Alice*, 54, is about to become a grandmother for the first time — and it’s twins! Mandatory bed rest for Alice’s daughter tempers the excitement. Alice has been stressed having to assume the role of primary caregiver for her daughter. Yesterday Alice noticed a line of several weepy blisters on the right side of her neck and upper chest. She remembers having chickenpox as a child and wonders if the blisters could be shingles. She tells you, her nurse, that her daughter never had chickenpox and was not vaccinated against it. Alice asks you whether she should take any special precautions. She also asks about the new shingles vaccine as a possible treatment for her outbreak.

Seventy-six-year-old Mario* describes a persistent, intense burning pain on the left side of his abdomen that wraps around to the middle of his back. The pain has persisted even though the skin lesions associated with a recent outbreak of shingles disappeared five months ago. He asks you, “What can help my pain, and when will it go away?”

These are two scenarios are caused by the varicella virus, more commonly known as the chickenpox virus. Nearly 1 million Americans each year over the age of 50 who have had chickenpox will develop herpes zoster, also known as shingles, a viral infection easily identified by the telltale blisters, or vesicles, that usually appear on one side of the body.¹ Would you, the nurse, be able to answer these patients’ questions confidently? Would Alice or Mario be appropriate candidates for vaccination?

Out pox…out!

For adults, childhood diseases like chickenpox are merely a distant memory … right? However, the initial emergence of the varicella virus may be just the beginning of a long and painful recurring story. About one in five people who have had chickenpox will develop shingles sometimes in their lifetimes. Shingles equally affects all races and both sexes, and reactivation occurs throughout all seasons of the year.¹

After initial infection, the varicella virus remains dormant in the nerve roots in the spinal or cranial ganglia, where it may reactivate and emerge as a shingles outbreak. While shingles occurs most often among older adults, young adults and even infants can experience an outbreak, especially if they were exposed to chickenpox or herpes zoster during pregnancy.

The incidence of shingles is expected to increase as baby boomers age. But as children who received the varicella vaccine (in either a single-dose or two-dose vaccine series) reach adulthood, the incidence is expected to decline because the vaccine has been found to be 94.4% to 98.3% effective in protecting against initial varicella infection that must precede shingles.² People who are vaccinated may still develop shingles, but much less often than those who have experienced chickenpox.³

What to expect

Why some people who have had chickenpox are spared and others experience a reactivation of the varicella virus isn’t exactly known. What is known is that with advancing age, weakening of the immune system, or stressful conditions, shingles becomes more common. Immune compromise from HIV, cancer and associated treatment, or even the common cold can trigger an outbreak of shingles.

When the varicella virus reactivates, it travels along the sensory nerve fibers in the skin to areas that are linear in structure and referred to as dermatomes. The point of reactivation determines where on the skin the lesions will be seen and also provides a telltale sign of where the virus has lain dormant.

Some patients experience a pronounced prodrome period before a rash appears consisting of numbness, itching, or painful sensations. Others may only report a mild tingling sensation or nothing noticeable until the rash appears. This may be similar to the sensations before an outbreak of oral or genital herpes. Some patients experience fever, chills, headache, and upset stomach.

The rash accompanying shingles is very pronounced — clusters of fluid-filled blister-like lesions appear on a reddened base, usually on a single area of the body in a strip-like pattern that affects one side of the body.³ The blisters burst, crust over, and heal, a process that can take several days or weeks. At times, new blisters may appear while older ones have crusted over — especially if antiviral therapy initiation is delayed. The pain usually subsides, typically in three to five weeks.⁴ Rarely, patients with shingles will not have lesions or will have so few that they may go unnoticed, a condition known as zoster sine herpete.

Shingles is most often diagnosed based on the characteristic lesions and distribution alone; however, a sampling of fluid from the blisters or a blood test can provide laboratory confirmation of the diagnosis.

