In 2013, I’ve featured American Academy of Dermatology (AAD)’s Dermatology A: Z Videos (here). Since then, AAD has added several other videos which are informative and practical. AAD’s public relations team has once again been most helpful in introducing me to the dermatologists who assisted with my questions, making it possible to bring this special AAD Dermatology A:Z video series to you!
The video covered today is “Shingles: Pain Management”. For this video, I interviewed Dr. Daniela Kroshinsky M.D., MPH, who is an Associate Professor of dermatology at Harvard Medical School in Boston and the director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.
MarcieMom: Dr Daniela, thank you for helping out in this AAD video series. Shingles affects about 1 in 5 people and more common in people over the age of 50. However, it’s possible to get it at any age though, as my daughter with eczema and chickenpox (at age 2) had shingles at the age of 4! We’d like in this interview to learn more about managing the pain and the rash associated with shingles and pointers for an eczema child/patient with shingles.
Key points in the AAD Video
- Anyone can get shingles if they have the chicken pox virus (varicella zoster), either from having had chicken pox or from chicken pox vaccination
- Shingles rash – More pain experienced than chickenpox, commonly in one region of the body and usually confined to one side of the body
- Symptoms of Shingles – Area of skin that burns, tingles, itches or sensitive; begins as red spots that turn to raised areas and blisters in the same area. This is followed by crusting.
- 2 to 3 weeks for the blisters to heal with reducing pain
- If pain, itch, numbness or tingling develops, it can last months to years
- Anti-viral medication used within 72 hours of rash appearing may shorten the course of the rash and lessen the pain. After 72 hours, anti-viral medication can still lessen the pain.
- At home – Cool the rash, apply calamine lotion, do not peel, pick at or pop the blisters, cover the rash with loose, sterile bandage and wear loose-fitting, cotton clothing
- Shingles is contagious – can spread in the form of chicken pox to someone who has not had chicken pox or to the fetus of a pregnant person.
MarcieMom: Shingles is caused by reactivation of an infection that is dormant in a nerve and the area of skin supplied by the nerve. Dr Daniela, can you explain which nerves get infected most often and is that why most people get the shingles rash on their torso? In the video, it is mentioned that some people get it on their face – does a person’s age and immune system affect which nerves will get infected? Once infected, can it spread from one part to another of the body?
Dr Daniela: In general, shingles will arise in the area of the body that had the greatest concentration of blisters at the time of the chicken pox but it varies widely. Most chickenpox blisters arise on the torso. Once someone is infected, they can spread the lesions to other parts of theirs skin through contact with the blister fluid which contains active virus. In addition, people who have compromised immune systems may experience widening of the affected area beyond the initial skin patch fed by the nerve. This is called “disseminated zoster” and requires urgent attention and treatment.
Reducing Pain in Shingles
MarcieMom: We learnt in the video that anti-viral medication can help to reduce pain and pain relief measures at home can help. Why do certain people feel more pain than others? (Age, immune system, or existing medication they are on?) Are there any measures one can take to reduce the likelihood of prolonged pain, ie months after the rash has healed (Postherpetic neuralgia or PHN)?
Dr Daniela: There are many factors that can influence people’s perception of pain, many that we are still starting to understand. Starting antiviral medication as soon as possible is the most helpful tool to help minimize the risk of pain. If PHN develops, seeking medical attention as soon as possible, including with a pain specialist if needed, can help to better manage these symptoms.
Lowering Likelihood of Shingles’ Complications
Apart from postherpetic neuralgia, there are other complications such as
- Skin infection, from bacteria/germs
- Shingles at the eye can cause eye inflammation
- Muscle weakness (palsy) due to shingles infection of the motor nerve
MarcieMom: Of particular interest is skin infection. What are the factors that will increase the chance of skin infection and what measures should one take to reduce the chances of skin infection?
Is someone with eczema skin that is already colonized with staphylococcus aureus bacteria more likely to suffer from skin infection? If yes, is it advisable to clean the shingles rash with chlorhexidine?
Dr Daniela: Picking or touching the lesions can introduce bacteria that could create bacterial infection of the shingles. Keeping the lesions clean and covered helps to minimize this. With eczema in general, keeping eczema controlled and minimizing wounds helps to prevent secondary infection. It is not necessary to clean shingles with a medicated soap. Chlorhexidine can be irritating and can dry out skin, further exacerbating eczema and as such I would not recommend it be used for shingles. Keeping the lesions covered and clean with gentle care is usually sufficient.
Managing Shingles for those with Active Eczema
For some eczema children and adults, they may be on various courses of corticosteroids or immunosuppressant, such as prednisolone, mycophenolate mofetil and cyclosporine. Will taking such medication increases the risk of getting shingles?
Is it possible that shingle rash will appear over a patch of skin with eczema flare-up? If so, what topical medication should be applied? (still ok to apply topical corticosteroid over the eczema if shingles appear on the same patch?)
Dr Daniela: Immune-lowering medications can make it more likely that someone will have their shingles spread more widely so it is important to watch shingles as it develops to assess whether the eruption is spreading more widely, warranting more aggressive treatment. Once antiviral treatment has been started, topical steroids can be used cautiously to the eczema around the shingles lesions but it is important not to rub the viral lesions as it is possible to spread the viral particles and extend the infection. Anti-itch medications like antihistamines can be very helpful to control the symptoms of itch that can accompany eczema.
Thank you Dr Daniela for helping us to understand how to manage shingles and offering clarity for those suffering with eczema who also get shingles.