Chickenpox, herpes zoster, and understanding the shingles vaccine

Chickenpox was all the rage back in the day.  Oatmeal baths with your siblings, unexplained weekday sleep-overs with pox-laden, peripheral childhood friends.  Even the sweet but short-lived relief of itching and scratching made the week-long infectious endeavor, if anything, a pleasant respite from the doldrums of early childhood.

Unfortunately for a handful of us unsuspecting chickenpox veterans, the infection that we so fondly include in our potpourri of childhood nostalgia will someday shape-shift into our most evil adulthood nemesis: shingles.

Whereas chickenpox is a household concept to many of us (at least to those of us who missed out on the varicella vaccine introduced to the U.S. in 1995), shingles occur much less frequently and often much later in life.

That being said, it’s worth covering the topic of shingles, not only because of it’s fascinating clinical presentation, but also because of the fact that diagnosing it and thus treating the condition earlier can shorten its duration and help prevent its potential complications.

Varicella zoster virus

To understand shingles, one must understand the virus that causes it.

Both chickenpox (varicella) and shingles (herpes zoster) are both manifested from a single virus: the varicella zoster virus (VZV).  This virus is unique in that it has the capacity to cause two very distinct forms of clinical disease in the same infected person throughout his or her lifetime.

VZV is a highly contagious virus and transmission occurs both via indirect contact with aerosolized droplets and by direct contact with someone experiencing chickenpox.

According to the NIH Conference on VZV some years ago, an individual without prior exposure to VZV has over a 90% chance of becoming infected with the virus if they live in the same household with someone with active chickenpox.

Chickenpox is the hallmark disease that occurs as a result of a primary infection of VZV.  While this predominantly childhood condition is an interesting subject in itself, the remarkable part of the evolution of a VZV infection really occurs in the events that follow.

From chickenpox to shingles

Although the memory of having chickenpox was not an unpleasant one, the actual skin findings of chickenpox are pretty nasty; red, fluid-filled mini-blisters from head-to-toe that itch like crazy.  What’s worse is knowing that the fluids in these vesicles are chock-full of replicating VZV.  From these vesicles, the virus makes way to the skin’s nerve endings, travels down deep into the body’s nervous system, and settles there for the duration of the infected host’s lifetime.  Admittedly, a foul and unsettling notion.

This asymptomatic stage of the infection is called the latent stage, where the virus remains relatively dormant for years and years without producing any clinical signs of disease.  Fortunately, the majority of VZV-infected individuals out there will live the rest of their lives unperturbed by this uninvited live-in guest.

Nevertheless, as is the potential for any unscreened roommate to wreak havoc at the homestead, a good percentage of us will experience quite the falling out with this virus once it reactivates into an active infection known as shingles.

You have shingles

Once fully expressed, the clinical characteristics of a classic case of shingles are so identifiable that often no lab test is needed to make the diagnosis.

Here’s a quick summary of the most common presentation of shingles:

  • Most patients with reactivated VZV will experience days to weeks of burning pain in the area of affected skin prior to the typical rash.
  • Within 3-4 days, a blistery, infectious and painful rash emerges in a very unique distribution on the skin.  The rash typically presents itself on only one of half of the body, and these streaky patches correspond with discreet areas of skin that are often innervated by a single infected nerve root. Commonly, these rashes form on the chest and/or back but can present anywhere on the body.
  • After a week or so of this angry-looking rash, the vesicles begin to crust over, become less painful, and are no longer infectious

Sounds awful.

So are all of us with a history of chickenpox at risk for shingles?

Don’t shoot the messenger, but yes.

According to a 2006 report conducted by the Advisory Committee on Immunization Practices (ACIP), up to 32% of us will experience shingles at some point within our lifetimes.

Although anyone at any age with a post-primary VZV infection can get shingles, individuals that suffer from immune problems are at a much higher risk for VZV reactivation.  This is due to the fact that their immune systems have more trouble suppressing the infection than those with normal immune function.

Along this same line of reasoning, the geriatric population is also at a higher risk for reactivation due to the physiologic waning of VZV-specific immunity.

