Following the onset of shingles, significant confusion and fear ensues for many individuals. Explore the role of the pharmacist in reassuring patients and pointing them towards optimal management tips, courtesy of Marian Nicholson, Director of the Herpes Viruses Association & Shingles Support Society, who overviews the painful condition.
Shingles is more likely in the elderly, and they are more likely to be affected by long-term pain afterwards. This post-herpetic neuralgia (PHN) ‘can render the patient’s final years an unendurable misery’, to quote a pain expert.
The pharmacist has a very important role in the treatment of shingles as prompt antivirals can help prevent PHN. Therefore, recognising the signs and telling patients that a prescription drug could help, is paramount.
Pharmacists also need to reassure patients that what they have been prescribed is the ‘right thing’ for PHN, because the drugs used were first developed as antidepressants and anti-epileptics. Pharmacists should reassure patients that these drugs can help with pain, as they may think they are being fobbed off, or have an erroneous prescription. The pharmacist should also inform the patient that the starting dose of the pills prescribed for pain is unlikely to be high enough to be effective and that the patient should return to the doctor after a few weeks to get the dose increased.
News: A Vaccine to Prevent Shingles
A vaccine to prevent shingles in the elderly is available in the UK. Zostavax is licensed for anyone over 50. From September 2020, the NHS vaccination programme will include anyone from 70-to-79 years old. The vaccine is well-tolerated because it boosts the antibodies that the patient already has. It has been found to prevent half the cases of shingles, and in the cases that do occur, it lessens the level of PHN by two-thirds. Zostavax is safe for people with no history of chickenpox. It is contraindicated for those with a weakened immune system.
What Causes Shingles?
Shingles is a recurrence of chickenpox. Most of us have chickenpox before the age of 10. The virus that causes it is called herpes varicella and like all herpes viruses it remains hidden in the body after it is caught. As a person gets older, it is more likely that this virus will reactivate.
When it does it is called herpes zoster and the condition it causes is called shingles. In younger people (under 50) shingles is usually a minor problem and gets better quickly without treatment. In people over 50, shingles may be a longer, more painful problem.
A person develops shingles because their body’s ability to suppress this dormant virus has been reduced. This can be caused by an illness, trauma, operation, old age – sometimes there is no apparent trigger.
Recognise the Signs
A doctor can prescribe antiviral tablets to help clear the rash, but to be effective they should be started within three days, so prompt diagnosis is important.
The warning signs of an impending outbreak are often mistaken for something else. They include:
• An unexplained pain or discomfort, or numbness, often on the face or around the ribs. The patient may have thought this is ‘a pulled muscle’ but there has been no recent activity to cause it; an ‘allergic reaction’ but they can’t think to what; an ‘insect bite’; or an ‘odd injury’ with no obvious cause. These sensations are caused by the reactivating virus travelling in the nerve and irritating it
• The pain and the subsequent blisters or rash will occur near the area where this pain has been. Shingles usually affects a single dermatome – nerve area – and is only on one side of the body
• The duration of the outbreak can vary from a few days in a young person to several weeks in an older person
• In older patients, it is more likely that the nerve pain will continue after the shingles blisters or rash have cleared up. See later in the article
Is Shingles Caught?
People are often mystified when they develop shingles. They also wonder if others can catch it from them. They may be told to stay away from pregnant women without any reason being given.
• Shingles is always a recurrence of chickenpox
• Most people have had chickenpox, although they may not remember. Since chickenpox is highly infectious, anyone who has ever nursed someone with chickenpox, or even been in the same house as a person with chickenpox, will have caught it, although it may have been so mild that they don’t remember
• No-one can catch shingles (though they may catch chickenpox if they haven’t had it yet). In fact, the more often a person meets a patient with chickenpox, the less likely they are to develop shingles
• A person who has never had chickenpox may catch it by rubbing directly against shingles sores. Chickenpox is not caught just by being in the same room as someone with shingles
• Therefore, there is no need for a person with shingles to refrain from normal social / work activities if they are feeling well enough
• This applies to pregnant women as well – they will not catch chickenpox by being in the same room as a shingles patient unless they touch the sores
There is one exception, which is when a person has active shingles sores on the face or head. Infectious matter from the rash could be inhaled by someone nearby. In this case, the rash should be carefully covered when going out in public. If the rash can’t be covered, then ‘social distancing’ is necessary.
