Shin­gles pain can linger af­ter rash dis­ap­pears

The Middletown Press (Middletown, CT) - - YOUR DAILY BREAK - Robert Ash­ley

DEAR DOC­TOR >> I’m a 78-yearold woman who de­vel­oped shin­gles in De­cem­ber 2014. The rash set­tled in the nerves on my left side, from un­der the breast, to the waist and around the mid­dle of my back. Is there any­thing I can take to ease the pain? Would the vac­cine help?

DEAR READER >> Shin­gles is a re­ac­ti­va­tion of the her­pes zoster virus — the virus that causes chick­en­pox. When peo­ple con­tract chick­en­pox, usu­ally as chil­dren, the virus makes its way along their sen­sory nerves, end­ing up at the nerve cells along the spine. The virus then sits within the cells in a dor­mant state. It can stay there for the rest of a per­son’s life and not cause prob­lems, with the body’s im­mune sys­tem keep­ing the virus in a dor­mant state.

How­ever, when im­mu­nity de­creases, the virus can repli­cate within a nerve cell, fol­low­ing a par­tic­u­lar nerve path­way to the skin and cre­at­ing a rash along that path­way. The most com­mon risk fac­tor for de­vel­op­ing shin­gles is age, with 80- to 89-year-olds hav­ing 10 times greater risk com­pared with those 10 years old and younger.

The nerve pain cre­ated by shin­gles can be very se­vere and can per­sist even af­ter all the le­sions have dis­ap­peared. The pain can be burn­ing, sharp or stab­bing and can worsen with even the light­est touch. When the pain lasts for more than four months, the di­ag­no­sis is termed “pos­ther­petic neu­ral­gia.” That’s the pain syn­drome you have.

There are many med­i­ca­tions for pos­ther­petic neu­ral­gia. Tri­cyclic an­tide­pres­sants like amitripty­line, nor­tripty­line and de­sipramine work to de­crease pain sig­nals from the skin to the cen­tral ner­vous sys­tem. How­ever, they’re of­ten not well-tol­er­ated in older pa­tients and can lead to se­da­tion, dry mouth and wors­en­ing mem­ory. They would not be my first choice for you.

Gabapentin (Neu­ron­tin) and pre­ga­balin (Lyrica) work di­rectly through the nerves to de­crease pain. Gabapentin causes much more drowsi­ness com­pared to pre­ga­balin, so many of my pa­tients who have dif­fi­culty sleep­ing at night due to the pain of pos­ther­petic neu­ral­gia do well with it. How­ever, be­cause peo­ple with symp­toms that also oc­cur dur­ing the day of­ten can’t tol­er­ate the se­dat­ing ef­fects of gabapentin, I switch many of these pa­tients to pre­ga­balin; although this drug can cause drowsi­ness, it is bet­ter tol­er­ated. The anti-seizure drug val­proic acid also can sig­nif­i­cantly de­crease pain.

Cap­saicin, the ac­tive com­po­nent of chili pep­pers, is known for ir­ri­tat­ing the sen­sory nerves, but per­haps re­mark­ably, can lead to pain re­lief when used in cream form for those with pos­ther­petic neu­ral­gia. Note that you must ap­ply cap­saicin mul­ti­ple times per day, and for many peo­ple, the burn­ing, sting­ing sen­sa­tion is in­tol­er­a­ble.

Opi­ates also can re­lieve the acute pain, but when used long-term, they can cause tol­er­ance and ad­dic­tion.

As for the vac­cine, although you had shin­gles more than two years ago, it could still re­duce the risk of fu­ture episodes. How­ever, no vac­ci­na­tion stud­ies have been done in pa­tients who have al­ready had shin­gles, so the po­ten­tial ben­e­fit is un­clear. In ad­di­tion, the vac­cine won’t re­duce your cur­rent nerve pain.

In sum­mary, I rec­om­mend speak­ing to your doc­tor about med­i­ca­tions like gabapentin or pre­ga­balin and whether to get the shin­gles vac­cine to per­haps de­crease the risk of fu­ture episodes.

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