Chronic Pain

Postherpetic Neuralgia

Postherpetic Neuralgia is a complication of shingles, which is caused by the chickenpox (herpes zoster) virus. Postherpetic Neuralgia affects nerve fibers and skin, causing burning pain that lasts long after the rash and blisters of shingles disappear.

Once you’ve had chickenpox, the virus remains in your body for the rest of your life. It never completely goes away, but instead stays in the nerve fibers under the skin by the spine. The virus can remain dormant in your body’s nerve cells after childhood and can reactivate years later. Shingles is a reactivation of your old chickenpox virus and when active, it travels down a dermatome, or pathway, that follows the distribution of the nerve involved. Postherpetic Neuralgia occurs if nerve fibers are damaged during an outbreak of shingles. Damaged fibers can’t send messages from your skin to your brain as they normally do. Instead, the messages become confused and exaggerated, causing chronic, often excruciating pain that can last months- or even years. It is unclear what triggers this re-activation, causing shingles, but you are at higher risk as you age and if your immune system is suppressed (such as from medications or chemotherapy).

When you have shingles you might be at greater risk of developing Postherpetic Neuralgia as a result of:

• Age- You’re older than 50

• Severity of shingles- You had a severe rash and severe pain

• Other illness- You have a chronic disease, such as diabetes

Location of Shingles– You had shingles on your face or torso

Since it’s the varicella zoster virus, or chickenpox, shingles cause the same symptoms. There is a precursor of tingling in the area, followed by a burning sensation, then a red rash that turns into blisters that scab over and finally resolve. You cannot give shingles to anyone, but until there are no new lesions and those seen are scabbed over, you are still shedding the chickenpox virus and can infect anyone who has never had chickenpox.

If caught in the early stages, it can be treated with medications to diminish the outbreak and possible pain. See your healthcare provider at the first sign of shingles. Getting treated early can help it go away faster and may help you avoid related problems. For instance, shingles on the face can cause hearing or sight problems, including blindness.  Family members who have never had chickenpox should see a provider immediately to investigate getting the chickenpox vaccine to prevent an active infection. Since it’s only spread by the fluid in the blister itself, covering the area of concern while in public is sufficient to prevent transmission.

As we age, the potential for a residual, exceedingly painful persistence of the pain due to nerve damage after shingles, or Postherpetic Neuralgia, increases significantly. The CDC, (Center for Disease Control and Prevention), estimates that one in three people will get shingles in their lifetime and over half of those untreated will get Postherpetic Neuralgia after the age of 60.

If you’ve had shingles once, you probably won’t get it again. That doesn’t mean it can’t happen, it’s just unlikely. Experts don’t know exactly how many people get shingles more than once. They do know it comes back more often in people with weakened immune systems. It can also return a second, or rarely, a third time. In healthy individuals, your chances of having shingles again in the first several years are lower than it is for people who have never had shingles. Over time though, your chances of a second bout go up. One study found that within 7 years, the odds of getting it again may be almost 5%. That’s about the same as the odds of getting shingles the first time.

Who Is Most Likely to Experience Shingles Again?

You’re more likely to get it again if:

• You suffer from Postherpetic Neuralgia that caused severe pain from shingles lasting more than 30 days

• You are female

• You were age 50 or older when you had shingles the first time

• Your immune system is weak from conditions like cancer, or you take medicines that suppress your immune system

A shingles vaccine, Zostavax, was developed in 2006 to prevent this potentially devastating process. It uses a weak form of the chickenpox virus to send your body’s immune system into action to fight the disease. It lowers your chances of getting shingles by about 50% and your odds of long-term nerve damage by about 67%. At that time, the FDA recommends anyone over the age of 50 should get the vaccine (if there’s no contraindication, such as an allergy to the vaccine or those who take immune-suppressing medications) to significantly decrease the risk of getting shingles and ultimately, Postherpetic Neuralgia. Since Zostavax is a live virus, you should not get it if you are allergic to the vaccine, have a weakened immune system, will be around somebody with a weakened immune system, or are pregnant or thinking about becoming pregnant in the next 4 weeks.

Now, the CDC suggests getting the newer shingles vaccine, Shingrix. It was approved in 2017, and has been found to be up to 90% effective in preventing shingles and the complications caused by the disease. Even if you’ve already had shingles (wait until the rash has completely resolved), the CDC says the vaccine can help prevent a second event. Shingrix is preferred over the earlier vaccine, Zostavax, and is recommended even if you received the older vaccine- just wait at least 8 weeks since getting the Zostavax vaccine. You should not get the Shingrix vaccine if you are pregnant or nursing, allergic to the vaccine, or if you tested negative for immunity to chickenpox. If so, you should ask about the chicken pox (varicella) vaccine. Shingrix is given as a single dose and should be repeated in 2-6 months. It lasts for 5 years. Unfortunately, it is currently on back order. Talk to your pharmacy or health department about getting on a waiting list. According to the pharmacies I contacted, many insurances will cover the cost, but you may need a prescription.

The risk of Postherpetic Neuralgia increases with age, primarily affecting people older than 60. There’s no cure, but treatments can ease symptoms. For most people, Postherpetic Neuralgia improves over time. If you suffer from Postherpetic Neuralgia, or pain that has persisted for more than a month after having shingles, there are multiple treatments available. Some options include: anti-seizure pills that help with the neuropathic pain such as gabapentin, topical creams and patches, tens unit, anti-depressants, and anti-inflammatories- all can offer tremendous relief. I’ll discuss these options in more detail in later posts. For now, don’t give up, help is out there-ask your healthcare provider.

    -Dr. Courtney

-Main image provided by Everydayhealth.com

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