Varicella-Zoster Virus

Varicella–zoster virus (VZV) is known to cause two diseases: chickenpox (varicella) and shingles (herpes zoster). Chickenpox is a common contagious disease of children that usually has a benign course. However, chickenpox in adults or people with weakened immune systems can have serious complications. Second attacks of chickenpox are very rare. Shingles is caused by a reactivation of the latent VZV. In other words, the virus lies dormant in nerve cells in the spine and can re-emerge in the form of shingles years after you have had chicken pox.

Signs and Symptoms

Chicken Pox
The typical rash of chickenpox is made up of groups of small, itchy blisters surrounded by inflamed skin. The rash usually begins as one or two lesions, quickly spreading throughout the body including the trunk, scalp, face, arms, and legs. The total number of blisters varies greatly from person to person. Over four days, each blister tends to dry out and form a scab, which then falls off between 9 to 13 days later.

The rash is usually preceded by:

• Fever, usually low-grade
• Fatigue
• Headache
• Flu-lke symptoms

Shingles
The typical rash of shingles begins as redness (erythema) followed by the appearance of blisters that cover one concentrated area of the body on either the face, trunk, shoulders and neck, or legs (unlike the rash of chicken pox, which is generally diffuse, meaning that it is widespread throughout the body). These eruptions follow the path of an infected nerve. Usually only a single nerve is involved, confining the rash to one side and one section of the body (called a dermatome). The trunk is the area affected in 50% to 60% of cases. The next most common site is one side of the face, which may even involve the tongue, the eye, or the ear.

Before the rash appears, you will have warning symptoms of pain experienced as a sharp, aching, piercing, tearing, or burning sensation limited to the specific part of the body where the rash appears 1 to 5 days later. That area may also feel itchy, numb, and unbearably sensitive to touch, even just from your clothes touching your skin in that section.

Other symptoms that you may experience include:

• Fever (not so common)
• Malaise (feeling bad overall) and other flu-like symptoms including muscle aches
• Headache
• Swollen lymph nodes
• Visual disturbances, drooping eyelid, loss of eye motion (if in a nerve that affects one of your eyes or the muscles surrounding it)
• Taste abnormalities (if in a nerve that affects your tongue)
• Hearing loss (if in a nerve that affects one of your ears)

Causes

Chickenpox
Anyone who has not had chickenpox or the vaccine, is at risk for contracting the virus if exposed to someone with either chickenpox or shingles. The time between exposure to the virus and appearance of symptoms (called an incubation period) is between 10 and 20 days. The virus is spread through sneezing, coughing, and breathing – in other words, when someone with chickenpox sneezes or coughs, there are respiratory droplets with the VZV virus in the air. Then, you can breathe in those infected droplets and, if you have never had chickenpox or the vaccine, get chickenpox yourself.

Another possible way to get chickenpox, is to come into direct or indirect (like the clothes of someone with shingles) contact with discharge from VZV skin lesions.

The virus is contagious from two days before the rash appears until all of the lesions have crusted over.

Shingles
While shingles is caused by the same virus that leads to chickenpox, the way that you develop this painful skin lesion is quite different. After you have had chickenpox, the virus lives in a dormant state (like it is hibernating) in nerve cells along the spine. Later in life, when it is reactivated (usually from a weakened immune system, aging, or other risk factor), the virus travels down the tract of the particular nerve where it was "hibernating", first causing the pain and other sensations followed by the rash. The pattern or path that the symptoms follow is called a dermatome, which essentially means the area of the skin that the nerve supplies.

Risk Factors

Chicken Pox

• Exposure to VZV if you have neither had chicken pox nor received the vaccine
• Age under 10
• Late winter and early spring is the most common time that the virus is spread

Shingles

• Increasing Age
• Stress
• Impaired immune system (see Special Populations)
• Having had chicken pox before age 1

Diagnosis

Your health care provider will generally be able to diagnose chickenpox easily because of its characteristic rash. If there is any doubt, however, the doctor may take a scarping from one of your skin lesions to look at under the microscope. This is called a Tzanck test.

Similarly, if you have shingles, it is rare that your provider needs to perform any tests because the history of pain and other symptoms and the rash itself are very typical. If the doctor is not certain, however, a Tzanck test may be performed or some blood tests.

