Shingles: Causes, symptoms, vaccine, infection, cure, Dangers And Effects, Contagious, Vaccine And Treatments.

What is shingles

When the red and itchy pustules of chickenpox disappear and return to normal, the battle against the virus that causes the infection seems to have been won. In reality, for many (indeed too many) of us the victory of the immune system is not definitive, the virus is not destroyed, but remains latent in the nerve cells, ready to strike again at a later time. The second eruption of chickenpox virus causes a disease called shingles or shingles.

The characteristic symptoms of herpes zoster are:

1. Appearance of small blisters.
2. Redness.
3. Feeling sick and sometimes fever.
4. Burning sensation and / or itching.
5. Tingling.

“I went to university and it was a period of exams: suddenly I was hit by a rash, a kind of strip towards the side, at chest level. Pustules really hurt. At first I thought I had chicken pox, but I had already had it years and years before, ”recalls a boy who was struck by the Saint Anthony fire when he was about twenty years old.

The boy's memory was correct. He had really had chickenpox when he was a child. You cannot suffer from St. Anthony's fire if you have not already come into contact with the varicella virus and most people who develop varicella have an increased risk with regard to the painful manifestations of shingles. The boy suffered from a belt rash on his hip and the pain typical of this frequent neurological disorder, however his age was rather unusual.

Even the young can be hit by the St. Anthony fire, but this disorder appears more frequently after the age of 40. However, it is a very common disease that affects about a quarter of the US population at least once in their life, so overall cases in young people are by no means few.

The incidence, as mentioned, increases with age: shingles are 10 times more likely in adults over the age of 60 than in children under the age of 10. People with immune system problems arising from

1. use of immunosuppressive drugs such as cortisone ,
2. serious diseases like tumors
3. or from HIV infection

They are particularly at risk of contracting the disease. These patients can also suffer from relapses and in some of them the shingles never disappear definitively, even if most of the people who get sick "renew" the immunity to the responsible virus and for some decades after the episode don't get sick anymore.

Post-herpetic neuralgia is the most common complication and is characterized by the appearance of persistent pain in the area where the rash occurred; it can last for weeks or months and occasionally for many years.

Other possible complications include:

1)       eye involvement,

2)       Involvement of other organs and development of dangerous inflammations (meningoencephalitis, pneumonia, hepatitis,).

Children whose mothers have had chickenpox in the last few weeks of pregnancy (5 to 21 days before giving birth) or who have had chickenpox during early childhood are at greater risk of contracting Zoster in pediatric age. Sometimes these children are already born with chickenpox or become ill with a typical form of the disease after a few days after birth.

Is it possible to prevent it?

Prevention essentially passes through vaccination, which is already available for more than 10 years, but which will see a net increase in effectiveness with the marketing of a new and much more effective vaccine formulation.

Is shingles contagious?

Shingles is not contagious, but it is possible to contract varicella (if you are not immune, perhaps because you have done it in the past) by an acute phase patient with shingles; as we shall see later, however, this is an unusual occurrence.

Shingles and shingles?

Shingles is popularly called fire of Saint Anthony because in the past it was invoked the Saint Anthony Abbot, considered able to heal the disease thanks to his thaumaturgical abilities (that is the possibility to perform miracles), to find relief to the pain and to the other symptoms.

During the middle Ages and the early Modern Age the expression indicated a large number of conditions, which the medicine of the time was not able to differentiate from the diagnostic point of view.

What Are The Causes Of Shingles

Scientists call the virus responsible for chickenpox and shingles varicella-zoster virus or VZV.

1)       The word varicella comes from the Latin variola, smallpox: smallpox is another infectious disease that can resemble chickenpox, but it is an extremely contagious infection that often causes the death of the patient (it has disfigured or killed millions of people, especially during the middle Ages.)

2)       Zoster is the Greek word that means belt or band: normally the shingle fire causes the appearance of a band of pustules or lesions, at waist height and on one side only.

The VZV is part of a group of viruses called herpesviruses: this group includes the virus called herpes simplex which causes fever on the lips and genital herpes (a sexually transmitted disease) and the Epstein-Barr virus associated with infectious mononucleosis . Like VZV, other herpesviruses can also nest in the nervous system after a first infection and then spread through nerve cell tissues to cause a second infection: the most frequent example is repeated episodes of fever on the lips.

