When the itchy red spots of childhood chickenpox disappear and
life returns to normal, the battle with the virus that causes chickenpox
seems to be won. But for all too many of us this triumph of the body's
immune system over the virus that causes chickenpox is only temporary. The
virus has not been destroyed, but lays low, ready to strike again later in
life. This second eruption of the chickenpox virus is the disease called
"I was having exams at college and I got a rash in a band around my
waist. I first thought it was chickenpox, but I'd had that years before
and instead of itching, this time the spots were very painful," recalls a
young woman who had shingles in her twenties.
The young woman's memory was correct. She had had chickenpox as
a child. You cannot develop shingles unless you have had an earlier bout
of chickenpox, and everyone who has had chickenpox is at risk for
shingles. The woman had the typical symptoms of shingles, this common neurological
disorder: more pain compared to chickenpox but less itching. Her age was
unusual, however. While young people do develop shingles, the disease most
often strikes in later years.
Scientists call the chickenpox/shingles-causing agent
varicella-zoster. Varicella is a Latin word meaning "little pox" to
distinguish the shingles virus from smallpox, the highly contagious and often fatal
scourge that disfigured or killed millions of people, especially during
the Middle Ages. Zoster is the Greek word for "girdle"; shingles often
produces a girdle of blisters or lesions around the waist. This striking
pattern also gives the disease its common name: the word shingles comes
from cingulum, the Latin word for belt or girdle.
What is Shingles Virus?
Scientists believe that in the original battle with the chickenpox
virus some of the virus particles leave the skin blisters and move into
the nervous system. There the viruses settle down in an inactive (latent)
form inside specific nerve cells (neurons) that relay information
to the brain about what your body is sensing — whether your skin feels hot
or cold, whether you've been touched or feel pain. These lie in clusters
(ganglia) adjacent to the spinal cord and brain and are one type of
When the chickenpox virus reactivates, the virus moves down the long
nerve fibers that extend from the sensory cell bodies to the skin. The
viruses multiply, the telltale rash erupts, and the person now has herpes
zoster, or shingles. With shingles, the nervous system is more deeply
involved than it was during the bout with chickenpox, and the symptoms of
shingles are often more complex and severe.
The virus responsible for shingles and chickenpox belongs to a group of
viruses called herpesviruses. This group includes the herpes
simplex virus that causes cold sores, fever blisters, mononucleosis,
genital herpes — a sexually transmitted disease, and Epstein-Barr virus
involved in infectious mononucleosis. Like the shingles virus,
many other herpesviruses can take refuge in the nervous system after an
individual has suffered an initial infection. These viruses may remain
latent for years, then travel down nerve cell fibers to cause a renewed
The varicella-zoster shingles virus looks as though it were designed by a
mathematician. It is a microscopic sphere encasing a 20-sided geometric
figure called an icosahedron. Inside the icosahedron is the genetic
material of the virus, deoxyribonucleic acid (DNA). When activated, the
shingles virus reproduces inside the nucleus of an infected cell. It acquires its
spherical wrapping as it buds through the nuclear membrane.
Who is at Risk for Shingles Virus?
About 10 percent of normal adults can be expected to get shingles
during their lifetimes, usually after age 50. The incidence increases with
age so that shingles is 10 times more likely to occur in adults over 60
than in children under 10. Most people who get the condition develop immunity
to the shingles virus and will not get the disease again, however, shingles may
recur in some individuals. These cases usually involve people with
declining or compromised immune systems, such as those infected with HIV
or receiving chemotherapy.
A person who is suffering from a disease that damages the immune
system, or who is taking anticancer drugs that suppress the immune system,
is a prime candidate for an attack of shingles. Even among healthy
individuals, temporary depression of the immune system because of stress,
a cold, and even sunburn may be associated with an attack of shingles.
Youngsters whose mothers had chickenpox late in pregnancy — 5 to 21
days before giving birth — are also vulnerable to shingles. Sometimes
these children are born with chickenpox or develop a typical case within a
few days (see section entitled "Do Women Have Special Risks from Shingles"
for more information).
What are the Symptoms of Shingles?
The first sign of shingles is often burning or tingling pain, or
sometimes numbness, in or under the skin. The individual may also feel ill
with fever, chills, headache, or stomach upset. After several days, a rash
of small fluid-filled blisters, reminiscent of chickenpox, appears on
reddened skin. The pain associated with shingles can be intense and is
often described as "unrelenting." People with lesions on the torso may
feel spasms of pain at the gentlest touch or breeze. The blisters are
usually limited to a band, called dermatomes, spanning one side of the
trunk, around the waistline, or clustered on one side of the face.