Preventive Care

• Chicken Pox vaccine (which has been available since 1995) is given to every child over 1 year old; if you (or your child) receive the vaccine before age 13, then you only need one dose. If you receive the vaccine when you are older than 13 (which may be recommended if you have not yet had chickenpox or received the vaccine), then you should get a second dose 1 to 2 months later.
• If you have never had chickenpox or the vaccine, avoid contact with anyone who has chickenpox and avoid contact with the skin lesions of anyone with shingles.
• To avoid spreading to others, children with chickenpox should be kept out of school or day-care until all of the blisters have scabbed over.
• Capsaicin cream (from cayenne pepper) may help prevent post-herpetic neuralgia, a possible complication from shingles (see Prognosis and Complications).

Treatment Approach

Both chickenpox and shingles generally resolve spontaneously in those not at high risk for complications. The goal, therefore, is to make you as comfortable as possible while you have either condition and to shorten the length of time that you have the pain and itching associated with shingles in particular. Many lifestyle approaches and medications may be helpful for these purposes. Mind/Body techniques for relaxation can also help alleviate pain and reduce stress associated with shingles.

Lifestyle

Certain measures, in the list that follows, can reduce itching from chickenpox and its complications. The less you scratch, the less likely it is that you will develop a secondary baterial infection of the skin (see Prognosis and Complications).

• Apply cool water compresses to your skin or soak in a bathtub filled with cool water
• Add finely gound oatmeal (there are special brands sold in drugstores) to the bathtub
• Apply calamine lotion to the affected areas of your skin
• Trim your fingernails to avoid infection
• For infants with chickenpox, try loose fitting, soft cotton or flannel mittens

Medications

• Acetaminophen—for fever and pain reduction
• Acyclovir—this may be prescribed for children over 2 years old and adults with chickenpox in whom symptoms are severe, for those who are immunocompromised (see Special Populations), and for people with shingles
• Other acyclovir-like medications that may also shorten the course of shingles, reduce pain, reduce complications, and/or protect you if you are immunocompromised include famciclovir and valacyclovir. For best results, one of these medications should be started within 24 hours of the onset of pain or similar sensations described in the Signs and Symptoms section and before the blisters appear.
• Prednisone or other corticosteroids, prescribed with acyclovir, may be used to reduce pain from shingles
• Antihistamines, like diphenhydramine, may be considered to control itching, especially at night for children
• Tricyclic antidepressants, such as nortriptyline, amitriptyline, and desipramine, are prescribed for post-herpetic neuralgia (pain from shingles that persists for months after the rash has resolved; see Prognosis and Complications)

Nutrition and Dietary Supplements

Because supplements may have side effects or interact with medications, they should be taken only under the supervision of a knowledgeable healthcare provider. Lysine
Taking lysine supplements may speed recovery time from shingles and reduce the chance of recurrent breakouts of this skin condition. More research is needed.

Herbs

The use of herbs is a time-honored approach to strengthen the body and treat disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care and only under the supervision of a practitioner knowledgeable in the field of herbal medicine.

In certain parts of the world, herbs are the standard form of medicine for conditions such as shingles. In an observational study in Uganda, for example, people receiving hrebal medicine for this skin condition were compared to people attending a clinic who received typical Western therapy. Those who were treated by the herbal therapists with traditional medicinal herbs suffered from less pain associated with the shingles and were less likely to have post-herpetic neuralgia (see Prognosis and Complications) than those who received Western medical therapy.

Cayenne (Capsicum frutescens/Capsicum spp.)
Capsaicin cream made from cayenne pepper has very powerful pain-relieving properties when applied to the surface of the skin. Capsaicin may help relieve the pain of post-herpetic neuralgia (see description of this potential shingles complication in Prognosis and Complications).

German Chamomile (Matricaria recutita)
Traditionally, this herb has been used to treat skin conditions and childhood illness like chickenpox. Research on how well this herbal remedy alleviates the symptoms of chickenpox is lacking, however. Therefore, specific recommendations regarding effectiveness and safety of chamomile for this condition cannot be made. An herbal specialist would be able to direct you in terms of whether it is appropriate to try this herb and how to do so.

Peppermint Oil (Mentha x piperita)
A case report in the scientific literature suggests that applying peppermint oil to the painful area may help relieve symptoms of postherpetic neuralgia, a potential complicaion of shingles (see Prognosis and Complications).

Others
Although not studied scientifically for VZV specifically, some herbalists may consider one of the following herbs because either it has been used traditionally for skin lesions or because the herb has been used for another virus in the same group as VZV, namely herpes simplex virus. All of the herbs mentioned below would be prescribed to be used topically for shingles or chicken pox.

