Transcription:
Shingles: What Are They and Should I Get the Vaccine

Melanie Cole (Host):  According to the CDC, almost one out of every three people in the United States, will develop shingles at some point. It’s also known as herpes zoster. When it comes to preventing the painful rash and blisters of shingles, a new vaccine has arrived that promises to be more effective at protecting people from these agonizing symptoms. Welcome to BayCare HealthChat. I’m Melanie Cole and today, we’re discussing shingles and the shingles vaccine. Joining me is Dr. Michael Gannon. He’s a Family Medicine physician at BayCare.

Dr. Gannon, it’s a pleasure to have you with us today. Let’s start by giving kind of a working definition. What is shingles and do we know what causes it?

Michael Gannon, MD (Guest):  So, what shingles are, as you mentioned, also known as herpes zoster. It’s an acute viral infection that is caused by reactivation of the chickenpox virus, also known as varicella zoster. And what happens after any acute infection of the chickenpox virus, is it travels to our space in our spinal canal called the dorsal root ganglia where this virus can remain dormant there for years, often decades. Dorsal root ganglia supplies sensation to our skin in the pattern of what’s called dermatomes. And each level of our spinal cord gives sensation to different dermatomes. So, what happens later in life often decades after an infection with the chickenpox, the chickenpox virus will be reactivated along one of these dermatomes in the form of what we would call shingles or again, herpes zoster. It’s not known exactly why any one dermatome is affected and one isn’t. but it usually only affects one dermatome at a time, and it can occur anywhere from our face down to our lower extremities. So, that would be the spinal cord going all the way up to our cervical spine which is towards the top of our head and all the way down to the lower back and that’s what innervates, gives sensation to our lower extremities and legs.

As to what causes it, why some people get it and others don’t. Not 100% understood, but there are some theories that have been researched, and have some good results, and give us some good information. And it’s probably a combination of factors. Over time, what is called our cellular mediated immunity decreases. This is basically the amount of antibodies we have in our bodies to fight a previously recognized infection, in this case with shingles, it would be chickenpox. And the cell mediated immunity decreases with age which is probably why shingles usually affects those over the age of 50. A majority of cases, approximately two thirds, will be over the age of 60.

And then, along with this decrease in cellular mediated immunity, the patient will often have or be going through a period of stress. And this stress could be severe emotional stress from life in general like we have going on in our world or it can be from physical illness. Anything from a common cold to flu to types of cancers. So, it’s usually a combination of those two which is again, the decrease in immunity over time with age and the stressor, although there are patients who are completely healthy, and they do have sporadic cases of shingles.

Host:  Thank you so much for that definition and explanation. But if you did not get chickenpox as a child, or if you got the chickenpox vaccine; can you still get shingles?

Dr. Gannon:  Yes. You can. So, two parts to that question. If you never had chickenpox as a child, we still recommend that you get a vaccine which is called Shingrix and the reason being, people can have cases that are not symptomatic called asymptomatic infection where they won’t have the active form of the chickenpox. This would give you the antibodies over time, again, they would decrease like I had mentioned so  the vaccine is still recommended. That leads us to the second part of the question when you discussed those who had received the immunization to chickenpox. There’s not a great answer right now; it’s still being studied. It seems like those people who have received the chickenpox vaccine, there is a lower incidence of shingles later on in life. But as the chickenpox vaccine has only been around for a few decades, it’s still being studied, but it does seem to give some immunity to shingles as well, as we age. But us, as clinicians certainly see shingles in patients who also have received the chickenpox vaccine.

Host:  Well so then let’s talk about what someone would notice, the symptoms we’ve heard about, the pain, and postherpetic neuralgia and these painful rashes people get. How is it diagnosed and who diagnoses it? Is it a dermatologist, an internist? If someone notices one of the symptoms, you’re going to mention for us; who do they go see?

Dr. Gannon:  Shingles will be diagnosed by your primary care physician or at an urgent care clinic as it is quite a common condition. So, basically, there’s three phases of shingles, the shingles outbreak. And those three phases are the pre-eruptive phase and then we have the eruptive phase and finally the one that we try to avoid at all costs, but can’t always, is the postherpetic neuralgia which you discussed.

So, the pre-eruptive phase: this usually starts with what we call paresthesia’s or numbness or tingling or pain or itching along the dermatomes which I had mentioned before. A lot of times, during this pre-eruptive phase, patients will also complain of just feeling fatigue or even having flu like symptoms. This is followed by the eruptive phase, what starts with these red patches that are spread out along a dermatome and then that’s followed by these little wet looking vesicles, almost like raised tear drops that are clear and the eruptive phase is then completed once all these vesicles they crust over like scabs. And that leads us to the third stage which not everyone goes through but there is probably around 40 to 50% of people who experience the postherpetic neuralgia phase which is as you would see on commercials for medications, people with severe pain and feeling like their body is on fire. And this occurs by definition, up to thirty days of pain after the onset of shingles and the pain is often severe and it’s right along that distribution of skin where the shingles was affected. And this can last for weeks, months or even years and it tends to be that the older the patient, the more severe case, the more debilitating the pain is going to be.

In terms of diagnosis of shingles, and how we are making a diagnosis of a primary care physician, or an urgent care clinic and a dermatologist for that reason. It’s really a clinical diagnosis meaning that we’re – us as clinicians will listen to the patient’s symptoms and then after examining them, come to a conclusion that this is shingles or that this is something else. And we always consider the differential diagnosis, but we do see a lot of it so it’s something that usually is just the eyeball test, taking a look at it and making a diagnosis. There are tests that are available, something called PCR, but these are usually reserved for patients in the hospital that are having complications and we’re unsure of a diagnosis. So, on a regular basis, there’s no blood test or invasive type of testing to make the diagnosis of shingles. It’s usually a clinical diagnosis.