Take home point

Most episodes of shingles, albeit painful and less than pleasing to the eye, are self-limiting.  Nevertheless, complications (prolonged pain syndromes, secondary bacterial infections, even loss of vision if the rash extends to the eye) are not uncommon, and practitioners should be quick to treat shingles with at least a solid week of antiviral therapy to help prevent these complications from occurring.

For those of you 50 years and older, I will end this pseudo-public awareness piece with some good news: A herpes zoster vaccination is currently available that, when administered appropriately, can significantly reduce your chances of getting shingles.

Trust me, it’s worth a shot.

Brian J. Secemsky is an internal medicine resident who blogs at The Huffington Post.  He can be reached on Twitter @BrianSecemskyMD.

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  • aabxy

    Here in Norway a few years ago, it was announced that the shingles vaccine Zostavax was to be approved soon. And in due time, I heard that it was. I did my best to get the vaccine. But no doctor or nurse seemed to have heard of this vaccine, even specialists in relevant areas, whom I would expect to be the first to know about it.

    Then a few months ago, I read that although the vaccine had been approved in Norway, it had not yet become available (not been imported, apparently?) here. My later searches regarding the availability of the varicella zoster vaccine Zostavax (and more recently the alternative Varilrix) have been equally fruitless.

    I am glad our kids are vaccinated, but I have never wanted to drop vaccinations in adulthood. I am in my early sixties. I have always done my best to get the available vaccines/boosters for most of the diseases which have been reported in our part of the world. (There have been four exceptions, but I had to be given a good reason each time.) One doctor exclaimed that “you want all the vaccines that exist!” (That was slightly exaggerated.) In some cases I had to do considerable detective work and sometimes argue to get a particular vaccine or adult booster vaccine. But sometimes, the public health services here do a turnabout a few years later and start RECOMMENDING that particular vaccine or booster for adults. Well, better late that never!

    But the varicella zoster vaccine remains unavailable here, it appears. More than frustrating!

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    This was a very good article. Thanks for sharing it. I now have a question. You mentioned that for those that are 50 and older that they should get the shingles vaccine, but what about those that are in their 40s that have had chickenpox as a child. The reason I ask this is because I am wondering if this is going to be something that I need to talk to my PCP about in the future as I had chickenpox when I was 16.

    • Brian Secemsky, MD

      I am unaware of any studies comparing the age of contracting chickenpox with the age of developing shingles. Therefore, I’d treat your case as I would with myself and most of the readers here who had chickenpox in the past: because shingles tends to present itself later in life, I would seek the zoster vaccine when in the recommended age group (>50). Kristy, thanks for reading.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Thank you for the reply back. This gives me additional information to ask my doctor about when I see him next.

  • NormRx

    A word to the wise for people on Medicare, especially Medicare advantage programs The price of this vaccine varies widely, depending on where you get it. Check the price at the pharmacy, make sure you go to a network pharmacy. Some plans might let you get it from your doctor. Check with your plan provider and document the answer, it could save you a hundred dollars.

  • wiseword

    I had a mild case of shingles (forgot to get the vaccine), took the anti-viral meds and it cleared up. Then, two doctors disagreed: one said I still l should get the shot, the other said I didn’t need it. Which is right ?

    • Brian Secemsky, MD

      Excellent question. Most individuals, including yourself, who have had shingles in the past are unlikely to re-experience another episode in the future. That being said, a very small percentage (think <5%) can get recurrent episodes; however most of these patients have some element of poor immune systems and/or an infection with a different type of virus in the same family as VZV. Therefore, it's really judgement call as opposed to a specific standard of care (a weak answer, wiseword, but its all I have for you at the moment) Thanks for taking time to read the article.

      • wiseword

        Thank you. A lot of medicine is pretty iffy, so one might as well choose an answer that appeals. Assume I’m immune, no shingles shot.
        wiseword

  • Chriss

    Is there a way to prevent herpetic encephalitis if you know you carry a latent virus? (this killed my grandmother so it’s worth an inquiry)