Shingles:

The pain of shingles comes about three days before a rash of tiny red spots appear,which usually become blisters. There is usually a narrow belt of pain and blisters,from your backbone across your ribs on one side. Or possibly an area on one side of the neck and upper arm.

It is a myth that dreadful things will happen to you if the strip goes right around your body and meets in the middle. If you get a pain in your face,this can be a warning of shingles developing near your eyes. If this is the case,you may need referring to an eye specialist.

As soon as you feel the pain,it is worth telling your GP. If shingles is suspected,anti-viral tablets can be given to lessen the attack. These are most effective if given as early as possible.

Shingles and chickenpox are caused by the same virus. You can only get shingles if you have already had chickenpox,usually in childhood. The virus stays in the body and for some of us for no known reason,it is triggered later in life and causes shingles.

You can’t get shingles from contact with chickenpox,but if you have shingles,it is possible for someone who has not had chickenpox to develop it after contact with you.

A shingles attack usually lasts for three to four weeks and it is common to feel unwell and depressed. All you can do,is keep the affected skin clean and dry. Calamine lotion is very soothing and you can take paracetamol or aspirin for the pain.

Unfortunately,in some people,especially the elderly,the pain can persist for months or even years. This post-herpetic pain needs drugs prescribed by a GP, like an analgesic cream to rub into the area,strong painkillers or drugs called anticonvulsants.

If a person is depressed which is natural,antidepressants help. Other pain relief methods are acupuncture,injecting a nerve to block pain or cutting a nerve. Your Gp may refer you to a NHS Pain Clinic,but they have long waiting lists.

'Global Year against Pain in older persons' calls for
better pain awareness
Prevention of shingles through vaccination could reduce the burden of pain

Istanbul, 12 September 2006 – Pain is a major health problem in Europe. Though all types of pain are important, chronic pain remains one of the most under-recognised, under-treated medical problems of the twentieth century1. Although acute pain may reasonably be considered a symptom of disease or injury, chronic and recurrent pain is a specific healthcare problem, a disease in its own right2. During a press conference the European Federation of the IASP Chapters (EFIC) with the International Association for the Study of Pain (IASP) launched a new pain campaign. From September 2006 to October 2007 and by various activities in several European countries, IASP and EFIC want to raise awareness of pain in older adults. Chronic pain due to shingles is amongst the most common pain conditions on which the 'Global Year against Pain' will focus. Prevention of shingles and postherpetic neuralgia through vaccination with ZOSTAVAX® (zoster vaccine (live)) could contribute to the overall reduction of pain in older adults in Europe.

Pain is a very common problem for older adults. They are more likely to suffer from chronic pain than younger persons. Shingles (herpes zoster) is often accompanied by acute pain and can lead to a chronic and persistent pain called postherpetic neuralgia (PHN). Shingles' treatment including pain control is often difficult and unsatisfactory due to a lack of understanding of the disease and its complications by doctors and patients. Many patients are refractory to prescribed treatments for PHN because of inadequate pain relief or adverse reactions3. Shingles and its associated intense and debilitating complications can have a severe and underestimated impact on quality of life4. This may be manifest as depression (including suicide risk)5, poorer physical functioning, increased emotional distress and limitations in the performance of daily activities4. Patient symptoms are not always recognised by general practitioners making early diagnosis difficult6.

The risk of shingles and the severity of the disease increase with age due to a natural decline in cell mediated immunity. The incidence is expected to increase as the population ages. In the European Union it can be estimated that approximately 1.8 million7,,,8910 people develop shingles every year of which 12,000i shingles cases are hospitalised annually, i.e. 33 cases per day. Although people may not feel at risk of getting shingles, it is estimated that one in four will suffer from shingles at some point in their life5,,,111213.

Shingles and PHN can cause serious pain
Shingles is the reactivation of the chickenpox virus (varicella zoster virus, VZV), hiding in the nerves after initial infection, mostly in childhood. It is characterised by itching, tingling or burning pain while the virus causes damage where it runs up the nerves. When the virus reaches the skin, the rash appears looking like a band or a grouping of raised dots usually confined to one side of the trunk or face in most cases. The rash is followed by the formation of fluid-filled blisters that can take up to two to four weeks to heal and can lead to severe skin infections and scarring or permanent changes in skin colouring14.
Postherpetic neuralgia is the most frequent and painful complication of shingles15. It is a chronic and persistent nerve pain that occurs after the shingles rash has healed (between one and three months) and can last for months, or even years16. Approximately one out of five shingles patients develops PHN7,,,,171819ii mostly after the age of 50. Individuals, who have experienced PHN, have described this pain as “ burning, stabbing and sharp”15. A worst form of PHN is allodynia, a distressing pain caused by an increased sensitivity to light or touch such as cloth or wind20.
i The calculation is based on 1998-2001 epidemiology data in The Netherlands, extrapolated from the European Union population (25 countries) – 2005 population
ii pain persisting between one and three months after rash onset
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Shingles can appear on any part of the body, but about half of shingles cases21 affect the upper body. The second most frequently affected area is the head22 with shingles appearing on one side of the head or the eye (ophthalmic zoster) in about 12% of cases8. Shingles on the head can make it impossible to bear the pain of combing one's hair or wearing a hat22. Ophthalmic zoster can lead to visual complications23. These ocular complications can range from inflammation of the eye to loss of vision24.