Already in 1909 the researchers began to suspect that chicken pox and shingles were caused by the same virus, in the Twenties and Thirties this thesis was reinforced by an experiment in which children were injected with the liquid contained in the lesions of the fire of Sant 'Antonio. Within two weeks about half of the children had suffered from chickenpox. Finally, in 1958, in-depth analyzes of viruses taken from patients with chickenpox or St. Anthony's fire confirmed that it was the same virus.

In the first contact with the VZV (varicella) some particles of the virus pass from the blood to the agglomerates of nerve cells (neurons) called sensory ganglia, where they remain even for many years in inactive (latent) form. The sensory ganglia, which are located near the spinal cord and the brain, provide sensory information to the brain: they communicate the sensations of coming from the body.

1. Hot.
2. Cold.
3. Contact.
4. And pain.

When the VZV virus reactivates, it spreads through nerve extension fibers (axons) that start from the cellular body of neurons and reach the skin. The virus multiplies and the rash appears as a characteristic symptom : now the person can be said to be affected by shingles or shingles, in this case the nervous system is more radically involved than is the case with the Chickenpox attack and the symptoms are usually more complicated and serious.

Risk factors Of Shingles

1)       depression of the immune system ( leukemia , AIDS, transplants, ...);

2)       age over 60;

3)       chickenpox contracted in the first year of life;

4)       sex (higher frequency in women);

5)       Ethnicity (in the United States, whites fall ill at least 50% more than African-Americans).

On the other hand, it is interesting to note that exposure to the virus, such as can occur for adults with children, acts as a protective factor against the virus.

Finally, herpes zoster has no correlation with the season, nor does it show epidemic trends.

Contagion

Chickenpox and shingles are caused by the same virus: varicella zoster virus (VZV).

A patient suffering from the fire of St. Anthony can infect another person, for example a child who has never had chickenpox and who has not been vaccinated (although in Italy it is mandatory since 2017): the child will be affected by the chicken pox and not from St. Anthony's fire and because contagion occurs it is necessary to come into contact directly with the open lesions of the erythematic, while if it remains in the same environment as a person suffering from the fire of Saint Anthony the child will not be able to get sick of chickenpox, because during the infection triggered by shingles the virus usually does not affect the lungs and therefore cannot spread by air.

Varicella patients, on the other hand, cannot pass on St. Anthony's fire to anyone, but they can obviously transmit chickenpox to those who have never had it before. In the case of chicken pox, the virus can spread by air, because it affects the upper respiratory tract.

The shingles appear when an unknown triggering factor activates the virus hidden inside the organism; unlike chickenpox so you can't "switch" to someone else. When reactivated the virus reaches the skin through the nerves and causes the appearance of the characteristic painful erythematic. In shingles the virus usually does not pass into the bloodstream or into the lungs and therefore cannot be spread by air.

Its Duration

The eruption forms vesicles that tend to dry out in 10-15 days and resolve in 2-4 weeks. Post-herpetic manifestations (such as pain) could last several months instead.

What Are The Symptoms

Some patients may experience symptoms such as 

1.     Fever.

2.      chills 

3.      Widespread malaise.

But being non-specific they are rarely related to the reactivation of the zoster virus.

These disorders are then followed by the first specific symptom of St. Anthony's fire, which is normally the burning, tingling or itching , usually located in a very specific area, for example only on one side . After a few days, or at most a week, erythema appears in the same area with pustules filled with liquid, similar to those of chickenpox.

Recent research has shown that the cases of milder shingles, with only a few lesions or none, are more frequent than previously thought. These episodes are usually not diagnosed. If no lesions are present it is called zoster sine herpete .

The pain caused by St. Anthony's fire can vary from mild to intense. Some patients suffer especially from itching, others instead feel pain if they are touched gently. The area in which the shingles are most frequently manifested is a band (called dermatome) that extends over only one side of the trunk at waist height, and the disorder can also occur frequently on one side of the face, around the eye and on the forehead. However the disorder can affect any area of ​​the body and the number of lesions can vary: the bubbles can unite and create an area similar to a deep burn. Other patients may have only a few scattered lesions that do not cause severe symptoms.

