisters. Most of them contain tanins, zinc, menthol or polidocanol. If blisters have already formed, people are sometimes advised to use cooling wraps. But there’s no good scientific research on how well these treatments work.
Drugs that fight viruses can be used in people who are over 50 or have a weakened immune system, if the condition is very severe, affects the head and neck area, or there is a higher risk of complications. This is known as "antiviral therapy." Using antiviral medication early on can help speed up recovery and make the pain go away faster. So people are advised to start antiviral therapy no later than 72 hours after the rash starts. In severe cases the medicine can also be given through a drip into a vein (intravenous infusion). If the ear is affected, steroids are often used too. But it still isn’t clear what pros and cons this kind of combination therapy may have.
It is important to not scratch the blisters if possible: The fluid in them is contagious and blisters that have been torn open can leave scars. As long as they are still contagious – that is, until the very last blisters have gone away – people who have shingles should avoid direct contact with others if they do not know whether they are immune to chickenpox. This is especially true of people with a weakened immune system and pregnant women.
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Gagliardi AM, Andriolo BN, Torloni MR, Soares BG. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev 2016; (3): CD008858.
Han Y, Zhang J, Chen N, He L, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2013; (3): CD005582.
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Robert Koch Institute (RKI). Epidemiologisches Bulletin. Aktuelle Daten und Informationen zu Infektionskrankheiten und Public Health. Statement issued by the German Standing Committee on Vaccination (STIKO) at the Robert Koch Institute. December 13, 2018.
Robert Koch Institute (RKI). RKI-Ratgeber für Ärzte. Windpocken, Herpes zoster (Gürtelrose). March 30, 2016.
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