Varicella-zoster virus

Signs and Symptoms

Chickenpox

The typical rash of chickenpox is made up of groups of small, itchy blisters surrounded by inflamed skin. The rash usually starts on the face, scalp, or chest, and quickly spreads throughout the body. It usually appears a few days after you have been exposed. Over 4 days, each blister tends to dry out and form a scab, which then falls off 9 to 13 days later.

The rash may be preceded or accompanied by:

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

Shingles

The typical shingles rash starts as redness followed by blisters that usually cover only one side of your body. The rash follows the path of the nerve where the virus has lain dormant. About 50 to 60% of people with shingles have the rash on their trunk. The next most common site is one side of the face, which may even include the tongue, eye, or ear.

Before the rash appears, you will have warning symptoms of pain, usually a sharp, aching, piercing, tearing, or burning sensation, on the part of your 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.

Other symptoms may include:

• Fever
• Malaise (feeling unwell) and other flu-like symptoms, including muscle aches
• Headache
• Swollen lymph nodes
• Upset stomach

Causes

Chickenpox

Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), a type of herpes virus. The virus is spread when you come into contact with the rash, or by sneezing, coughing, and breathing. In other words, when someone with chickenpox sneezes or coughs, there are droplets with the VZV virus in the air. The person is contagious from 2 days before the rash appears until all of the blisters have crusted over.

Shingles

While shingles is caused by the same virus that leads to chickenpox, the way you develop this painful skin condition is different. After you have had chickenpox, the virus lives in a dormant state, as if it is hibernating, in nerve cells along your spine. Later in life, when it "wakes up", usually from a weakened immune system, aging, or other risk factor, the virus travels down the path of the particular nerve where it was "hibernating," causing pain followed by the rash. About 30% of people who have had chickenpox will develop shingles. Getting vaccinated can reduce your risk.

Risk Factors

Chickenpox

• Exposure to the virus if you have not had chickenpox nor received the vaccine
• Being under 10 years of age
• Time of year: late winter and early spring is the most common time that the virus is spread

Shingles

• Age (most common in people over 60)
• Stress
• Weakened immune system (for example, people with HIV/AIDS, or those taking drugs to suppress the immune system due to autoimmune diseases or organ transplants)
• Having had chickenpox before age 1

Diagnosis

Your doctor can usually diagnose chickenpox easily because of its characteristic rash. However, if there is any doubt, the doctor may view a scraping from one of the blisters under the microscope.

If you have shingles, your doctor can usually make a diagnosis from the history of pain and other symptoms and the rash itself. He or she may take a scraping from one of the blisters for a laboratory test.

Preventive Care

Chickenpox

• The chickenpox vaccine (Varivax) is given to children over 1 year old. If a person receives the vaccine before age 13, then he or she only needs one dose. If a person receives the vaccine when he or she is older than 13, a second dose is needed 1 to 2 months later.
• If you have never had chickenpox or the vaccine, avoid contact with anyone who has chickenpox.
• Children with chickenpox should be kept out of school or daycare until their doctor says otherwise to avoid spreading the virus.

Shingles

• If you have never had chickenpox, the chickenpox vaccine can reduce your risk of getting chickenpox and shingles. Even if you do get the disease, having had the vaccine reduces the risk of complications.
• The shingles vaccine (Zostavax) can reduce the risk of getting shingles among people who are over 60 and have had chickenpox. It does not completely ensure you will not get shingles. If you do develop shingles, being vaccinated reduces the severity and the risk of postherpetic neuralgia.

The shingles vaccine is not recommended for people who:

• Have ever had a reaction to gelatin or neomycin
• Have a weakened immune system
• Take drugs to suppress the immune system (such as corticosteroids)
• Have tuberculosis
• Have a history of lymphatic or bone marrow cancer

One study found that older adults who regularly practice tai chi had a better immune response to the varicella virus, and their immunity increased even more when they had the shingles vaccine.

Treatment Approach

Both chickenpox and shingles generally get better by themselves, unless you are at high risk for complications. The goal of treatment is to reduce pain and itching.