In some patients it is also possible to observe an enlargement of the lymph nodes.

In most healthy people the lesions caused by the fire heal within a few weeks, the itching and pain diminish and the pustules generally leave no scars (only rarely, in the case of large blisters, can permanent signs persist or discolored skin.). Other patients, on the other hand, may have sensory symptoms that last for a few months.

What Are The Dangers Of Shingles?

1.     People suffering from ophthalmic herpes (with lesions in the eye, around the eye and on the forehead) may suffer from very painful eye infections and in some cases the vision may be partially compromised, immediately or after some time. 

2.     People affected by ophthalmic herpes should be seen immediately by the ophthalmologist. Infection inside the eye or around the eye (Ramsay-Hunt syndrome) can cause hearing problems or balance and muscle weakness on the side of the face being hit.

3.     In very rare cases, the virus can spread in the brain or spinal cord and can cause serious complications such as heart attacks or meningitis (an infection of the membranes lining the brain and spinal cord). Anyone who has been affected by the virus should immediately visit the doctor if he or she notices neurological symptoms outside the area where the first episode occurred.

4.     Immune suppressed people, for example due to diseases such as HIV or certain medications are at greater risk of serious complications. In this case it is likely that the shingles will spread and will affect different parts of the body, or that the erythematic lasts longer or occurs more frequently. Many of these patients are helped by regularly administering antiviral drugs.

What About Pregnant Women?

Many future mothers are rightly concerned about any infection contracted during pregnancy: some infections can be transmitted from the mother's blood to the fetus, or they can affect the baby at the time of delivery. Infection with VZV during pregnancy presents certain risks for the child, depending on the stage of pregnancy in which one is affected.

1. During the first 30 weeks, if the mother gets chickenpox, in some cases the baby can be born with congenital malformations. These cases are rare and experts have differing opinions on the severity of the risks. But most of them agree that shingles in a pregnant woman (a very rare event) are even less likely to cause harm to the fetus.

2. If a pregnant woman develops chickenpox between 21 and 5 days before giving birth, the baby can be born with chicken pox or become ill within a few days. However, in general, the time between the onset of the disease in the mother and the birth of the baby allows the mother's immune system to react and produce the antibodies necessary to fight the virus. These antibodies can be transmitted to the baby and help fight infection. However, a small percentage of children who have come into contact with chickenpox 21 to 5 days before birth are affected by shingles in the first 5 years of life, because the baby's immune system is not yet fully functional and able to keep the virus in a latent state.And what if the mother gets chickenpox at the time of birth? In this case the mother's immune system cannot mobilize. Although some of the maternal antibodies are transmitted to the newborn through the placenta, the newborn will not be able to fight the attack alone, because its immune system is immature. If children are affected by chickenpox in this way, the disease can be lethal. To combat the disease, they are given anti-varicella-zoster immunoglobulin, a blood-based preparation rich in antibodies of adult individuals recently healed of chicken pox or shingles.

Therapy

There is no definitive cure for herpes zoster, but antiviral drugs can help make the attack shorter and less severe, also reducing the risk of developing post-herpetic neuralgia; the effectiveness is greater the more timely the start of treatment. Pain control medications may be prescribed in combination.

The treatment is essentially aimed at relieving symptoms until the infection is regressed, which occurs over 2-4 weeks.

In case of suspicion of the onset of the condition it is recommended to contact the doctor quickly, as starting the therapy early can reduce the severity of the symptoms and the risk of potential complications.

Self-medication

1. Keep the rashes as clean and dry as possible, thus reducing the risk of bacterial super infection.
2. Avoid tight-fitting clothes that could ignite the zoster rash.
3. Unless expressly prescribed, avoid using antibiotic creams, which could slow down the healing process.
4. Use a non-adherent patch if it is necessary to cover the blisters, to avoid risks of infection to third parties.

Drugs

The duration and severity of shingles can be reduced by using antiviral drugs prescribed by a doctor, such as acyclovir, valaciclovir or famciclovir; they prove to be much more effective when started within 3 days of the onset of the rash, so it is advisable to contact the doctor quickly if in doubt (in the presence of important risk factors they can however be started up to a week later) .