• Aloe (Aloe vera/Aloe barbadensis/Aloe ferox) – for herpes and other skin conditions
• Burdock root (Arctium lappa) – used traditionally for skin lesions
• Lemon balm (Melissa officinalis) – used topically for herpes lesions
• Licorice root (Glycyrrhiza glabra) – used traditionally for skin lesions; demonstrates activity against VZV in test-tubes; and, glycyrrhizin (an active component derived from licorice) may help reduce pain associated with shingles more quickly; this herb should not be used if you have high blood pressure
• Madonna lily (Lilium candidum) – medicinal plant used traditionally in Northern Italy for shingles

Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of chicken pox and shingles based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual. Chicken Pox:

• Antimonium crudum — for irritable children who are extremely sensitive to touch and may have a thick white coating on the tongue
• Antimonium tartaricum — for large, slowly appearing pox lesions accompanied by
• Mercurius — for large, pus-filled pox which may ooze; this remedy is most appropriate for individuals who sweat profusely and may have enlarged lymph nodes
• Pulsatilla — for fever associated with chicken pox; children who tend to be whiny, clingy, and weepy but have very little thirst despite the fever
• Rhus toxicodendron — for severe itching that worsens at night and improves with warm compresses or a bath; this remedy is the most commonly prescribed
• Sulphur — for extremely itchy lesions that worsen with heat or bathing and which children will often scratch to the point of bleeding

Shingles:

• Arsenicum — for intense burning sensation that improves with warmth and worsens with cold
• Lachesis — for particularly dark, sometimes purple, lesions on the left side of the body
• Mezereum — for burning, sharp pains that worsen with touch; this remedy is most appropriate for individuals who are naturally chilly and sensitive to cold
• Rananunculus bolbosus — for lesions located on the chest or back; pain worsens with touch and movement
• Rhus toxicodendron — for intense itching and pain that may be relieved by touch

Mind/Body Medicine

The following relaxation techniques may help reduce the pain and stress associated with shingles and its potential complication of post-herpetic neuralgia:

• Meditation
• Breathing exercises
• Progressive muscle relaxation
• Biofeedback

Also, cognitive behavioral therapy can help you restructure your thinking about the pain from feeling completely helpless to feeling like the pain is only one negative aspect of your overall positive life.

Another practice from which people with post-herpatic neuralgia have reported some relief is:

• Hypnosis

Traditional Chinese Medicine

In a case series (a type of study that observes groups of people) of 56 people with post-herpetic neuralgia (see Prognosis and Complications for description of this post-shingles pain syndrome), the addition of the following traditional Chinese medical techniques to usual Western medical care helped reduce their pain of the participants in the trial:

• Acupuncture
• Cupping (cups with suction are applied to areas of the skin to stimulate circulation)
• Meditation
• Chinese herbs

In addition, a traditional Chinese herb called Clinacanthus nutans (Bi Phaya Yaw) is able to kill VZV and other herpes viruses in test tubes. An extract of this herb has been compared to placebo in small numbers of people with shingles. It appears that a topical form of C. nutans extract may shorten the length of time that one has skin lesions from this condition. More research would be helpful. In the interim, it may be worthwhile to work with a certified Traditional Chinese physician in your area. Be sure to discuss this with your regular doctor as well.

Other Considerations

Pregnancy

If you acquire chickenpox when you are pregnant, the infection may spread to the fetus.

Special Populations

If you have a compromised immune system, shingles lesions may be widespread rather than localized to one area of the body and it will likely take longer for the symptoms to heal, maybe lasting for months. Conditions that compromise your immune function include:

• Human Immunodeficiency Virus (HIV) infection
• Acquired Immunodeficiency Syndrome (AIDS)
• Organ transplant recipient on medications to avoid rejection of the new organ
• Cancer, especially leukemia, Hodgkin's disease and other lymphomas, or if you are receiving chemotherapy
• If you have an autoimmune disease (like rheumatoid arthritis, lupus, multiple sclerosis, and Crohn's disease) and are taking drugs that suppress your immune system in order to control the inflammation from any of these conditions

Warnings and Precautions

• Aspirin must not be used in children with chickenpox or shingles because of risk of Reye's Syndrome which can cause liver and brain damage.
• Call the health care provider if symptoms of confusion, vomiting, or weakness, even paralysis, of the arms, legs, trunk, or face begin during or soon after a chickenpox or shingles infection.

Prognosis and Complications

While chickenpox usually goes away on its own with non-serious complications like itching and scarring, severe and sometimes fatal infections may occur, particularly in newborn infants, adults, and people whose immune systems are weakened (see Special Populations just above). Such potential infections include:

• Encephalitis (a brain infection)
• Myocarditis (an infection of the heart muscle)
• Pneumonia
• Secondary bacterial skin infection

Shingles usually clears in 2 to 3 weeks and rarely recurs. Your chance of getting another bout of shingles is only 1% to 5% if you have a normal, working immune system. If you are immunocompromised (see Special Populations above), your risk for recurrence is higher.