Host:  So, before we get to the vaccine, answer just a few myths for us. Is shingles contagious? Can stress bring on a bout of shingles?  And just tell us a little bit about that. Is it contagious?

Dr. Gannon:  So, shingles itself is unlikely that a person is going to give another person shingles. So, as mentioned, we know it’s reactivation of the chickenpox virus. So, if a patient with active shingles is exposed to somebody without immunity to chickenpox; that person without that immunity could develop chickenpox itself as an acute viral illness. An example of that patient population would be young infants who might not have received the chickenpox vaccine or those who might be immunocompromised for instance would be a patient on chemotherapy who is older and doesn’t have immunity anymore to chickenpox. So, those are the two types of patients that we will tell someone with active shingles to stay away from until all those lesions have crusted over which means that they are not contagious anymore.

And in terms of the second part of that question, does stress bring on shingles. The research is a little bit iffy on it, but I will tell you I see on quite a regular basis, patients coming in who are under a lot of emotional stress and that is the only thing going on and they will have shingles. So, I think certainly there is a component of emotional stress that can bring on shingles.

Host:  Well then now tell us about the vaccine and you mentioned it a little bit at the beginning. Tell us about Shingrix and how it differs from the previous vaccines that we’ve had before.

Dr. Gannon:  Along the way, there has been two vaccines. The old one was what’s called Zostavax and the newer vaccine is Shingrix. This was approved in 2017. It’s a series of two vaccines that are given two to six months apart from each other so you would receive the first vaccine and then two to six months later, get the second. I usually have my patients just go after two months just so they don’t forget about it. Now the difference is compared to the prior vaccine, the Zostavax, the Shingrix is effective in preventing shingles itself and the complications namely the postherpetic neuralgia in up to 90%, some studies suggest even more than that, 91 to 92%. So it’s a very effective vaccine compared to the prior where prevention was only around 50%. So, it’s certainly a vaccine that we recommend for our patients. And if we go by strict guidelines, it’s often recommended for patients 50 and up although most insurances won’t start covering it until the age of 60.

Host:  So, then tell us a little bit about how it works and who should be really getting this as far as someone at risk or immunocompromised. Just give us a little overview.

Dr. Gannon:  Yeah, so anyone who is 60 and above, I would recommend this vaccine to. It is not a live vaccine, so the past vaccine the Zostavax was a live vaccine so, those who are immunocompromised, again a good example would be a patient on chemotherapy, we would be very hesitant to give the vaccine. But this is a non-live vaccine that confers immunity. So, we recommend it to everyone over 60. I myself, will have my patients who are even above the age of 50, contact their insurance companies and say heh, is this something that’s covered that I can get. Again, because if we look at the FDA recommendations, it is above the age of 50. And it tends to be a well-tolerated vaccine. There are some side effects with it. But certainly the side effects are not as bad as postherpetic neuralgia that you can get with shingles. And some people get fatigue and that’s anywhere between 30 to 50% of people. Some people get body aches and pains, some nausea, vomiting. But again, this is very short lived, usually 24 to 48 hours. And then after that, we are pretty confident that they are immune to shingles at that point after receiving the second vaccine.

Host:  How cool is that? And Dr. Gannon, as we wrap up, when people do get shingles, and it can be so painful and as you and I have discussed; give us some treatment options. And then reiterate for us, the importance of contacting their provider and investigating the Shingrix shingles vaccine.

Dr. Gannon:  Sure. So, the most important part when you look at two parts of treating shingles. One is treating the acute viral infection. The most important aspect of that is starting treatment as soon as possible. So, as soon as somebody has that numbness, tingling or rash at the outbreak, then we like to start treatment the sooner the better, certainly within a period of seventy two hours or three days. The first line treatment for that is antiviral medications. The common ones that we use are acyclovir or valacyclovir usually for a period of seven to ten days. And that tends to be a very well tolerated medication. So, that’s how we try to prevent the spread of the disease itself, more vesicles and more rash erupting as well as preventing postherpetic neuralgia.

Then we look at the second part of treating shingles and that is the pain that comes along with it and if you’re lucky enough to be one of those patients that just has mild pain, we can use NSAIDS which would be something just like ibuprofen, Aleve, Advil, that type of stuff as well as topical what we call capsaicin helps a little bit or lidocaine cream. But more often than not, we again, we have patients with more severe pain, and we use a medication called gabapentin or Neurontin which is – originally was an anticonvulsant medication but it has utility with treating nerve related pain. So, that’s usually the first line. If the pain is very severe, sometimes we will prescribe narcotic pain medications something like Percocet and there’s a group of antidepressants called tricyclic antidepressants which also help block nerve related pain.

So, when we talk about this again, I’ve seen patient after patient who does have debilitating long term pain and a lot of times, in the older population, and now we have the Shingrix vaccine which is up to 90% perhaps even more effective with prevention, so to prevent months and perhaps years of misery from nerve related pain; the Shingrix is a great option for people.

Host:  Thank you so much Dr. Gannon. It’s really great information and so important for listeners to hear. Thank you again for joining us and that concludes this episode of BayCare HealthChat. To learn more about BayCare’s Primary Care services, please visit our website at www.baycare.org for more information. Please also remember to subscribe, rate and review this podcast and all the other BayCare podcasts. For more health tips such as these, follow us on your social channels. I’m Melanie Cole.