Aciclovir and valaciclovir are also available as generic drugs; in the case of aciclovir the tablets should be taken five times a day, while valaciclovir and famciclovir require an intake with a frequency of three times a day. It is important not to forget any dose and not to stop the therapy before the prescribed time limit by the doctor.

These drugs cannot kill the Zoster virus, but they can contribute to drastically reducing its multiplication, thus helping to:

1. reduce the severity of the skin manifestation,
2. reduce the time needed to heal,
3. Preventing the appearance of complications, such as post-herpetic neuralgia.

For most healthy people who start the therapy immediately after the onset of erythema on the skin, the lesions disappear, the pain regresses within 3-5 weeks and the blisters usually leave no scars. Shingles however represents a serious threat to immunosuppressed patients, such as those suffering from HIV infections or undergoing cancer treatment that can weaken their immune system. Even those who have undergone transplantation are more vulnerable to the virus, because they are treated with drugs that inhibit the functioning of the immune system.

Antiviral drugs can almost halve the risk of getting post-herpetic neuralgia, a chronic pain that continues for months or years after the disappearance of skin lesions. Doctors advise starting therapy with antiviral drugs at the first symptoms of the rash, or even when the warning symptoms indicate that it is about to appear. Even if the patient is not visited by the doctor at the time of the onset of the disease, it may still be useful to start antiviral therapy if new lesions are already forming. Other therapies to consider include corticosteroid anti-inflammatory drugs, such as prednisone. They are normally used when the disease affects the eye or other nerves of the face.

If pain is present, it may be useful to combine pain medication, from traditional ones (such as paracetamol and anti-inflammatory) to specific drugs for neuropathic pain.

Post-herpetic neuralgia        

Sometimes, especially in the elderly, the pain caused by shingles continues even for a long time after healing of the skin lesions (it is estimated that it affects up to one in five patients).

Post-herpetic neuralgia can be mild or very severe: severe cases can cause insomnia, weight loss, depression and disability, but it does not directly cause death. Clinical experiments have shown that about ten drugs, divided into four categories, are effective for reducing pain. Among them we find

• Tricyclic antidepressants (TCA): they are often the first type of drug that is given to patients suffering from post-herpetic neuralgia. Amitriptyline, a tricyclic antidepressant, has often been prescribed in the past but, despite being effective, it has a high incidence of side effects. Desipramine and nortriptyline have fewer side effects and are therefore more suitable for the elderly, the age group most at risk for post-herpetic neuralgia. Among the frequent side effects of tricyclic antidepressants we find: dry eyes and mouth, constipation and numbness. Patients with a history of heart attacks or those with narrow -angle glaucoma should use different types of medication.
• Anticonvulsants: some effective drugs against convulsions are also able to cure post-herpetic neuralgia because both convulsions and pain have to do with an overexcitation of nerve cells. Carbamazepine, an anti- epileptic drug, is effective for the treatment of post-herpetic neuralgia, but has rare and potentially dangerous side effects: for this reason, a more recent drug, gabapentin, is prescribed more frequently. Among the side effects of the latter we find: drowsiness or confusion, dizziness and, in some cases, ankle swelling.
• : opiates are very potent analgesic drugs, effective against any kind of pain, including of course that caused by shingles. Among them we find: oxycodone, morphine, tramadol and methadone. Opiates can have side effects such as drowsiness, mental clouding and constipation, and can be addictive, so their use must be carefully monitored in patients with a history of dependence.
• Local anesthetics for topical use: Opiates local anesthetics applied directly to the skin of the area affected by post-herpetic neuralgia are also effective. Lidocaine, the one most frequently prescribed, is available in lotion, gels, patches or sprays. In the case of topical local anesthetics, the drug remains in the skin and therefore does not cause problems with drowsiness or constipation. Capsaicin-based creams can be quite effective and are sold without a prescription, but most patients believe that they cause intense burning during application.

Post-herpetic itching

The itching that sometimes appears during or after shingles can be quite severe and painful.

Medical experience suggests that post-herpetic itching is even more difficult to treat than post-herpetic neuralgia. Local anesthetics for topical use (which numb the skin) greatly alleviate this in some patients. Since post-herpetic itching usually develops in areas of skin with problems of lack of sensitivity it is essential not to scratch. Scratching insensitive skin for too long or with too much force can cause serious injury.

