DEAR DOCTOR K:
I’ve been diagnosed with shingles. What can I take for the pain?
Shingles, also known as herpes zoster or just zoster, is caused by the varicella-zoster virus. It is the same virus that causes chickenpox. Once you have had chickenpox, the varicella-zoster virus remains in your body’s nerve tissues. It is inactive, but it can be reactivated later in life. This causes shingles.
When the virus reactivates, it causes a burning or tingling sensation in the affected areas. A few days later, the virus causes a blistery rash. Your affected skin may be so painful and sensitive that you cannot even stand having your clothing touching the area. One patient of mine with shingles on his forearm switched for several weeks to wearing a short-sleeved shirt to the office, something he never had worn to work before.
If you’re over age 50 and have had shingles pain for less than three days, the current recommendations call for doctors to prescribe antiviral medicine to kill the virus that causes shingles. (If you are younger than 50 and very uncomfortable from shingles that began in the last three days, your doctor may still prescribe antiviral therapy.)
The two medicines recommended most often are famciclovir (Famvir) and valacyclovir (Valtrex). These antiviral medications not only help shorten the days of pain that you have, they also help reduce the risk of long-lasting shingles pain, a condition called post-herpetic neuralgia.
The pain that accompanies shingles can be intense. If the antiviral medicine does not provide enough relief, you can take additional pain medicines. Start with nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. If necessary, your doctor will prescribe more potent pain medicines; these include codeine, tramadol and (when the pain is very severe) oxycodone.
Some studies led doctors to add corticosteroid drugs such as prednisone to the treatment of shingles. However, as more studies of this treatment have been completed, it looks as though these medicines may offer more risks than benefits.
You should also gently rinse your skin rash and blisters once or twice daily with cool water. Your doctor may suggest that you use antibiotic ointment on open areas.
Shingles usually takes seven to 10 days to run its course. Blisters may take several weeks to disappear completely. The duration of pain is highly variable. Most people’s pain decreases within two or three months.
However, a small number of people develop post-herpetic neuralgia and continue to have pain for many months, or even years. Different medications from those used during the attack of shingles are effective. These include tricyclic drugs, gabapentin and pregabalin. These drugs alter the way your central nervous system perceives pain signals. If the pain is severe, then the more potent drugs used for the pain of shingles may also be helpful. These include oxycodone, morphine and methadone.
Other treatments for post-herpetic neuralgia being evaluated, but as yet unproven, include capsaicin, topical lidocaine and acupuncture. A shingles vaccine is recommended for most adults age 60 and older. Even though treatment is effective, nothing beats preventing the condition in the first place.
(This column originally appeared in October 2013.)