Myths and Facts: Shingles

PEOPLE OFTEN DESCRIBE shingles as the most unbearable pain ever experienced — pain they wouldn’t wish on their worst enemies. Its symptoms include a mix of electrical shock and small needles against the skin, accompanied by muscle pain and exhaustion. People with shingles find it extremely painful to wear clothes, and they can’t tolerate being touched.¹

Also known as herpes zoster, shingles is an infection of an individual nerve and the skin surface that is supplied by that nerve. It is caused by varicella-zoster virus (VZV), the same virus that causes chickenpox. Once a person is exposed to VZV, the virus can lay dormant in the body for years.²

Today, almost one in three people in the U.S. will develop shingles during his or her lifetime, with an estimated one million cases each year.³ While shingles is uncommon in children, it can occur at any age, with approximately one million cases of pediatric shingles occurring in the U.S. each year.⁴ And, the older one gets, the higher the risk of getting shingles. In fact, a person’s chance of getting the virus increases with each passing year, especially after age 40. According to the National Institute of Neurological Disorders and Stroke, a person who is 60 years old is 10 times more likely to develop shingles than a child who is 10 years old.⁵ In fact, half of the population who lives to 85 years of age will experience shingles during their lifetime.⁶ In addition, approximately 1 percent to 4 percent of people with shingles, many of whom are older adults and 30 percent of whom have a weakened or suppressed immune system, must be hospitalized for complications.³

Unfortunately, shingles is increasing among adults in the U.S., and this upturn has been gradual over a long period of time.³ Therefore, it is important people understand the many myths and misconceptions surrounding the illness.

Separating Myth from Fact

Myth: Shingles is the same as chickenpox.

Fact: Shingles and chickenpox are both caused by VZV, which belongs to a group of viruses called herpes (this is why shingles is also known as herpes zoster). However, shingles and chickenpox are not the same illness. Chickenpox is a milder illness that mainly affects children, while shingles results from reactivation of the virus. After a person recovers from chickenpox, the virus remains dormant in the body’s central nervous system. But, under the right circumstances, the herpes zoster virus can reactivate and travel down nerve fibers. While the causes of reactivation are unclear, it is believed to happen when something weakens the immune system. Possible triggers could include older age; other diseases such as cancer, human immunodeficiency virus (HIV) or AIDS; cancer treatments such as chemotherapy and radiation therapy that lower a person’s resistance to disease; stress or trauma; medications (especially immunosuppressive drugs) used to treat patients after an organ transplant; and children who had chickenpox in infancy or whose mothers had chickenpox late in pregnancy.^2,6

Myth: Only elderly people get shingles.

Fact: It is true people’s risk of getting shingles increases as they get older, but anyone at any age can get it. Currently, about half of all shingles cases occur in people over age 60 years, which means the other 50 percent occurs in younger individuals. In fact, the incidence of shingles in those younger than 60 years old seems to be on the rise, although the cause is unknown. According to Niket Sonpal, MD, an assistant professor of clinical medicine at Touro College of Osteopathic Medicine in New York City, people whose immune systems are compromised due to a condition such as HIV or taking immune-suppressing medication to keep them from rejecting a transplanted organ are certainly at greater risk.⁷

A recent study shows a cancer diagnosis of any kind, which can occur in any age group, is associated with an approximately 40 percent increase in risk for developing shingles compared to those without cancer. The large prospective study expanded on previous research by examining therisk of shingles before and after a newcancer diagnosis and across a range of cancer types among approximately 240,000 adults in Australia from 2006 to 2015. Patients with a blood-related, or hematological, cancer diagnosis had a more than three-fold higher risk of developing shingles than people without cancer. And, individuals with a diagnosis of cancer related to a solid tumor had a 30 percent higher shingles risk compared to someone with no cancer. The study also found the higher risk for shingles among patients with blood cancers was present in the two years before their cancer diagnosis. However, for patients with solid tumors, the higher risk of developing shingles appeared to be largely associated with receiving chemotherapy after their diagnosis, rather than the cancer itself.⁸

Older adults are more prone to herpes zoster ophthalmicus (HZO) (occurring when shingles gets in the eyes) that can lead to corneal scarring and blindness. According to research at the Kellogg Eye Center in Vancouver, Canada, occurrences of HZO among a group of 21 million adults tripled during a 12-year period, occurring in 9.4 cases per 100,000 people at the beginning of the study period and growing threefold to 30.1 cases per 100,000 by the end of the study period. The study also showed HZO may be more of a problem for women and adults over age 75 (53 cases per 100,000).⁹

Myth: People who have never had chickenpox can’t get shingles.