In the area with lesions, patients may experience allodynia, extreme discomfort to otherwise minimal stimulation such as a gentle touch, changes in temperature, or a draft.⁴ Some patients can’t even tolerate bedsheets and clothing. Depending on the location of an outbreak, shingles can bring more than just discomfort. When the varicella virus invades the cranial nerves, complications can be severe. An infection involving the optic nerve, ophthalmic herpes, can impair vision, cause inflammation or infection of the cornea, and lead to blindness. Facial nerve involvement can bring intense ear and facial pain, hearing loss, and facial paralysis known as trigeminal neuralgia. In rare instances, the virus can invade the brain and cause encephalitis.⁴

Ophthalmic complications are quite common, affecting from 10% to 25% of patients who develop shingles. The most common complications seen with shingles are keratitis and iritis, and both usually resolve with treatment. People who are immunocompromised are more likely to develop more serious complications, including infections of the retina or ophthalmic nerve. If prompt treatment is not initiated, vision loss and blindness may result.⁵ For this reason, patients with shingles in or near the eye should see an ophthalmologists immediately.⁶

Shingles infections may also occur in or around the ear, a condition known as Ramsay-Hunt syndrome. This may result in hearing or balance problems, increasing the risk for falls or other injuries.⁶

Most patients experience just a single outbreak of shingles, confined to a single dermatome on one side of the body. Some patients will experience recurrent episodes or episodes that involve more than one dermatome or appear bilaterally. When three or more dermatomes are involved, or a bilateral pattern is present, the patient has disseminated herpes zoster, a condition that should send up a caution flag prompting evaluation of underlying factors (such as immune disorders including HIV or leukemia).

A long-lasting misery

Like Mario, some people with shingles develop postherpetic neuralgia (PHN), an intensely painful complication in which the pain from shingles persists long after the rash has subsided.⁴ The pain from PHN can be so severe it leads to insomnia, weight loss, depression, and total preoccupation with finding relief.⁶ PHN is second only to diabetic neuropathy as the most common form of neuropathic pain. It’s difficult to treat and does not respond well to traditional medications prescribed for arthritis or orthopedic pain, because it is not musculoskeletal in nature.

It’s important to address the psychological as well as the physical symptoms of shingles. Because shingles can be intensely painful, disrupt activities of daily living, and have lesions that occur on highly visible areas of the body, patients may experience problems with depression, feelings of isolation, and disturbances of body image. Patients with a complicated course and those who develop PHN may benefit from referral to a mental health professional or support group to help them cope with this debilitating disorder.⁷

Risk factors for developing PHN include many of the factors that precipitate a shingles outbreak in the first place: psychological stress, advanced age, immunosuppression, physical trauma, the presence of lesions around the eye area, and undertreated initial pain. Patients who experience burning or stabbing pain before the onset of the rash or severe pain when the rash develops are also more likely to experience PHN as are people who are not treated with antiviral medications within 72 hours of the onset of the rash.⁸

Treatment options

Antivirals prescribed for a shingles outbreak include acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir). All three lessen the pain and duration of the rash, yet they may cause upset stomach, headache, vomiting, and diarrhea. Patients taking acyclovir and valacyclovir should be alert for adverse events including fever, confusion, hematuria, and yellow tint to the eyes or skin.⁹ Depending on prescriber preferences, dosage may vary for the antivirals, with acyclovir being prescribed as many as five times daily and valacyclovir and famciclovir being prescribed three times daily.⁹ (See “Antivirals Prescribed for Herpes Zoster” for the recommended dosing schedules.) Adherence concerns arise when multiple daily dosages are required, especially with acyclovir. But keep in mind that the newer antiviral medications valavyclovir and famciclovir, while dosed less frequently, are more expensive.

