Dr. Clif CleavelandIntensifying pain began in the 50-year-old man's right lower abdomen. Concern about possible appendicitis prompted a visit to an emergency room. Blood work was normal, as was an ultrasound of his lower abdomen. He returned home with instructions to return if the pain persisted or worsened. The next morning, a pink rash developed in the area of pain, soon to be followed by the development of numerous tiny, fluid-filled bumps. An anti-viral medication eased the pain, and the rash resolved within two weeks.
Diagnosis: shingles or herpes zoster.
Pain in the left midfacial region led a 70-year-old woman to seek immediate medical evaluation. In the several hours before her work-in appointment, a pink rash developed in the area of pain. Her physician diagnosed shingles and prescribed appropriate anti-viral medication. Although the rash resolved, she experienced persistent facial pain that required pain medication for several months.
Diagnosis: post-shingles neuralgia (pain due to nerve damage).
These two fictitious cases illustrate the different patterns of shingles.
The same virus, VZV, causes chicken pox and shingles. After the rash of chicken pox resolves, the causative virus persists in the body. Most adults over age 40 harbor dormant VZV, even if they received vaccine to prevent VZV earlier in life. Years after infection with VZV, unknown factors prompt the virus to inflame a single spinal nerve, causing a painful eruption on one side of the body within the segment of skin from which the nerve transmits sensation. The risk of shingles steadily increases with age, ranging from 2 to 4 percent at age 50 to 10 percent above age 80.
Pain may precede the rash by a day or two. Left untreated, an increasingly painful rash may persist for weeks. Tiny sacs of fluid may become blisters. Bacteria may invade the affected area if blisters rupture. Scarring may develop in the affected area. The risk of chronic pain in the affected area, which may be disabling, increases with age. One in five people over 80 will suffer post-shingles neuralgia after an acute episode.
If shingles affects the nerve supplying the forehead and surface of the eye, vision may be permanently impaired. Prompt treatment with intravenous anti-viral medication is essential.
In 2006, the Food and Drug Administration approved a single-dose live-virus vaccine (Zostavax) for prevention of VZV. The Centers for Disease Control and Prevention recommended vaccination for people 60 and older. Follow-up studies have shown that protection against VZV infection decreases progressively over time, especially in those over 80.
In October 2017, the FDA approved a new VZV vaccine - Shingrix - for adults 50 and older. The vaccine consists of a component of the VZV capsule and an "adjuvant," a chemical to stimulate the body's immune response to the vaccine. Two injections are needed, spaced from two to six months apart.
Studies conducted before the approval of the new vaccine showed a reduction in risk of VZV infection of 97 percent for people under age 70 and 89 percent for people above that age when compared against placebo. Protection persisted longer compared to the single-injection vaccine.
The Advisory Committee on Immunization Practices, which sets policy and recommendations for vaccines, advises two-dose Shingrix for people 50 and older even if they had been previously vaccinated with Zostavax, unless their immune systems are compromised by medications such as steroids or by cancer. CDC makes the same recommendation.
Zostervax may still be used as a single dose for people 60 and above.
GoodRx.com lists the best price for single-dose Zostervax at $233. Two-dose Shingrix costs $580. Health insurance plans may vary regarding coverage and co-payments for vaccinations. Many plans cover preventive services such as recommended vaccines with no deductible or co-payment. Always discuss vaccine options with your health-care provider.
A full schedule of recommended vaccines for adults 19 and older is located at www.cdc.gov/vaccines/schedules.
Clif Cleaveland, M.D., is a retired internist and former president of the American College of Physicians. Email him at ccleaveland@timesfreepress.com.