Vaccine

Varicella vaccine

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Varicella vaccine

The varicella vaccine (which has become mandatory) is able to avoid infection. Those who have been vaccinated against chickenpox are less likely to be affected by shingles because the weak and attenuated variety of viruses used in the vaccine is less likely to survive in the body for decades. It will be known with certainty if the shingles fire can occur in later stages of life in a person vaccinated against chickenpox only when sufficient data have been collected over the next few decades.

Some researchers believe that vaccinating children against chickenpox increases the risk of having a shingle in adults who have not been vaccinated during childhood. This happens because if the adults take care of children suffering from chickenpox their immunity is recalled which prevents the virus present in the nerve cells from reactivating and triggering the shingles of Saint Anthony. If fewer children get chickenpox, there are fewer opportunities for adult immunization and therefore there could be more cases of shingles in the next 40 to 50 years.

The vaccine against shingles

In May 2006, the US Food and Drug Administration approved a vaccine against the VZV virus that can be used in people over the age of 50 already affected by chickenpox. When this vaccine will be more widespread, many older people will be able to benefit for the first time from a means of preventing St Anthony's fire and, to pursue this goal, in Italy the new vaccination plan provides for the vaccine to be offered free to adults of 65 years or more.

The vaccine, marketed by MSD (trade name Zostavax®, retail price € 192.40), reduces the risk of getting shingles by 64% in the population between 60 and 69 and reduces the risk of complications in 70% of the over-70s (the most at risk of this complication), as demonstrated by the Shingles Prevention Study , published in the New England Journal of Medicine in 2005. In the ZEST study ( Zostavax Efficacy and Safety Trial ) the vaccine reduced the incidence of zoster by 70% in a population of 50-59 years.

In cases of infection the symptoms are generally attenuated, while the most common side effects include reactions at the injection site, pain in the extremities and headache.

In an American study conducted thanks to the joint intervention of the Department of Veterans Affairs, the National Allergy and Infectious Diseases Institute and Merck & Co., which involved more than 38,000 veterans over the age of 60, half of the research participants was vaccinated with a version of the more powerful varicella vaccine, specifically designed for use in adults, and half received a placebo instead. Neither the volunteers nor the researchers knew if a particular patient had received the true vaccine or placebo before the conclusion of the research (double-blind study). During the study period, which lasted more than three years, the vaccine reduced the cases of shingles by 51 percent; in the placebo group there were 642 cases, against only 315 in the group actually vaccinated. In people who were actually vaccinated but still developed herpes zoster, the pain and discomfort were reduced by 61 percent. The vaccine also decreased the number of post-herpetic neuralgia cases by two-thirds compared to placebo.

The shingles vaccine is in any case only a preventive therapy and not a treatment option for those who have already been hit by shingles or post-herpetic neuralgia.

Shingrix

Much more recent is the approval of the Shingrix vaccine, developed by GSK; it is a vaccine registered in Europe “to protect adults 50 years of age or older against vesicular rashes (herpes zoster or S. Antonio fire) and post-herpetic neuralgia (long-term nervous pain that it follows the herpes zoster "", while in the USA the indication foresees exclusively the prevention from the zoster and not from the neuralgia.

The effectiveness of Shingrix is ​​estimated, on the basis of the literature available to date, over 90% in ideal conditions, against a figure equal to about half of the previous vaccine.

Unlike the previous one, based on the presence of a live vaccine, this formulation contains small amounts of proteins present on the surface of the virus that serve to stimulate the production of specific defense antibodies in case of reactivation of the zoster virus.

It is available only in injectable form, to be administered in the upper arm muscle, and the vaccination cycle consists of 2 injections given 2 months apart from each other (if necessary the second dose can be given more late, but no later than 6 months from the first dose). It can also be given to patients who have already received the vaccination with Zostavax.

The most common possible side effects are those typical of each vaccine, such as reactions in the area of ​​administration (pain, redness and swelling), chills, fever, muscle pain, fatigue, headache and gastrointestinal side effects, such as nausea, vomiting, diarrhea and stomach pain. The duration of most of these reactions is generally limited to only 2 to 3 days.

Shingrix requires medical prescription, while to date it has not yet been announced if it will be possible to access it through the SSN.