Helvedesild – sådan genkendes de typiske symptomer
Shingles is a viral disease that is most common among people of advanced age ( above the age of 50) and is characterised by a specific rash. The illness is associated with severe pain and, if left untreated, can lead to other health complications – making it particularly important that the condition is treated as early as possible. Read on to find out precisely what causes the disease and how to recognise the symptoms of shingles at an early stage.
The cause of shingles
Shingles (also known as herpes zoster) is caused by the varicella zoster virus (VZV). The varicella zoster virus belongs to the herpesvirus family and is transmitted from one person to the next by droplet infection. A droplet infection denotes the emission of tiny droplets containing the pathogen when an infected person sneezes, coughs or talks. This means that the pathogens are released into the air as a person exhales – and are subsequently inhaled by another person.
The varicella zoster virus is responsible for two diseases in humans: chickenpox and shingles. The primary infection with the virus always presents in the form of chickenpox. Even after the symptoms of chickenpox eventually recede, the virus remains in the person’s body for the rest of their life – but in an inactive (latent) state. For people with a strong immune system, the body is usually capable of keeping the virus in check so that they do not suffer a further onset of the disease. If a person’s immune system is weakened – due to another chronic illness, stress or a generally unhealthy lifestyle, for example – the latent virus can reactivate at a later date and cause a further case of disease. However, when the virus reactivates, the person develops shingles rather than another case of chickenpox. Estimates suggest that around 95% of people are carriers of the varicella zoster virus, the majority of whom were infected as children. While it is common for children to contract chickenpox, shingles is extremely rare among children: if the virus does reactivate, it tends to do so much later in life.
Description of shingles
Shingles’ less common name, herpes zoster, gives a clue to its symptoms: the word “zoster” is derived from the Greek word for belt and describes the shape of the typical rash, which appears like a belt or sash across the back and/or chest. However, the shingles rash can also affect the face, arms and legs. While inactive, the virus resides in the cranial nerve ganglia – responsible, among other things, for conducting stimuli in the face – and the so-called spinal ganglia. Spinal ganglia are nerve cells along the spinal cord. As soon as the varicella zoster virus reactivates, it begins to travel along the nerve fibres – thereby causing an inflammation of the corresponding nerve tissue. The typical pattern of the rash associated with the disease is caused by the routes of the nerves attached to the spinal cord; extending throughout the entire torso (chest, stomach, back and pelvis) in a belt-like shape and supplying specific areas of skin (known as dermatomes), the rash appears on the skin in a strip along the affected areas of the body.
Typical symptoms of shingles
As with many other illnesses, shingles can also start with a so-called prodromal phase, in which the symptoms include general signs of illness such as tiredness, fever and lethargy. This early stage of the illness lasts on average three to five days. People with the disease might also experience paraesthesia – abnormal sensations like pins and needles or dull feelings in the affected area of skin.
As the illness progresses, these abnormal sensations in the skin turn into pain. As shingles is a disease that directly affects a person’s nerves, the term neuropathic pain is used. Most patients describe it as severe and deeply unpleasant. In most cases, this pain takes the form of burning or stabbing sensations which occur suddenly and are accompanied by an unpleasant itchiness.
The characteristic rash associated with shingles generally begins with redness in the affected areas of skin. Within 12 to 24 hours, blisters then form in these areas. To begin with, these blisters are filled with a clear fluid; as the disease progresses, this fluid – which carries the virus – becomes cloudy, while more and more blisters appear and join to form larger strips before eventually bursting. Crusts then form over the blisters and, as they fall off, the rash slowly fades away. Generally speaking, the shingles rash only develops on one half of the body and not on the other.
For patients with a healthy immune system, the symptoms of shingles usually persist for an average of two to three weeks. However, this varies from patient to patient. In addition, in some rare cases, the illness can progress without developing the typical skin rash (known as zoster sine herpete). In such cases, patients experience severe burning, stabbing and itching sensations in the affected areas of skin despite the absence of the belt-shaped rash.
