An in-depth report on the causes, diagnosis, treatment, and prevention of shingles and chickenpox.
Chicken pox; Herpes zoster; Postherpatic neuralgia
The treatment goals for an acute attack of herpes zoster include:
Over-the-counter (OTC) remedies are often effective in reducing the pain of an attack. Antiviral drugs (acyclovir and others), oral corticosteroids, or both are sometimes given to patients with severe symptoms, particularly if they are older and at risk for postherpetic neuralgia (PHN). In addition, psychological therapies aimed at coping and reducing the effects of pain may be useful.
Applied Cold. Cold compresses soaked in Burrow's solution (an OTC remedy) and cool baths may help relieve the blisters. It is important not to break blisters as this can cause infection. Doctors advise against warm treatments, which can intensify itching. Patients should wear loose clothing and use clean loose gauze coverings over the affected areas.
Itch Relief. In general, to prevent or reduce itching, home treatments are similar to those used for chickenpox. Patients can try antihistamines (particularly Benadryl), oatmeal baths, and calamine lotion.
Over-the-Counter Pain Relievers. For an acute shingles attack, patients may take over-the-counter pain relievers:
Nucleoside Analogues. The best class of drugs developed against varicella-zoster are those known as nucleoside, or guanosine, analogues. These medicines block viral reproduction. None of these drugs can actually destroy the virus and cure the disease, but they can significantly reduce the severity of the attack, hasten healing, and reduce the duration. They may also reduce the risk of postherpetic neuralgia.
These anti-viral drugs are usually taken for 7 days. Ideally they should be started within 72 hours of the onset of infection. The earlier they are given the more effective these drugs are, but they can be helpful even if treatment is started after 3 days. Combinations of antiviral therapy with other drugs, such as tricyclic antidepressants or anticonvulsant drugs, are under investigation
Acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) are approved for shingles. Acyclovir is the oldest, most studied of these drugs, but either famciclovir (Famvir) or valacyclovir (Valtrex), which are both metabolized into acyclovir, are now preferred to treat herpes zoster in most patients because they require fewer daily doses than the five doses needed with acyclovir.
Because herpes zoster tends to resolve fairly quickly in young adults, these drugs are more important for patients at greatest risk for complications or persistent pain. They include:
These drugs appear to have little or no harmful effect on healthy cells and can penetrate most body tissues, including cerebrospinal fluid. Evidence to date suggests that they are safe during pregnancy.
Possible side effects of nucleoside analogues include rash, headache, fatigue, tremor, nausea and vomiting. Seizures are a very rare side effect. Patients with AIDS or other diseases that compromise the immune system are at increased risk for kidney damage and blood clots. Patients with suppressed immune systems are also more likely to have viral resistance to these drugs. These drugs are safe to take during pregnancy.
Foscarnet. Foscarnet (Foscavir) is a powerful antiviral drug known as a pyrophosphate analogue. It is used in cases of VZV strains that have become resistant to acyclovir and similar drugs. Administered intravenously, the drug can have toxic effects. It can impair kidney function (which is reversible) and cause seizures. Fever, nausea, and vomiting are common side effects. It can also cause ulcers on genital organs. As with other drugs, it does not cure shingles.
Brivudin. Brivudin (Helpin, Zostex), another antiviral drug, is not available in the U.S. It needs to be taken only once a day.
Oral corticosteroids, including prednisolone or prednisone, are powerful anti-inflammatory medications. They have some benefit for reducing pain in the first 2 weeks or so of an attack, when used with acyclovir or another nucleoside analogue. (They are not recommended without a nucleoside analogue.) They also may be helpful for improving symptoms of Bell's palsy and Ramsay Hunt syndrome. Corticosteroids do not appear to prevent a further shingles attack or reduce the risk for PHN. Side effects of corticosteroids can be severe, and patients should take oral steroids at as low a dose, and for as short a time, as possible. (Injected or intravenous steroids, however, may offer specific relief for PHN without significant side effects.)
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