The distribution of the shingles spots is a telltale clue to where the
chickenpox virus has been hiding since the initial infection. Scientists
now know that the shingles lesions correspond to the dermatome supplied by
a specific sensory nerve that exits from the brain or spinal cord.
For the majority of healthy individuals, this second bout with the
chickenpox virus is almost always a second triumph of the body's immune
system. The shingles attack may last longer than chickenpox, and the
patient may need medication for pain, but in most cases the body has the
inner resources to fight back. The lesions heal, the pain subsides within
3 to 5 weeks, and for most patients the blisters leave no scars.
The severity and duration of an attack of shingles can be significantly
reduced by immediate treatment with antiviral drugs, which include
acyclovir, valacyclovir, or famcyclovir. Antiviral drugs may also help
stave off the painful aftereffects of shingles known as postherpetic
neuralgia (see section entitled "What are the Complications of
Shingles?). Doctors now recommend starting antiviral drugs within 72 hours
of the first sign of the shingles rash. Early treatment is believed to
reduce the risk of postherpetic neuralgia and may speed up the healing
process. Other treatments for post-herpetic neuralgia include steroids,
antidepressants, anticonvulsants, and topical agents. Scientists continue
to work toward developing newer antiviral agents and more effective pain
Is Shingles Virus Contagious?
As early as 1909 a German scientist suspected that the viruses causing
chickenpox and shingles were one and the same. In the 1920's and 1930's
the case was strengthened. In an experiment, children were inoculated with
fluid from the lesions of patients with shingles. Within 2 weeks about
half the children came down with chickenpox. Finally in 1958 detailed
analyses of the viruses taken from patients with either chickenpox or
shingles confirmed that the viruses were identical.
This study also proved that a person with shingles can pass the virus
to individuals who have never had chickenpox, but these individuals will
develop chickenpox not shingles. A person with chickenpox cannot
communicate shingles to someone else. In order for people to develop
shingles they must already harbor the virus in their nervous system, and
for those who do harbor the shingles virus, having contact with someone with
chickenpox will not trigger shingles. Additionally, a person with shingles
cannot communicate shingles to another individual.
What are the Complications of Shingles Virus?
People with "optical" shingles (where the shingles virus has invaded an
ophthalmic nerve) may suffer painful eye inflammations that leave them
temporarily blind or impair their vision. Individuals with this type of
shingles should see an ophthalmologist immediately. If shingles appears on
the face and affects the auditory nerves, it can also lead to
complications in hearing. Infections of facial nerves can lead to
Postherpetic NeuralgiaSometimes, particularly in older people,
symptoms of shingles persist long after the rash is healed. In these
cases, facial paralysis, headache, and persistent pain can be the
aftermath. Possibly because the nerve cells conveying pain sensations are
hardest hit, or are exquisitely sensitized by the shingles virus attack, pain is
the principal persistent complication of shingles symptoms. This pain, called
postherpetic neuralgia, is among the most devastating known to mankind —
the kind of pain that leads to insomnia, weight loss, depression, and that
total preoccupation with unrelenting torment that characterizes the
chronic pain sufferer.
Although it can be extraordinarily painful, postherpetic neuralgia is
not life-threatening. Doctors treating the pain currently employ a variety
of medications. Powerful narcotic pain relievers can offer relief but,
because they can have serious side effects, doctors often prescribe newer
nonaddictive but potent painkillers. Ointments containing capsaicin, the
heat-producing ingredient found in hot chili peppers, are effective in
relieving pain from postherpetic neuralgia, as well as pain from other
disorders such as arthritis. Such ointments are currently available by
prescription. Although these creams contain less than 1 percent capsaicin,
new research suggests that patients may be able to tolerate creams
containing 5 to 10 percent of this active ingredient if used in
combination with other pain killers. More research is needed before these
higher dose ointments will be available to patients with postherpetic
neuralgia (see section entitled "What Research is Being Done?").
