Shingles Is a Concern At All Ages

Pharmacy Times, August 2021, Volume 87, Issue 8

Anyone, even young people, can get infected, so the varicella or zoster vaccines offer the best prevention.

Shingles, a varicella-zoster virus (VZV) infection of an individual nerve and the associated skin surface, is diagnosed by its defining characteristic: rash along a nerve path.1

Yet patients complain more about unbearable pain, often describing a sensation of electrical shock and small needles against the skin with muscle pain.2 Individuals with shingles find any touch, even from clothing, extremely painful.

Approximately 1 in 3 Americans will develop shingles, which translates to 1 million cases annually.3

Pain can begin 2 to 4 days before the rash appears, and severe pain can persist as postherpetic neuralgia (PHN).4,5 Patients with PHN report burning, shooting, stabbing, and/or throbbing pain. Other symptoms include chills, loss of or decreased hearing or vision, fever, gastrointestinal upset, headache, muscle weakness, scarring, or skin infection. Herpes zoster ophthalmicus (HZO) is a growing concern. An analysis of 21 million adults showed that HZO tripled during a 12-year period from 9.4 cases per 100,000 people to 30.1 cases per 100,000 people.

HZO can lead to blindness and corneal scarring.6

WHO IS AT RISK?

Shingles is uncommon but not unknown in children. Risk increases with age, especially after 40. Individuals 60 or older are 10 times more likely to develop shingles than a 10-year-old.7 Hospitalization for complications occurs in 1% to 4% of individuals with shingles, with the immunosuppressed and older adults at greatest risk.8

Although VZV causes both chicken pox and shingles, they differ. Chicken pox is a mild illness that mainly affects children and then remains dormant in the body’s central nervous system.1,4 Shingles results from viral reactivation when a trigger weakens the immune system. Investigators suggest several triggers (BOX1,4).

Approximately half of all shingles cases occur in individuals older than 60 and half in younger individuals, although shingles seems to be increasing in the latter group.5

Here, too, immunocompromise increases the risk.5

Shingles does not recur in most individuals, but it can recur a second and, rarely, a third time.9 After an outbreak, the risk of recurrence is initially lower than the risk of a first outbreak in shingles-naive people. However, within 7 years, recurrence risk approaches 5%, which is similar to the risk of first-time shingles. In addition to immunocompromised individuals, patients who experienced severe shingles-related pain lasting more than 30 days and women are at greatest risk of recurrence. Recurrences usually affect a different part of the body.9

A cancer diagnosis of any kind in any age group has been linked to a 40% increase in risk for developing shingles.10 Patients with hematological cancer have been associated with a 3-fold higher risk, and the risk appears to be present 2 years prior to the diagnosis.

Solid tumors also increase the risk (but slightly less than hematological cancer) and often while the patient is receiving chemotherapy, which is immunosuppressing.10

DISEASE MANAGEMENT

Individuals who have active shingles can pass the virus to others who never had chicken pox or who are not vaccinated.11 When blisters are present, direct contact with fluid from blisters can spread VZV. The CDC recommends avoiding scratching or touching the rash, covering the rash, and washing hands often.

It also recommends avoiding contact with individuals who are immunocompromised, low–birth-weight or premature infants, and pregnant women who have never had the chicken pox or the varicella vaccine.11

Vaccinating children with the chicken pox vaccine and adults 50 and older with the recombinant zoster vaccine (RSV; Shingrix) is the best prevention. Children who receive the varicella vaccine are significantly less likely to contract pediatric shingles,11 and RSV reduces the risk of developing shingles by approximately 90% and significantly reduces the likelihood of serious complications.5

Antiviral drugs, such as acyclovir, famciclovir, or valacyclovir, reduce the length and severity of a shingles outbreak if started within the first 3 days. Clinicians can also prescribe duloxetine or nortriptyline, 8% capsaicin (Qutenza) skin patches for affected areas, lidocaine skin patches, gabapentin or pregabalin, or opioids.9

Keeping the rash clean and dry reduces infection risk. Patients should avoid antibiotic adhesive or topical dressings, use products such as calamine lotion to relieve and soothe itching, and wear comfortable, loose-fitting clothing.1

CONCLUSION

To understand shingles better, investigators are conducting studies but need healthy individuals and those with shingles to volunteer. While we wait for better preventive methods and treatments, educating patients with facts about shingles can help them protect themselves against the condition and its complications.

ABOUT THE AUTHOR

Jeannette Y. Wick, MBA, RPh, FASCP, is the assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

REFERENCES

1. Cohen EJ, Jeng BH. Herpes zoster: a brief definitive review. Cornea. 2021;40(8):943-949. doi:10.1097/ICO.0000000000002754

2. Bianchi J. What it really feels like to have shingles. Prevention. February 24, 2016. Accessed June 15, 2021. https://www.prevention.com/health/a20500587/what-it-feels-like-to-have-shingles

3. Weinmann S, Naleway AL, Koppolu P, et al. Incidence of herpes zoster among children: 2003-2014. Pediatrics. 2019;144(1):e20182917. doi:10.1542/peds.2018-2917

4. Shingles myths and facts for consumers. National Foundation for Infectious Diseases. Accessed June 15, 2021. https://www.nfid.org/idinfo/shingles/consumers-myths.html

5. Newman AM, Jhaveri R. Myths and misconceptions: varicella- zoster virus exposure, infection risks, complications, and treatments. Clin Ther. 2019;41(9):1816-1822. doi:10.1016/j.clinthera.2019.06.009

6. Kirkendoll SA. Aging baby boomers push sky high incidence of shingles of the eye. Michigan Health Lab blog. May 1, 2019. Accessed June 15, 2021. https://labblog.uofmhealth.org/lab-report/aging-baby-boomers-push-sky-high-incidence-ofshingles-of-eye

7. Shingles: hope through research. National Institute of Neurological Disorders and Stroke. Updated March 23, 2020. Accessed June 15, 2021. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Shingles-Hope-Through-Research

8. Shingles (herpes zoster). CDC. Updated August 14, 2019. Accessed June 15, 2021. https://www.cdc.gov/shingles/surveillance.html

9. Yawn BP, Wollan PC, Kurland MJ, St Sauver JL, Saddier P. Herpes zoster recurrences more frequent than previously reported. Mayo Clin Proc. 2011;86(2):88-93. doi:10.4065/mcp.2010.0618

10. Qian J, Heywood AE, Karki S, et al. Risk of herpes zoster prior to and following cancer diagnosis and treatment: a population-based prospective cohort study. J Infect Dis. 2019;220(1):3-11. doi:10.1093/infdis/jiy625

11. Shingles vaccination. CDC. Updated January 25, 2018. Accessed June 15, 2021. https://www.cdc.gov/vaccines/vpd/shingles/public/index.html