“May you always live in interesting times.” ...ancient Chinese Curse

Life is full of interesting little surprises. Pain (or the avoidance of it) is a great motivator and takes precedence over any comedic relief which I could have offered in this month’s column. One of my readers recently asked why I didn’t write more articles on informative medical topics... so this one’s for him.
Physician Heal Thyself

For a night or two recently, I could not shake a strange discomfort behind my right ear and neck. On these occasions, I got up for a couple of Tylenol and made it through the night. Then one morning at 3:00 AM, I awakened to focus my bleary eyes on a blistering rash on the right side of my neck. This let me know immediately that I had fallen prey to an attack from the dreaded SHINGLES virus. Silent curse words were uttered, and in the dawn of the following morning, the self-loathing regret for not having gotten an updated shingles vaccine occupied my mind. I had intended all this past summer to take the new vaccine (Shingrix) that I have recommended to so many patients over the age of fifty. Somehow in the midst of the seemingly endless string of Covid boosters, preventing an outbreak of shingles (herpes zoster) got lost in the shuffle. “Well, it’s too late, baby, now it’s too late,” was the tune my mind played relentlessly until time to go to work next morning. I had taken the original shingles preventative vaccine (Zostavax) well over ten years ago and I realize now that its ability to ward off the Varicella virus was long gone. The live virus Zostavax injection was simply a high dose of the ‘chicken pox’ vaccine that children are now routinely given.

Without further ado, I got started on a regimen of anti-viral medication that morning (Valacyclovir) and feel certain this reduced my symptoms, and hopefully fended off a long siege of post-herpetic neuralgia (PHN), which is the lingering burning/stabbing pain that many with shingles outbreaks are left to endlessly endure. This type of antiviral medication only really helps if you can get started taking it within 48 hours after an outbreak.

Coincidentally, Lois Roberson, (my strong right-hand and the care-giving angel for my husband Roger), had suffered a more serious outbreak of shingles a couple of weeks before mine. Her siege started with what she thought was a severe sciatica, a low back pain radiating down her entire right leg due to pinched nerve. We treated it as if it was a lumbago with sciatica, but not much seemed to help. She said it was the worst pain she had ever endured. The tell-tale rash did not appear until she had suffered many days and nights of misery, and too late for the antiviral medication to help. She has dealt with this scourge for a month now. When I told her about my own outbreak, she was afraid that she had somehow given it to me. I assured her that shingles was not contagious and I didn’t ‘catch it’ from her! The viral fluid in those blisters can only infect someone who has never had contact with the virus, such as an unvaccinated child, and then can only transmit chicken pox, not shingles. This is a highly unlikely scenario at any rate.
What Causes Shingles Anyway???

Shingles, medically termed ‘herpes zoster,’ is a very painful blistering skin rash that is caused by a reactivation of that highly contagious chicken pox virus which most of us had as a childhood illness long ago. (I well remember having the chicken pox and my Bigmama escorting me out to the chicken yard to get a hen to fly over my head as a treatment!) Having the chicken pox was no fun, but the recycled varicella virus in the form of a shingles outbreak can become a mind-bending, never-ending torture when it damages the affected nerves causing ‘post-herpetic neuralgia’ (PHN).

Typically, the shingles rash breaks out in the distribution of a nerve on only one side of the body or face, never crossing over the mid-line of the body. (Another old Grand-maw tale was that if the shingles wrapped all the way around your body, you would die. This would never happen, of course.)

I have developed a simple-minded analogy to help patients understand how this could possibly be happening. The childhood chicken pox outbreak passes and the rash disappears but the virus itself never exits our bodies. The microscopic varicella virus lies dormant within some of our nerve cells. Think of your body’s nervous system as functioning to send electrical impulses from your brain and spinal cord out to the rest of your body. Then think of those nerves as very much like the insulated copper wiring that travels from your switch-box to direct functions within your home. You know that the copper wiring is protected by a coating of insulation that travels with it until the assigned destination is reached. If the plastic insulation is compromised somewhere, the wire will short-circuit of course. Our nerves have a coating of insulation as well, called a myelin sheath. The varicella virus that has been hiding between the nerve tissue and its insulation for perhaps 50 years seizes an opportunity to reactivate. It bursts through the protective layer, and ultimately out to the skin surface, short-circuiting those sensitive nerves and causing that stabbing, burning, shock-wave pain that shingles sufferers experience.

One of the most serious common complications of having shingles occurs when the outbreak involves the head and attacks the eye. This often leads to severely damaged vision and cataract formation.

The exact trigger for the resurrection of this sneaky virus is not well understood, but we do know there are risk factors for an outbreak:

- experiencing great emotional or physical stress;
- over age 50-- 1 out of 3 of us will get shingles in our lifetime;
- having cancer, especially leukemia and lymphoma;
- undergoing chemotherapy or radiation therapy;
- compromised or suppressed immune system;
- diabetes-- particularly if it is poorly controlled;
- organ transplant status on immuno-suppressant therapy.

What You Need to Do As soon as you recognize a rash as potential shingles, consult with your primary physician for a diagnosis and therapy as soon as possible for the anti-viral medication therapy. Timing is critical.

As dreadful as a shingles diagnosis is, at least the rash usually clears within 3-4 weeks. The resulting pain from nerve damage, the PHN, can in some cases become a permanent scourge if treatment has been delayed or unsuccessful. There are medications which can help that chronic nerve pain, such as Neurontin (gabapentin) and the newer Lyrica (pregabalin).

But, as with other adult vaccines many of us are now receiving (Covid and Influenza virus vaccines), the absolute best treatment strategy for shingles is preventing it in the first place.

A few years ago the original shingles vaccine, Zostavax, was prohibitively expensive (around $200) and not covered by insurance. It is no longer available. The newer Shingrix vaccine is a 2 part series... 1 injection followed by a second jab 2-6 months later. I recently learned that it IS covered by Medicare part D, and for at risk individuals, many private insurances will help with the cost. Availability is somewhat limited; for instance, we do not have it in our clinic. It is however readily available at many pharmacies which participate in vaccine therapy. (Check with your healthcare provider, and with your local pharmacy to see if they offer the vaccine, and if they don’t maybe they can let you know where may have it in your area!)
A Good Scare Is Worth More Than Good Advice

Yes, having an outbreak of shingles is indeed a wake-up call and us healthcare types are just as at risk as any other patient. If stress causes it, perhaps even more so! So, just as soon as my rash completely disappears, I’ll be headed for a vaccine and hopefully I’ll have the good sense to learn to take my own advice and get another series in the recommended 5 years.

Pictures being worth more than hundreds of words, included here are a couple of shingles illustrations for our readers.