In 1999, the Food and Drug Administration approved a new method of
treating the pain of postherpetic neuralgia. The product is an adhesive
patch containing lidocaine, a commonly used local anesthetic. The patch
allows lidocaine to be released into the top layers of the skin, reducing
pain from the damaged nerves. Because it delivers the drug via the skin,
it does not produce any significant levels of the drug in the blood and,
therefore, does not cause serious systemic side effects if used
Studies have also shown that some anticonvulsant drugs used to treat
epilepsy, such as carbamazepine, are sometimes effective in relieving the
pain of postherpetic neuralgia. Antidepressants can help also. In addition
to their effects on mood, the antidepressants appear to relieve pain. Some
doctors report that patients occasionally benefit from alternative
treatments for pain, such as acupuncture and electrical stimulation of
It is important to realize that individuals with postherpetic neuralgia
no longer have shingles: their infection is over. Instead, they are
suffering from damage to the nervous system. Scientists believe that the
shingles virus attack has led to scarring or other lesions affecting the cells in
sensory ganglia and associated nerves. Even in such severe cases, however,
the paralysis, headaches, and pain generally subside, although it may take
Is Shingles Life-Threatening?
Shingles is a serious threat to life in immunosuppressed
individuals — for example, those with HIV infection or patients with
cancer who are receiving treatments that can weaken their immune systems.
These treatments destroy cancerous tissue but unfortunately they also have
the potential to damage cells of the immune system that normally fight
invading organisms. Patients who receive organ transplants (for kidney
disease, for example) are also vulnerable to shingles. To prevent the body
from rejecting the foreign tissue of the transplant, these patients are
given drugs that suppress the immune system. Should any of these patients
contract shingles, there is a possibility that the zoster shingles virus will
spread throughout the body, reaching vital organs like the lungs. If
unchecked, such disseminated zoster can lead to death from viral pneumonia
or secondary bacterial infection.
Do Women Have Special Risks from Shingles?
Many mothers-to-be are concerned about any infection contracted during
pregnancy, and rightly so. It is well known that certain viruses can be
transmitted across the mother's bloodstream to the fetus, or can be
acquired by the baby during the birth process.
Maternal chickenpox poses some risk to the unborn child, depending upon
the stage of pregnancy during which the mother contracts the disease.
During the first 30 weeks, maternal chickenpox may, in some cases, lead to
congenital malformations. Such cases are rare and experts differ in their
opinions on how great the risk is.
If the mother gets chickenpox from 21 to 5 days before giving birth,
the newborn may have chickenpox at birth or develop it within a few days,
as noted earlier. But the time lapse between the start of the mother's
illness and the birth of the baby generally allows the mother's immune
system to react and produce antibodies to fight the shingles virus. These
antibodies can be transmitted to the unborn child and thus help fight the
infection. Still, a third of the babies exposed to chickenpox in the 21 to
5 days before birth develop shingles in the first 5 years of life because
the shingles virus must also be fought by immune cells.
What if the mother contracts chickenpox at precisely the time of birth?
In that case the mother's immune system has not had a chance to mobilize
its forces. And although some of the mother's antibodies will be
transmitted to the newborn via the placenta, the newborn will have
precious little ability to fight off the attack because the immune system
is immature. For these babies chickenpox can be fatal. They must be given
"zoster immune globulin," a preparation made from the antibody-rich blood
of adults who have recently recovered from chickenpox or shingles.
What Research is Being Done?
Because of the nervous system involvement, the chickenpox/shingles
virus is of great interest to the National Institute of Neurological
Disorders and Stroke, a component of the National Institutes of Health
(NIH) and the principal Federal agency supporting research on the nervous
system. The disease is of equal interest to another branch of the NIH —
the National Institute of Allergy and Infectious Diseases (NIAID). In
addition, the National Cancer Institute (NCI) and the National Institute
on Aging (NIA) support research on shingles: NCI's interest in the
disorder relates to the high incidence of shingles in patients receiving
immunosuppressant treatments for cancer, and NIA conducts studies because
of the prevalence and severity of the disease among elderly adults.
Shingles poses two immediate challenges to medical research. The first
is to develop drugs to fight the disease and to prevent complications. The
second challenge is to understand the disease well enough to prevent it,
especially in people known to be at high risk. To protect susceptible
patients from a shingles attack scientists need to know much more about
the varicella-zoster virus, especially how it remains latent in the body
for so long and what induces it to become active again. NIA-supported
scientists are studying the biology of the varicella-zoster virus in an
effort to gain a better understanding of the molecular basis of viral
latency and reactivation.
Although the shingles virus is presumed to hide in the nervous system between
bouts of chickenpox and shingles, it has never been recovered from nerve
cells at autopsies unless the patient had shingles at the time of death.
In contrast, herpes simplex, which causes recurrent infections of cold
sores and fever blisters, has been identified in spinal nerve cells during
its latent periods.
