Shingles and Chickenpox (Varicella-Zoster Virus)

Description

Alternative Names

Treatment for an Acute Shingles Attack

The treatment goals for an acute attack of herpes zoster include the following:

• Reduce pain.
• Reduce discomfort.
• Hasten healing of blisters.
• Prevent the disease from spreading (disseminating).

Over the counter remedies are often effective in reducing the pain of an attack. Antiviral agents (acyclovir and others), oral corticosteroids, or both are sometimes given to patients with severe symptoms, particularly if they are older and at risk for postherpes neuralgia. In addition, psychologic therapies aimed at coping and reducing the effects of pain may be useful.

Home Remedies for Shingles

Applied Cold. Cold compresses soaked in Burrow's solution and cool baths may help relieve the blisters. It is important not to break blisters, which can cause infection. Experts advise against warm treatments, which can intensify itching. Patients should wear loose clothing and use clean loose gauze coverings over the affected areas.

Itch Relief. In general, to prevent or reduce itching, home treatments are similar to those used for chickenpox. Patients can try antihistamines, particularly Benadryl, oatmeal baths, and calamine lotion.

Over-the-Counter Pain Relievers. For an acute shingles attack, patients may take over-the-counter pain relievers, including the following:

• Children should take acetaminophen.
• Adults may take aspirin or other nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil). Such remedies, however, are not very effective for postherpetic neuralgia.

Nucleoside Analogues and Other Anti-Viral Drugs

Nucleoside Analogues. The best class of drugs developed against varicella-zoster are those known as nucleoside, or guanosine, analogues, which are able to block viral reproduction. None of these agents can actually destroy the virus and cure the disease, but they can significantly reduce the severity of the attack, hasten healing, and reduce the duration. There is some evidence that early treatment (within 72 hours) with these agents can reduce the risk for postherpetic herpes.

Acyclovir (Zovirax), famciclovir (Famvir), and valaciclovir (Valtrex) are approved for shingles. Acyclovir is the oldest most studied of these drugs, but famciclovir (Famvir) or valaciclovir (Valtrex), which are both metabolized into acyclovir, are now preferred for herpes zoster for most patients. They relieve symptoms better than acyclovir and require fewer daily doses (typically three) than the five doses needed with acyclovir.

Because herpes zoster tends to resolve fairly quickly in young adults, these drugs are generally reserved for patients at greatest risk for complications or persistent pain. They include the following:

• Elderly people.
• Those with infections that threaten the eye.
• Patients who are HIV positive or immunocompromised in other ways.
• Patients whose infection covers a larger-than-average surface area of the skin.
• Those with very severe pain.

Anti-viral agents are usually taken for seven days. Ideally they should be started within 72 hours of the onset of infection. The earlier they are given the more effective these agents are, but they can be helpful even if treatment is started after three days. Combinations of antiviral therapy with other drugs, such as tricyclic antidepressants or anti-seizure agents are under investigation.

These agents appear to have little or no harmful effect on healthy cells and can penetrate most body tissues, including cerebrospinal fluid. Evidence to date suggests that they are safe during pregnancy.

Possible side effects and complications of all nucleoside analogues include:

• Rash.
• Headache.
• Fatigue.
• Tremor.
• Nausea and vomiting.
• Seizures (very rarely).
• Complications of intravenous administration, which is used for AIDS and other immunocompromised patients, include an increased risk for kidney damage and blood clots at the injection site.

As with antibiotics, physicians are concerned about signs of increasing viral resistance to acyclovir and similar drugs, particularly in immunocompromised patients (such as those with AIDS).

Brivudin. Brivudin (Helpin, Zostex) is another anti-viral agent of note that only needs to be taken once a day and is proving to be as effective as the standard agents. It is not yet available in the US. Studies suggest that it as at least as effective as the standard agents. It is also only needs to be taken once a day, which improves compliance.

Foscarnet. Foscarnet (Foscavir) is a powerful antiviral agent known as a pyrophosphate analogue. It is used in cases of VZV strains that have become resistant to acyclovir and similar drugs. Administered intravenously, the drug can have toxic effects; it can impair kidney function (which is reversible) and cause seizures. Fever, nausea, and vomiting are common side effects. It can also cause ulcers on genital organs. As with other drugs, it does not cure shingles.

Oral Corticosteroids

Oral corticosteroids, including prednisolone or prednisone, are powerful anti-inflammatory medications. They have some benefit for reducing pain and accelerating healing in acute attacks when used with acyclovir. (They are not recommended without acyclovir.) They also may be helpful for improving symptoms of Bell's palsy and Ramsay Hunt syndrome. Corticosteroids do not appear prevent a further attack or reduce the risk for PHN. Side effects of corticosteroids can be severe and oral steroids should be taken at as low a dose and for as short a time as possible. (Injected or intravenous steroids, however, may offer specific relief for PHN without significant side effects.)

Epidural Blocks

Epidural blocks are injections of local anesthetics or steroids outside the tough membrane surrounding the spinal cord (the dura matter). The injected substances block the nerves and offer relief from acute herpes zoster pain for some people. Some studies, but not all, have indicated that if they are administered early enough (within two months), they may prevent nerve damage that leads to postherpetic neuralgia. Combinations of anesthetics with steroids in the epidural blockade may be particularly beneficial. This procedure is invasive, however, and is not widely used.