Shingles is a contagious disease. Unlike chickenpox, however, shingles is not transmitted via droplet infection as the virus is only present in the fluid in the blisters – making this fluid the carrier of the disease. What’s more, people can only develop shingles if they have been ill with chickenpox in the past, as initial contact with the varicella zoster virus always results in chickenpox as the primary illness.
Shingles symptoms at a glance:
- Early (prodromal) phase of the illness: General fatigue, fever, lethargy
- Abnormal sensations in the affected areas of skin: Pins and needles, dull feeling when touched
- Pain: Sudden stabbing and burning sensations as well as itchiness
- Blister formation: The blisters, which initially fill with a clear fluid that becomes cloudy over time, form into belt-like bands.
- The rash generally only appears on one half of the body.
- People with a healthy immune system generally find that the symptoms of shingles persist for two to three weeks, depending on its severity.
Risk factors, potential complications and secondary diseases
Shingles can lead to dangerous and debilitating complications and secondary diseases, in particular in people with weakened immune systems due to existing conditions (e.g. HIV-positive people or cancer patients) and in older people, whose immune system is weaker than those of healthy adults on account of their age. The following risk factors can also lead to an elevated risk of onset of the disease:
- UV radiation: Severe sunburn not only damages the area of skin affected but also weakens the entire immune system – meaning that too much UV radiation can be a contributory cause of shingles.
- Chemotherapy: The medication administered during chemotherapy not only attacks the cancer cells but also places a short-term strain on the entire immune system, thereby making it more susceptible to illnesses like shingles.
- Immunosuppressants: Immunosuppressants are a type of medication that limit the function of the body’s in-built defence system – for instance, to prevent the body rejecting organs or tissue following a transplant or in order to treat severe allergic asthma, immune system disorders or autoimmune diseases.
- Infections: Infections – including mild cases of colds and flu – can also increase the likelihood of developing shingles, especially in people whose immune systems are already weakened, such as older people.
- Stress and prolonged physical and psychological burdens
Potential complications and secondary diseases
In the case of generalised herpes zoster, the varicella zoster virus spreads from the nerve pathways to individual internal organs. If the virus affects the central nervous system (the nerve structures in the brain and spinal cord), this can result in meningitis and serious cases of encephalitis. Furthermore, the virus can travel via the cranial ganglia to attack both the eyes and ears, potentially causing keratitis, conjunctivitis, blindness (zoster ophthalmicus) or deafness (zoster oticus).
As the areas of skin affected by the virus are weakened by the inflammation and therefore also more vulnerable to bacteria, one potential consequence of shingles is a secondary bacterial infection. This occurs when the areas of skin damaged by the shingles rash become infected with other bacteria. Other potential consequences include pigment disorders and bleeding into the skin, while scars can also form – in particular when the crusts that form over the blisters are scratched off rather than falling off of their own accord. In contrast to chickenpox, however, this is rather uncommon as scratching the crusted areas is usually quite painful. Some patients also present with sensory disorders and signs of paralysis in the affected areas once the disease recedes; in the worst case, these symptoms can be permanent if left untreated.
Up to 20% of all people who fall ill with shingles and fail to seek treatment go on to suffer from post- herpetic neuralgia. In this case, the neuropathic pain can persist for up to four weeks after the skin- based symptoms have subsided. At worst, this pain can stay with a person even for years after they suffer from shingles.
Diagnosis of shingles
As some of the symptoms of shingles are very characteristic of the disease, a doctor will usually be able to diagnose the disease during a basic physical examination. At this appointment, the doctor carefully inspects the affected areas of skin and asks the patient specific questions about other symptoms and how long they have experienced such complaints.
