In my practice, I treat individuals who suffer from chronic pain, which is caused by various medical conditions involving the musculoskeletal or the neurologic systems of the body. I frequently see patients who had shingles a few months ago and are now suffering from a complication of shingles called Post-Herpetic Neuralgia (PHN). In this article, I will briefly discuss shingles, but will explain PHN, its symptoms and its treatment in great detail.
Shingles are caused by a reactivation of the chicken pox virus (herpes zoster) in older adults. To get shingles, you must have had the chicken pox earlier in your life. While shingles can occur in younger adults, usually those who have compromised immune systems, they are most frequently seen in adults over the age of 50. Shingles are not contagious UNLESS a person who has never had the chickenpox is exposed; only then is there a small chance of transmission among individuals. There is a relatively new vaccine for shingles that can be administered after the age of 50 (60 is recommended), which has proven to be 50% effective in preventing shingles and 67% effective in preventing PHN, per the CDC website. The vaccine cannot be given during an active case of shingles.
If you have ever had a fever blister, aka cold sore, on your lips or face, you know how they tingle, itch, burn and hurt. The blister leaks fluid and forms a crust while healing, which is also unpleasant. Imagine having those blisters over a large part of your body and you can begin to understand what a patient who has a bad case of shingles is enduring.
Shingles usually present as a burning, tingling or stabbing pain on the truck, legs or back; however, they can occur anywhere on the body. Because they follow nerve pathways, the outbreak might be on one side of the body only. After a few days, most people will develop a rash of small, fluid-filled blisters in the painful area (although some persons never develop the rash). The blisters will leak a pus-like fluid and will slowly crust up, which indicates that they are healing. This rash will last anywhere from 1-3 weeks. The pain can be very intense and debilitating during this phase of the illness; however, the majority of patients will recover with few lingering effects.
Unfortunately, there are patients who will be left with a very painful reminder of their shingles outbreak and who will suffer from neuropathic pain for the rest of their lives. Sometimes, the nerve fibers in the affected areas are permanently damaged during an active case of shingles. This damage causes the nerve signals to become confused and hyperactive, causing the severe pain and discomfort that is characteristic of PHN.
The main symptoms of PHN are:
- Pain – most describe the pain as stabbing, burning or aching
- Numbness or Tingling
- Sensitivity to stimulus (Allodynia) – making touch or wearing clothing uncomfortable or unbearable
- Paralysis or Weakness
When I see a patient who has recently had shingles and reports having these symptoms, I do not have to run diagnostic tests to make the diagnosis of PHN.
Because PHN is so painful and distressing to the patient, I try to address first the symptoms that are most difficult. Like many other neuropathic conditions, PHN responds best to a multi-modal approach to treatment, meaning I may use a combination of drugs or therapies to help the patient feel better.
Opioid Drugs – These are the heavy-hitters of the pharmaceutical world. Narcotic pain medications may be needed to help with the severe pain of PHN; however, the side-effects are many and the patient can become addicted to these strong drugs. I try to use opioids only when absolutely necessary and control them carefully.
Anti-convulsants/Anti-seizure medications (e.g., Lyrica, gabapentin) – these drugs help to calm abnormal electrical impulses in the nervous system and can help alleviate some of the painful symptoms.
Antidepressants (e.g., Cymbalta) – Used in combination with other drugs, some antidepressants can help by affecting how your brain interprets pain signals by affecting the brain’s own chemistry. This can be very helpful to some patients in relieving their pain.
Prescription Pain Medication Patches (e.g., Lidoderm) – this is a different drug delivery method, whereby patients apply an adhesive patch, impregnated with pain relieving/numbing medication, to the painful site on the body. The patch can be worn for 12 hours during which the medication is released from the patch and absorbed into the skin.
Capsaicin Patches – Using a derivative made from a hot pepper to relieve pain, capsaicin can be delivered by a patch or in gel form. The mild burning sensation generated by the medication can be very soothing to those suffering from neuropathic pain. It can be purchased OTC or a more powerful dose (along with a numbing medication) can be administered by a Pain Management Specialist, for long term relief.
TENS units – These small, portable devices allow you to place adhesive leads on the affected areas of the body and administer a very low level of electrical current which can be modulated to best relieve pain.
Nerve blocks – These work by delivering a steroid medication (sometimes combined with a numbing agent and/or an opioid) directly at the site of the nerve, reducing the inflammation and numbing the pain. These may be done once or multiple times.
Neurolytic blocks – This involves freezing, burning or chemically injuring the offending nerve fibers so that the pain signal is temporarily disrupted. When the nerve fibers heal and regrow, many times they do so without sending pain signals to the brain.
Spinal Cord Stimulation – This procedure involves the permanent, surgical implantation of a battery that delivers a programmable electric current directly to the nerve roots. The site of spinal implantation directly correlates to the location of the nerve roots controlling the area of the body affected by PHN. Often considered the last resort of treatment due to its expense, SCS is effective at reducing pain levels in severe, intractable cases of PHN.
What You Can Do at Home
Learning to live fully with a painful condition for the rest of your life can be overwhelming and frustrating. However, becoming actively involved in your own care can be very empowering. It helps to feel a sense of control when you fully understand your condition, what triggers cause it to flare and what you can do to help yourself. Here are the self-help guidelines that I recommend to my patients:
- Learn about and understand your condition. Knowledge is power and by becoming an expert on PHN, you can help your physician treat you more effectively. You can also explain your condition to others and help them to understand how you are feeling and why you may have to say “no” sometimes when you are not feeling well.
- Talk/pray about it. Talk with your spouse, a good friend or a member of the clergy about your pain. Spending some time in prayer can be very therapeutic. It helps to have someone to listen and to understand what you are going through with PHN.
- Keep a pain journal. By charting how you feel each day, you may be able to identify potential triggers for your symptoms and learn what makes you feel better. This journal can become invaluable to you as a resource.
- Expect to have good days and bad days and plan your life accordingly. When you make plans, cut yourself some slack. If you are not feeling well, take time to care for yourself. If you are feeling great, do something fun that you enjoy. Your friends and loved ones will understand and make allowances for your condition.
- Start and maintain a gentle exercise program. While this may not be feasible during a severe flare of PHN, try to get some exercise each day. Take a walk, do some gentle stretching or yoga, or go for a swim. Exercise is a proven mood-lifter and produces “feel good” endorphins which can help to alleviate your pain.
- Get your mind off of your pain. There are a myriad of studies that prove pain can be greatly reduced when the pain sufferer focuses on something that they find interesting and engaging. Call a friend, watch a movie, knit a sweater, or paint a picture. Volunteer your time to teach someone to read. When we take the focus off of ourselves, we feel less pain.
If you are reading this article and have never had shingles, you would do well to remember that prevention of PHN is one of the biggest gifts that you can give yourself as you age. Know the warning signs of shingles and seek immediate medical attention if you have symptoms. Taking action to treat your shingles quickly is your best bet to prevent the painful complication of PHN.
If you suspect you have shingles, it is very important to see a physician immediately. Immediate treatment with anti-viral drugs can greatly lessen the severity of the outbreak and the chances of developing PHN. Steroids may also be used, although their efficacy is questioned.
Raj N. Sureja is a Board-Certified, Fellowship-Trained Interventional Pain Management Specialist who practices at Orthopaedic & Spine Center in Newport News, VA. Voted a “Top Doc” in 2012 and 2013, Dr. Sureja specializes in treating painful musculoskeletal and neurogenic conditions. For more information on Dr. Sureja, go to www.osc-ortho.com or call 757-596-1900 for an appointment.