Fact: Because shingles is caused by a reactivation of the chickenpox virus, it would make sense that if people haven’t had chickenpox, they can’t get shingles. However, getting the chickenpox (varicella) vaccine exposes people to the virus that causes both chickenpox and shingles. “The varicella vaccine is a live, attenuated virus, so if you’ve gotten it, you have the virus in your body, same as if you’d had chickenpox,” said Richard Lorraine, MD, a shingles specialist and researcher in Harleysville, Pa. In short, the vaccine makes people immune to chickenpox, but it leaves people at risk for shingles. Unfortunately, no one knows what the odds of shingles are in this case since the varicella vaccine is only 20 years old.⁷

Myth: The increase in shingles cases is caused by the chickenpox vaccine.

Fact: It has been suggested that since the chickenpox vaccine boosts a person’s immunity to VZV and reduces the risk of VZV reacting as shingles, then fewer children with chickenpox could theoretically lead to an increase in shingles in adults. However, research conducted by the Centers for Disease Control and Prevention (CDC) counteracts that theory, which found 1) shingles rates started increasing before the chickenpox vaccine was introduced in the U.S., and 2) shingles rates did not occur faster after the routine chickenpox vaccination program started. Increases in shingles has also been occurring in other countries without routine chickenpox vaccination.³

What’s more, the rate of shingles in children in the U.S. has been declining since the routine chickenpox vaccination program began. This is because the varicella vaccine is a weakened strain of VZV, which is less likely to reactivate as shingles than the wild-type VZV. Therefore, since children are less likely to become infected with wild-type VZV, they are at a much lower risk of shingles.³

Myth: Shingles is contagious.

Fact: VZV can spread from a person with active shingles and cause chickenpox in someone who had never had chickenpox or received the varicella vaccine; however, shingles itself cannot be passed from one person to another. Furthermore, VZV from a person with shingles is less contagious than the virus from someone with chickenpox. However, there are some individuals who are more susceptible to infection, including people who have medical conditions that keep their immune systems from working properly such as certain cancers like leukemia and lymphoma, HIV, and those who receive drugs that keep their immune systems from working properly such as steroids and drugs that are given after organ transplantation.¹⁰

During the blister phase of shingles, VZV can spread through direct contact with fluid from the rash blisters. It is not infectious before blisters appear or once the rash crusts. To avoid infecting another person with VZV during the blister phase, CDC recommends covering the rash, avoiding touching or scratching the rash, washing hands often, and avoiding contact with the following individuals until the rash crusts:¹⁰

• pregnant women who have never had chickenpox or the varicella vaccine;
• premature or low birth weight infants; and
• people with weakened immune systems such as those receiving immunosuppressive medications or undergoing chemotherapy, organ transplant recipients and people with HIV infection.

Myth: Rash is the biggest complication of shingles.

Fact: While rash is the defining characteristic of shingles, it is by far not the most troubling complication. Rather, pain associated with shingles that can begin two days to four days before the rash and last sometimes up to a year or more can be severe. Pain lasting after the rash is known as postherpetic neuralgia (PHN), which occurs when the damaged nerve sends impulses to the brain coded as “throbbing pain.” PHN is often described as burning, stabbing, throbbing and/or shooting pain. In addition to pain, other symptoms include long-term nerve pain, fever, headache, chills, upset stomach, muscle weakness, skin infection, scarring and decreased or loss of vision or hearing.^6,7 As mentioned previously, shingles can get into the eyes, which can lead to corneal scarring and blindness.⁹

Myth: There is nothing people can do to avoid getting shingles.