Potential complications from shingles include:

• Shingles lesions involving the mouth or eye; the latter may lead to blindness if not treated.
• Post-herpetic neuralgia, which occurs in 10% to 20% of those with shingles; this is persistent pain for months to years even after the skin lesions have cleared up.
• Secondary bacterial skin infections.
• Encephalitis (a brain infection) or sepsis (an infection in your blood stream, affecting many organs in the body) if you are immunocompromised.

References

Aikawa Y, Yoshiike T, Ogawa H. Effect of glycyrrhizin on pain and HLA-DR antigen expression on CD8-positive cells in peripheral blood of herpes zoster patients in comparison with other antiviral agents. Skin Pharmacol. 1990;3:268-271.

Acyclovir. NMIHI. Accessed at http://www.nmihi.com/a/acyclovir.html on February 11, 2018.

Boaler J. Acupuncture in the management of herpes zoster. Acupunct Med. 1996;14(2);80-83.

Charuwichitratana S, Wongrattanapasson N, Timpatanapong P, Bunjob M. Herpes zoster: treatment with Clinacanthus nutans cream. Int J Dermatol. 1996;35(90):665-666.

Chickenpox. NMIHI. Accessed at http://www.nmihi.com/c/chickenpox.htm on February 11, 2018.

Cummings S, Ullman D. Everybody's Guide to Homeopathic Medicines. 3rd ed. New York, NY: Penguin Putnam; 1997: 119-120, 263-264.

Davies SJ, Harding LM, Baranowski AP. A novel treatment of postherpetic neuralgia using peppermint oil. Clin J Pain. 2002;18(3):200-202.

Fluconazole. NMIHI. Accessed at http://www.nmihi.com/f/fluconazole.html

Gillingham G. Herpes zoster and post herpetic neuralgia. J Tradit Chin Med. 1995;47:5-7.

Everything you need to know about shingles. MedicalNews. Accessed at https://www.medicalnewstoday.com/

Homsy J, Katabira E, Kabatesi D, et al. Evaluating herbal medicine for the management of Herpes zoster in human immunodeficiency virus-infected patients in Kampala, Uganda. J Altern Complement Med. 1999;5(6):553-565.

Hu J. Acupuncture treatment of herpes zoster. J Tradit Chin Med. 2001;21(1):78-80.

Hui F, Cheng A, Chiu M, Vayda E. Integrative approach to the treatment of postherpetic neuralgia: a case series. Altern Med Review. 1999;4(6):429-435.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 174-175.

Kenney JK, Jamjian C, Wheeler MM. Prevention and management of pain associated with herpes zoster. J Pharm Care Pain Symptom Control. 1999;7(3):7-26.

Leffowitz M, Marini RA. Management of postherpetic neuralgia. Ann Acad Med Singapore. 1994;23(Suppl):139S-144S.

Pieroni A. Medicinal plants and food medicines in the folk traditions of the upper Lucca Province, Italy. J Etnopharmacol. 2000;70(3):235-273.

Rains C, Bryson HM. Topical capsaicin: A review of its pharmacological properties and therapeutic potential in post-herpetic neuralgia, diabetic neuropathy, and osteoarthritis. Drugs Aging. 1995;7(4):317-328.

Reilly MP. Clinical applications of acupuncture in anesthesia practice. CRNA. 2000;11(4):173-179.

Sangkitporn S, Chaiwat S, Balachandra K, Dechatiwongse Na-Ayudahaya T, Bunjob M, Jayavasu C. Treatment of herpes zoster with Clinacanthus nutans (Bi Phaya Yaw) extract. J Med Assoc Thal. 1995;78(11):624-627.

Shingles. American Academy of Family Physicians Accessed at https://familydoctor.org/ on February 11, 2018.

Stankus SJ, Dlugopolski M, Packer D. Management of herpes zoster (shingles)and postherpetic neuralgia. Am Fam Physician. 2000;61(8):2437-2438.

Terbinafine. NMIHI. Accessed at http://www.nmihi.com/t/terbinafine.html

Ullman D. Homeopathic Medicine for Children and Infants. New York, NY: Penguin Putnam; 1992: 58-59.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995: 174-176.

Wu J, Guo Z. Twenty-three cases of postherpetic neuralgia treated by acupuncture. J Tradit Chin Med. 2000;20(1):36-37.

What are the symptoms of shingles? Cleveland Clinic. Accessed at https://my.clevelandclinic.org/ on February 11, 2018.