ZOSTAVAX®, the first and only vaccine to prevent shingles and PHN In a large Phase III study, including 38,546 men and women aged 60 or older who received one dose of vaccine or placebo, ZOSTAVAX® reduced shingles pain and discomfort by 61%iii, reduced the incidenceiv of PHN by 67%v and reduced the incidence of shingles by 51 %vi compared to placebo. In addition, ZOSTAVAX® reduced the incidence of shingles with severe and long-lasting painvii by 73%viii,25. Individuals enrolled in the study were followed for three years.

The European Commission granted a marketing authorisation for ZOSTAVAX® in May 2006. ZOSTAVAX® is indicated for the prevention of herpes zoster (shingles) and herpes zoster-related postherpetic neuralgia in individuals 60 years of age or older. This licence is for a frozen formulation of the vaccine. Sanofi Pasteur MSD has filed for a licence for the refrigerated formulation, which fits the European vaccine distribution infrastructure better. ZOSTAVAX® was developed by Merck & Co. Inc. and Sanofi Pasteur MSD and will be marketed in Europe by Sanofi Pasteur MSD. In the US, ZOSTAVAX® is marketed by Merck & Co. Inc. and has been available since June 2006 for the prevention of herpes zoster (shingles) in individuals 60 years of age or older.

About IASP and EFIC
IASP is the largest multidisciplinary international association in the field of pain. Founded in 1973, IASP is a non-profit professional organization dedicated to furthering research on pain and improving the care of patients with pain. Membership in IASP is open to scientists, physicians, dentists, psychologists, nurses, physical therapists, and other health professionals actively engaged in pain research and to those who have special interest in the diagnosis and treatment of pain. Currently IASP has more than 6,900 individual members from over 100 countries. EFIC is the European Federation of the IASP Chapters in Europe, bringing together 29 chapters (pain societies) representing 33 countries and having a total number of 18,000 medical members. Established in 1993, its aim is to advance research, education, clinical management and professional practice related to pain and to serve as an authoritative, scientifically based resource concerning policy issues related to pain and its management.
Chapters and chapter members, who undertake national activities, have been advised to organize activities relaying information on pain relief in older people.

References
1 http://www.efic.org/chronicpain.html 06/09/06
2 http://www.efic.org/declarationonpain.html 06/09/06
3 Dworkin RH et al. Pregabalin for the treatment of postherpetic neuralgia. A randomised, placebo-controlled trial. Neurology 2003;60:1274-83.
4 Katz J et al. Acute pain in herpes zoster and its impact on health-related quality of life. Clin Infect Dis 2004;39:342-48.
5 Chidiac C et al. Characteristics of patients with herpes zoster on presentation to practitioners in France. Clin Infect Dis 2001;33:62-9.
6 Henry T. Herpes zoster: a comparative study of general practitioner and patient experience. Curr Med Res Opin 1994;13:207-13.
7 Paparatti UdL et al. Herpes zoster and its complications in Italy : an observational survey. J Infect 1999; 38:116-20.
8 Opstelten W et al. Herpes zoster and postherpetic neuralgia: incidence and risk indicators using a general practice research database. Fam Pract 2002;19(5):471-75.
9 Dworkin RH et al. Pregabalin for the treatment of postherpetic neuralgia. A randomised, placebo-controlled trial. Neurology 2003;60:1274-83.
10 Eurostat population by the European Commission (EU 25) – European figures were calculated by extrapolating the incidence rate and the hospitalisation rate to the European population. http://epp.eurostat.cec.eu.int/extraction/evalight/EVAlight.jsp?A=1&language=en&root=/theme3/proj/proj_top_pop
11 Miller E, Marshall R, Vurdien J . Epidemiology, outcome and control of varicella-zoster infection. Rev Med Microbiol 1993;4:222-30.
12 Brisson M et al. Epidemiology of varicella zoster virus infection in Canada and in the United Kingdom. Epidemiol Infect 2001;127,305-14.
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14 Gnann JW et al. Herpes Zoster. N Engl J Med 2002;347:340-6.
15 Johnson RW. Consequences and management of herpes zoster. J Infect Dis 2002;186 (Suppl 1):S83-S90.
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17 Meister W et al. Demography, symptomatology, and course of disease in ambulatory zoster patients. Intervirology 1998;41:272-7.
18 Scott FT et al. A study of shingles and development of post Herpetic neuralgia in East London. J Med Virol 2003;70:S24-S30.
19 Czernichow S et al. Zona : enquête d'incidence chez les médecins généralistes du réseau "Sentinelles". Ann Dermatol Venereol 2001;128:497-501.
20 Oxman MN. Clinical manifestations of herpes zoster. In : Varicella-Zoster Virus. Virology and clinical management. Eds: Arvin AM & Gershon AA. 2004:247-75.
21 Arvin AM. Varicella-Zoster Virus. In: Fields Virology, vol 2, fourth edition. Eds: Knipe DM, Howley PM. 2001;2731-67.
22 Pavan-Langston D. Ophthalmic zoster. In : Varicella-Zoster Virus. Virology and clinical management. Eds: Arvin AM & Gershon AA. 2004:276-98.
23 Marsh RJ. Herpes zoster ophthalmicus. J R Soc Med 1997;90:670-4.
24 Shaikh S, Christopher N. Evaluation and Management of Herpes Zoster Ophthalmicus. Am Fam Physician 2002;66:1723-30,1732.
25 Oxman MN et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005;352(22):2271-84.
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