Fact: Vaccination is the best way to avoid getting shingles. This means children should receive the chickenpox vaccine, and adults should receive one of the two U.S. Food and Drug Administration-approved shingles vaccines: zoster vaccine live (ZVL, Zostavax), which has been in use since 2006, and recombinant zoster vaccine (RZV, Shingrix), which has been in use since 2017 and is recommended by the CDC’s Advisory Committee on Immunization Practices as the preferred shingles vaccine.¹⁰

Researchers at the Kaiser Permanente Center for Health Research found children who receive the varicella vaccine are significantly less likely to contract pediatric shingles. In the study, the researchers looked at the incidence rates of herpes zoster (shingles) overall per 100,000 person-years, including by age and gender. “We saw the highest rates of herpes zoster in the early years of the study, when there was a higher proportion of children, particularly older children, who had not received the varicella vaccine,” said Sheila Weinmann, PhD, lead investigator of the study. What’s more, the researchers found the rate of herpes zoster among children who were unvaccinated climbed from 2003 to 2007 and then declined sharply through the end of the study period (perhaps related to the introduction of the second vaccine dose beginning in 2007). And, increasing rates of vaccination over the study period reduced the risk of contracting herpes zoster overall for all children, including those who were unvaccinated.⁴

In adults, CDC recommends healthy adults age 50 years and older receive two doses of RZV to protect against shingles and its complications, and those age 60 years and older receive either RZV or ZVL, although RZV is preferred.⁶ A systematic review of clinical studies conducted in 2018 involving more than two million patients aged 50 years and older found RZV 85 percent more effective in reducing shingles cases than ZVL, but it also carried a 30 percent greater risk of site-adverse events such as redness or swelling. However, there were no statistically significant differences between the two vaccines for serious adverse events and deaths.¹¹

Myth: People can’t get shingles if they’ve been vaccinated against it.

Fact: While the shingles vaccine greatly reduces the risk of getting shingles, it doesn’t drop the odds to zero. Instead, it reduces the risk by about 50 percent and significantly reduces the chance of serious complications. The vaccine’s protection lasts approximately five years, which is why CDC recommends individuals 60 years and older get vaccinated.⁷

Myth: People can get shingles only once.

Fact: While shingles doesn’t recur in most people, it can come back a second and, rarely, a third time. In the first several years, chances of shingles recurring are lower than it is for people who have never had shingles. But, over time, chances of a recurrence go up. One study found that within seven years, the odds of a recurrence may be almost 5 percent, which is about the same as the odds of getting shingles the first time. Recurrence most often occurs in people with weakened immune systems. But, recurrence also occurs in people with healthy immune systems who are female and/or who had severe pain from shingles that lasted more than 30 days. If shingles does recur, it is likely to return in a different part of the body. For instance, if a person had it on the right side of the stomach, it might come back on the left side or on the face, chest, neck or back.¹²

Myth: There is no treatment for shingles except enduring the course of the virus.

Fact: The severity and length of a shingles outbreak can be reduced if an antiviral drug is prescribed within the first three days of an outbreak. Antiviral drugs include acyclovir (Zovirax), famciclovir (Famvir) and valacyclovir (Valtrex). In addition, medicines can be prescribed to help lessen the pain such as:

• Lidocaine skin patches that can be worn on the affected area;
• 8 percent capsaicin (an extract of chili peppers) skin patches;
• Anti-seizure drugs such as gabapentin (Neurontin, Gralise, Horizant) and pregabalin (Lyrica);
• Antidepressants such as duloxetine(Cymbalta) and nortriptyline (Pamelor); and
• Opioid painkillers.¹³

Lastly, symptoms can be eased by keeping the rash dry and clean to reduce the risk of infection, wearing loose-fitting clothing for comfort, avoiding rub-on antibiotic creams or adhesive dressings that can slow the healing process, and using products such as Calamine lotion to soothe and relieve itching.²

Dispelling the Myths Now

The National Institute of Neurological Disorders and Stroke currently funds and conducts research on a wide range of neurological disorders such as shingles to understand their causes and to develop and improve ways to diagnose, treat and prevent them. Medical research on shingles has two main goals: 1) to develop drugs to fight the disease and to prevent or treat its complications, and 2) to understand the disease well enough to prevent it, especially in people at high risk. To achieve these goals, more needs to be learned about VZV and its effects, including how it becomes latent in nerve cells, what induces it to become active again and how such reactivation can lead to PHN and other complications.

In addition, clinical trials involving the zoster virus and PHN may lead to better understanding of shingles and identify potential treatments. These studies are in need of both healthy individuals and people with disorders to advance the understanding of diseases and how to treat them.¹⁴

While studies of shingles and ways to prevent and treat it continue, the established facts about the virus can help individuals to better protect themselves against it and its complications, as well as how to treat it should they be one of the growing number of adults affected.