However, to be on the safe side – and also to distinguish the disease from other herpes simplex viruses that occur in humans – the doctor will usually take a wound swab. By sending this to a laboratory, it allows the doctor to ascertain the virus strain beyond doubt, either through cell cultures or polymerase chain reaction testing. The virus can also be identified indirectly through an antibody test. This involves testing the patient’s blood for antibodies against the virus. Antibodies are an important part of the human immune system. Produced by white blood cells, their role is to fight any bacteria, viruses or other foreign substances (collectively known as antigens) which have infiltrated the body.
Treatment for shingles
There are various treatment options for shingles. The aim of each therapy is to alleviate acute symptoms and complaints while simultaneously limiting the spread of the skin alterations caused by the disease. As shingles directly affects the nerves, it is crucial that people with the disease see a doctor as soon as possible and start a corresponding course of treatment as soon as possible in order to prevent the risk of complications and secondary diseases.
Treating the pain
In most cases, opioid analgesics are prescribed to treat severe and acute pain. Opioid analgesics are strong painkillers that bind to opioid receptors in order to curb the pain a person feels. These opioid receptors are primarily located in the brain and spinal cord. The opioids prescribed work to prevent the pain stimulus from being processed and passed on, thereby alleviating the pain. Less severe pain can also be treated with milder painkillers like ibuprofen and paracetamol.
Treating the skin rash
The skin rash in shingles is usually treated with ointments and tinctures that work to dry out the blisters. This not only alleviates the acute pain but also reduces the risk that the person will contract a secondary bacterial infection. Moreover, the ointments and tinctures – which can be specifically composed based on the stage of the disease and the intensity of the rash – support the healing process.
Antiviral therapy is primarily used on patients over the age of 50 who have an acute case of the disease and/or a weakened immune system (e.g. HIV-positive people and cancer patients) and/or a shingles rash across their face or neck.
For patients under the age of 50 with a mild form of the disease, targeted pain management in combination with targeted treatment of the skin rash is usually sufficient. Antiviral therapy is also not given to pregnant women, who are instead prescribed only symptomatic and localised treatments for the disease.
The objective of antiviral therapy is to prevent the varicella zoster virus from reproducing further in the body. The medications used to this end – known as virostatic agents – may be administered orally or intravenously depending on the individual case. The substances used in antiviral therapy for shingles include aciclovir, famciclovir and valaciclovir.
For people with a healthy immune system, the prospects for treatment are very good; as a result, the shingles rash should heal completely after just a few weeks of treatment. The disease can take a far more complicated and acute form in patients with a weakened immune system, making it all the more important that they begin treatment with medication at an early stage.
A herpes zoster vaccine is once again available in Austria after its introduction in 2013. The Austrian Vaccination Programme recommends that all over-50s are given the vaccine – whether they have previously suffered from shingles or not. The protection from the vaccine lasts several years and goes a long way to preventing the person from developing a severe form of the disease or post-herpetic neuralgia. Despite this, the vaccination does not provide absolute protection against the potential onset of shingles. Nevertheless, if people who have received the vaccine do develop the disease, it is usually a milder form which passes more quickly.
Dr Birgit Weinberger, Research Institute for Biomedical Ageing Research, University of Innsbruck; Immunseneszenz und Impfungen im Alter, Ärzte Krone 17/2014, Ärztekrone VerlagsgesmbH [in German]
Dr Robert Müllegger, Department of Dermatology, Wiener Neustadt State Hospital; Update Herpes Zoster, die Punkte 01/2014, MedMedia Verlag und Mediaservice GmbH [in German]
Dr Herbert Kiss, Clinical Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynaecology, Vienna; Virusinfektionen in der Schwangerschaft - Varizellen und Herpes zoster, Gyn-Aktiv 03/2011, MedMedia Verlag und Mediaservice GmbH [in German]
Johnson R.W. et al., Postherpetic Neuralgia, New England Journal of Medicine 2014; 371:1526-1533
Robert Koch Institute, Department of Infection Disease Epidemiology; Varizellen (Windpocken), Herpes Zoster (Gürtelrose), RKI-Ratgeber für Ärzte 06/2013 [in German]
Autor: Katharina Miedzinska, MSc