Treatment for PHN can include the anticonvulsant gabapentin (Neurontin), the tricyclic antidepressants amitriptyline (Elavil) or nortriptyline (Pamelor), and the extended-dose opioid pain medications oxycodone (OxyContin) or fentanyl (Duragesic patches). Combination therapy involving several medications is often necessary to provide adequate relief of symptoms because each medication works in a different way to control the pain of shingles. Anticonvulsants reduce the release of neurotransmitters that cause the neuralgia. Tricyclic antidepressants and opioid pain medications block pain perception by reducing the uptake of norepinephrine and serotonin.¹⁰

Gabapentin is usually prescribed three times daily, posing an adherence and convenience problem for some patients. The typical effective total daily dose is 1,800 mg, but upward titration is required when initiating therapy to reduce adverse effects including nausea, dizziness, ataxia, and somnolence.⁹ A weaning-off schedule is also recommended; abrupt discontinuation of gabapentin can cause palpitations, anxiety, insomnia, and diaphoresis.⁹

Tricyclic antidepressants (TCAs) are especially helpful in improving patients’ sleep and reducing the depression that often accompanies a chronic pain syndrome. TCAs can cause anticholinergic adverse effects, including postural hypotension, dry mouth, and constipation.

While highly effective in providing pain relief, opioids can cause sedation, nausea, constipation, and loss of appetite. Some patients may also have concerns about using a “narcotic” pain medication; explain that when strong pain medication is indicated and properly used, addiction is quite rare. An evidence-based guideline on neuropathic pain diagnosis and treatment can be accessed at: www.guideline.gov/summary/summary.aspx?doc_id=4671&nbr=3405.

The adverse effects from oral medications may cause some patients to seek alternative pain relief. Transdermal lidocaine patches and capsaicin cream are options. While effective for some patients, each has limitations.

Lidocaine (Lidoderm) patches target pain by “numbing” the nerves causing the pain. There is minimal systemic absorption when the patches are used as directed for 12 hours a day. Extended use or use of more patches than prescribed at one time can result in lidocaine toxicity, with symptoms including changes in level of consciousness, seizures, bradycardia, hypotension, and diplopia. Remind patients to follow package directions carefully, especially to never apply the patches directly to open lesions or breaks in the skin and to not cut patches into smaller sizes before applying them. The patches are expensive and may not be an option for some patients.

Capsaicin creams (Capsin, Zostrix) contain a numbing extract from peppers. While often providing relief of the painful postherpetic sensations, they can be irritating to the skin initially and may cause a burning sensation or a rash for sensitive patients.⁸ Caution patients not to apply capsaicin cream to open lesions or broken skin. Additionally, patients should be cautioned to wash their hands thoroughly after applying the product and before touching mucous membranes or their face, especially near the eyes.

Some patients may experience relief with nonpharmacologic modalities, including acupuncture, biofeedback, injected nerve blocks, and transcutaneous electric nerve stimulation (TENS).¹¹ Activities the patient finds pleasurable and relaxing, such as listening to music, may provide diversion and stress relief. When the pain from shingles is prolonged or the patient appears not to be coping well with the diagnosis, screening for depression and intervening with psychotherapy may be beneficial.

At last … a vaccine!

The FDA recently approved Zostavax (zoster vaccine live) to reduce the risk of reactivation of the varicella zoster virus that causes shingles.¹² Available as an injectable vaccine delivered into the upper arm, Zostavax is administered as a single dose given to people age 60 and older. The vaccine reduces the risk of reactivation of the varicella virus that typically lies dormant after an earlier infection of chicken pox. While no vaccine is 100% effective, research with Zostavax has shown that even people over 70 who develop shingles despite vaccination experience less-frequent PHN.¹³

The most common adverse reactions are pain and tenderness at the injection site. Some patients experience headache. More serious, but less common, adverse allergic-type reactions may include hives, difficulty breathing, and swelling of the face or lips. Before administration, be sure to ask about allergies to neomycin because this is a contraindication to vaccination.¹³