If the whole varicella-zoster virus does not remain intact in nerve
cells, perhaps its core genetic material — the DNA — survives. Scientists
suspect that the viral DNA may be inserted into one of the chromosomes of
the nerve cell — the larger units that house the cell's own genetic
What keeps the varicella-zoster virus quiet during its long latency?
Probably the immune system. A healthy immune system protects against all
kinds of diseases, but people with depressed immunity are vulnerable to
many illnesses, and have a high incidence of shingles. Antibodies, one of
the immune system's major defense mechanisms against infection, are not
very helpful against shingles. Studies have shown that patients with
shingles produce varicella-zoster antibodies but they don't halt the
infection. Similarly, injections of antibody-rich blood serum do not
prevent the dissemination of shingles in cancer patients or others whose
immune systems are depressed. (This is in contrast to the protection
conferred by the immunoglobulin given to newborns with chickenpox.)
The components of the immune system that do appear to combat shingles
are two types of white blood cells: the T lymphocytes and scavenger cells
called macrophages. Scientists are trying to find ways of boosting the
activity of these cells — especially in patients at high risk for severe
or disseminated shingles (a rare condition in which the virus spreads to
other areas of the body, sometimes vital areas such as the blood or the
Current research is aimed at finding new methods for treating shingles
and its complications. In one NINDS-supported study, investigators are
studying the effectiveness of a long-acting preparation of morphine (a
type of analgesic used to manage pain) as a possible treatment for
postherpetic neuralgia. Research from this study could lead to improved
treatment for this condition, which complicates many cases of
Capsaicin ointment (containing less than 1 percent of the active
ingredient) is a currently available treatment for the pain of shingles,
especially postherpetic neuralgia. In 1998 a group of scientists tested a
higher dose capsaicin cream (5 to 10 percent) in a small group of patients
suffering from pain caused by a number of different conditions, including
diabetes, arthritis, and HIV infection. Seven of ten patients reported a
50 percent reduction in pain after using these higher dose creams. Further
studies, using larger groups of patients, will be conducted to establish
the safety and effectiveness of this promising treatment, which could
bring relief to patients suffering from postherpetic neuralgia.
The development of preventive measures and treatments for shingles has
long been hindered by scientists' difficulty in working with the
varicella-zoster virus in the laboratory. The virus grows very poorly in
laboratory cells and does not infect animals other than man. Recently,
however, the Department of Veteran Affairs (VA) launched a nationwide
trial — the Shingles Prevention Study — to study an experimental shingles
vaccine (see the Information Resources card in the back pocket of this
brochure for information on the VA trial). In the study, which is a
cooperative Federal government effort involving the VA and NIAID,
investigators will test a more potent version of the vaccine currently
used to immunize children against chickenpox. The purpose of the trial is
to find out if the vaccine is safe and how well it works to prevent
shingles. Successful results would represent a big step toward eradicating
Although shingles will continue to afflict people in the years to come,
there is now hope that scientists are close to creating a vaccine capable
of preventing this painful condition. In the course of this work on
vaccines, scientists expect to uncover important information to use
against other diseases, to learn more about the body's immune system, and
ultimately to outwit the clever viruses that evade that system.
On Catching Chickenpox . . . but not Catching ShinglesChickenpox
and shingles are caused by the same virus — varicella-zoster. When a
person, usually a child, is first exposed to the varicella-zoster virus,
he or she develops chickenpox, a highly contagious disease. Most of us
catch it during childhood because the virus can be spread through air as
well as through contact with the rash. The infection begins in the upper
respiratory tract where the virus reproduces over a period of 15 days or
more (the incubation period). The virus then spreads to the bloodstream
and migrates to the skin, giving rise to the familiar rash.
In contrast, you can't catch shingles. You must already have had a case
of chickenpox and harbor the virus in your nervous system to develop
shingles. When reactivated - most often because the immune system is
weakened, allowing the virus to break out of its dormant state — the virus
travels down nerves to the skin causing the painful shingles rash. In
shingles, the virus does not normally spread to the bloodstream or lungs,
so the virus is not shed in air. Because the shingles rash contains active
virus particles however, a person who has never had chickenpox can
contract chickenpox by exposure to the shingles rash.
Keeping on Top of Your Condition
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More Information on Shingles Virus
P.O. Box 5801
Bethesda, Maryland 20824
VZV Research Foundation
40 East 72nd Street
New York, NY
American Chronic Pain Association
P.O. Box 850
National Chronic Pain Outreach Association, Inc.
Millboro, VA 24460
National Foundation for the Treatment of Pain
1330 Skyline Drive,
Monterey, CA 93940