Treatment for Shingles
Antiviral treatment (aciclovir, valaciclovir or Famvir) is used for shingles. It needs to be started within three days of the onset of symptoms to be effective. After that, the drugs will be of less use even though GPs may still prescribe them.
Taking antiviral tablets and amitriptyline may help to reduce the chance of developing post-herpetic neuralgia – the pain that may follow shingles, especially in the elderly – see later in the article.
Self-Help for Shingles
• Patients may wish to take systemic treatment if a flu-like illness accompanies the onset of shingles
• Treatment for shingles pain is often required, either OTC or in some cases stronger medications
• Topical pain relief includes lidocaine hydrochloride five per cent ointment (indicated), lidocaine 10 per cent spray, calamine lotion – and products containing benzocaine or prilocaine
• Cover lesions that are not under clothes while the rash is still weeping to prevent secondary (bacterial) infection
• Keep the rash clean and dry to reduce the risk of secondary infection. Patients should seek medical advice if there is an increase in temperature, as this may indicate bacterial infection
• Patients will need to rest if they feel weak and tired. Only they can judge how badly they are affected by shingles
When the blisters have healed there may still be pain in the nerve that has been irritated by the virus as it travels to the skin. It is termed post-herpetic neuralgia (PHN) when the pain has continued for three months after the skin has cleared. PHN occurs in approximately one-in-five people with shingles, and the risk increases with age.
The sooner treatment for PHN is begun, the more likely it is to be effective. It may slowly fade away, but there is a risk that it can continue. It has been found that after two years, one-in-five patients with PHN are still somewhat affected.
This means that when a patient has PHN, there is no way to predict for how long this pain will last. It is up to the patient to decide how vigorously to treat PHN – is the idea of continuing with this discomfort / pain, even though it has improved, acceptable? If not, they will need to talk to the GP about treatment.
Treatment for PHN
The pills used for PHN slowly build up ‘a pain block’ over several weeks or even months. They must be started at a low dose which is slowly increased over the following weeks to reach an effective dose. When the starting dose is too high, the side-effects are more likely to cause the patient to discontinue treatment.
Gabapentin and pregabalin were developed as anti-epileptic drugs and now have a specific licence for neuropathic pain.
Tricyclic antidepressants, such as amitriptyline or nortriptyline, are frequently used to treat this nerve pain.
Axsain (capsaicin 0.075 per cent cream) has an indication for treating PHN. It may cause a sensation of burning, so it is advisable to apply lidocaine five per cent ointment to the area first.
Versatis plasters (or patches) may sometimes be prescribed when other treatments are not effective or for patients who find swallowing tablets a problem. They are used on the affected area: 12 hours on, then off for 12 hours, to allow the skin to recover.
If, after two months, the treatment seems not to be working, it is time to try a different one.
If none of these are helping, then patients could be referred to a pain clinic. This should not be left too long as after about a year treatment is much less likely to be successful.
Self-Help Tips that May Be Worth Trying
TENS machines are available in some pharmacies. Using TENS can be useful to either alleviate the pain or just counter-stimulate the area to ‘take your mind off it’. Patients should experiment with different settings, how often to use it, and where exactly the pads should be placed.
Some people with shingles have found these ideas helpful – they are not medically-tested:
• Holding a hot-water bottle to the area
• Holding a well-wrapped ice pack to the area for up to 90 minutes at a time
• Firmly bandaging the area or wearing a compression garment underclothes in order to prevent the pain of a light touch if the patient has allodynia
• Eurax cream
• Lidocaine five per cent ointment on the area
NHS Clinical Knowledge Summary supplies a list of complications that could apply to patients with shingles. Two that the pharmacist may wish to bear in mind:
• Long-term corticosteroid use lowers the immune response and therefore makes any infection more likely to be serious
• Shingles on the face – when the eye may be involved. If the patient has discomfort /pain in one eye, there may be a danger to eyesight. The patient should have a fluorescein stain to detect involvement of the virus
Shingles Support Society
41 North Road, London N7 9DP
Office: 020 7607 9661
Helpline: 0845 123 2305