Because Zostavax is a live vaccine, it must not be given to people with compromised immune systems associated with radiation or chemotherapy treatments, cancer, AIDS, or corticosteroid use. Zostavax is not a substitute for the varicella vaccine (Varivax) given to children and younger adults, nor is it a treatment option for an active shingles outbreak. Patient monitoring includes observing for vaccine site discomfort, fever, and allergic reactions.¹³

In one study of over 38,000 patients, half of whom were vaccinated and half who were not, the vaccine was shown over a three-year period to reduce the incidence of shingles by 51%. Of the 315 people who did develop shingles after vaccination, 61% reported a reduction in pain, and the number of people progressing to PHN decreased over 66%.¹⁴ Evidence-based guidelines detailing vaccination for shingles can be found at www.guideline.gov/summary/summary.aspxdoc_id=10198&nbr=005379&string=shingles.

How nurses can help

Even though the skin lesions are confined to a relatively small area of the body, an outbreak of shingles can cause a person to feel quite ill. Patients are often surprised at how much discomfort and misery they may experience and how shingles, and especially PHN, may affect their daily routine. Remind patients with shingles and PHN to pace themselves and rest adequately, especially if they have underlying compromise of their immune systems. Research has confirmed that outbreaks are more likely to occur when the body is rundown and the mind stressed.^1,4 One study revealed that t1ai chi, a traditional set of guided, controlled slow movements from China, performed three times weekly, not only reduced the incidence of shingles outbreaks but also increased immunity and health functioning, especially among older adults.¹⁵ Promoting a healthy lifestyle — encouraging physical activity and adequate rest, and reducing stress — is crucial for the patient who harbors the varicella zoster virus.

Patients prescribed TCAs and opioids should be encouraged to stay well hydrated, select high-fiber foods, and if necessary use a fiber laxative or stool softener to avoid constipation, unless such measures are contraindicated by other conditions. TCAs are potentially lethal in overdose, so carefully assess the patient with PHN for suicidal ideation and promptly refer the patient for treatment if needed. TCAs can also cause drowsiness, dizziness, and blurred vision, increasing the risk for falls.¹⁰

While shingles itself is not contagious, close exposure can pass the varicella virus to others, causing an initial episode of chickenpox. Educate patients with open shingles lesions, like Alice, to reduce exposing others, especially unvaccinated, immunocompromised, or pregnant individuals who never had chickenpox.¹⁶ The virus can be transmitted until scabs have formed over all the blisters. Teach and reinforce good hand hygiene as open blisters can transmit virus from hands to eyes or mucous membranes.

Patients may experience profound itching before, during, and after a shingles outbreak. The temptation to scratch may be great; however, scratching should be strongly discouraged and measures to protect the skin and reduce the risk from bacterial infection are important. When lesions are open, soothing oatmeal baths, painted-on topical lotions (such as calamine or diphenhydramine [Benadryl]), and application of washcloths with cool water may provide some relief. Compresses soaked with Domeboro astringent and gel from the aloe vera plant may also relieve itching and pain. Remind patients to check with their prescribing professional before adding over-the-counter oral or topical remedies to their treatment plan.

Patients may become anxious when they pick up their antiviral prescription from the pharmacy and read the information related to genital herpes on the product insert. Remind patients that while shingles is caused by a herpes virus, it is not the same virus that causes common oral or sexually transmitted genital herpes. Shingles is not sexually transmitted.¹⁶

Nurses can play a vital role in educating the public about shingles, especially about early recognition and treatment to reduce complications and exposure to others. Promoting healthy behaviors and encouraging vaccination, unless contraindicated, will contribute to a declining incidence of shingles outbreaks. Now that an effective vaccine is available, nurses should encourage patients over age 60 to discuss vaccination with their prescribing healthcare provider. For patients who are not candidates for vaccination, such as Alice and Mario, and those who develop shingles despite vaccination, nurses can offer education and comfort measures, and play a supportive role for patients with shingles and PHN.