Lifestyle

You can reduce symptoms of chickenpox and shingles with some simple steps:

• Apply cool water compresses to your skin or soak in a bathtub filled with cool water
• Add finely ground oatmeal (there are special brands sold in drugstores) to the bathtub
• Apply calamine or an over-the-counter hydrocortisone lotion to the affected areas
• Trim your fingernails to avoid infection
• For small children with chickenpox, cover hands with loose fitting, soft cotton or flannel mittens to prevent scratching

Medications

Chickenpox

• Antihistamine. If itching is severe, your doctor may suggest an antihistamine (such as Benadryl).
• Acyclovir (Zovirax). An antiviral drug prescribed for children who are at high risk of complications from chickenpox, or for adults who have chickenpox.
• Pain relievers. Acetaminophen (Tylenol) and ibuprofen (Advil, Motrin) can help reduce pain. DO NOT give aspirin to children under 19 because of the risk of a rare but serious illness called Reye syndrome.

Shingles

Antiviral drugs. Most effective when started within 72 hours of the first sign of a rash, these drugs are often given to people who are at risk of postherpetic neuralgia. They include:

• Acyclovir (Zovirax)
• Famciclovir (Famvir)
• Valacyclovir (Valtrex)

Corticosteroids. Used with Zovirax to reduce inflammation.

Pain relievers. For pain associated with shingles, an over-the-counter pain reliever, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) may be effective. For severe pain, or pain associated with postherpetic neuralgia, your doctor may prescribe a narcotic (opioid) pain reliever.

For postherpetic neuralgia

Capsaicin. Contains a pain reliever derived from chili peppers that produces a burning sensation when applied to the skin. It is available as an ointment (Zostrix) or a patch. A 2003 study reported that the patch reduced pain by 33% in about half of people with postherpetic neuralgia.

Lidocaine patch (Lidoderm). Applied to the skin to reduce pain.

Tricyclic antidepressants. Low doses of tricyclics, especially nortiptyline (Pamelor), may help reduce pain.

Gabapentin (Neurontin). An anticonvulsant (antiseizure) medication that may also help reduce pain.

Nutrition and Dietary Supplements

Since supplements may have side effects or interact with medications, you should take them only under the supervision of a knowledgeable health care provider.

• Adenosine monophosphate (AMP). An early study looked at injections of AMP, a compound that is made by the body, for treating the initial symptoms of shingles, as well as preventing postherpetic neuralgia. Researches gave people with shingles injections of either 100 mg of AMP or placebo. At the end of 4 weeks, 88% of those who got AMP were pain free compared to 43% who got placebo. The study used injections of AMP, so researchers do not know if taking AMP orally would have any effect. People who take dipyridamole (Persatine) or carbamazepine (Tegretol) should not take AMP. People with heart disease or gout should not take AMP.
• Vitamins B-12 and E. A few studies suggest that vitamin E (1,200 to 1,600 mg per day) and injections of B-12 (but not oral B-12) might help reduce symptoms of postherpetic neuralgia. But the studies were not good quality, and more research is needed.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. However, herbs can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care practitioner.

• Cayenne (Capsicum frutescens/Capsicum spp.). Capsaicin cream made from cayenne pepper can relieve pain when applied to the skin. Capsaicin may help relieve the pain of post herpetic neuralgia, and an over-the-counter ointment is approved for this treatment (see Medications). Capsaicin causes burning when applied to the skin, so use sparingly and do not use around eyes, nose, or mouth.
• German Chamomile (Matricaria recutita). Traditionally, this herb has been used topically to treat skin conditions and childhood illnesses like chickenpox. However, no scientific studies have examined whether chamomile is helpful in treating chickenpox. Chamomile interacts with a number of medications, so ask your doctor before taking it. People who are allergic to ragweed, chrysanthemums, daisies, and other members of the aster family, should not take chamomile.
• Licorice (Glycyrrhiza glabra). Traditionally, licorice gel has been used topically (applied to the skin) to treat shingles and postherpetic neuralgia. In test tubes, one of the constituents of licorice, called glycyrrhizin, stops the varicella zoster virus from reproducing. However, no scientific studies have examined whether licorice gel is helpful in treating either shingles or postherpetic neuralgia. Licorice, if absorbed systemically, interacts with a number of medications, and can potentially aggravate certain medical conditions, such as hypertension. Ask your doctor before using it.

Acupuncture

Although the results of scientific studies have been mixed, acupuncture may help relieve the nerve pain associated with shingles, especially when combined with traditional medications. Acupuncturists treat people based on an individualized assessment of the excesses and deficiencies of qi (or energy) located in various meridians. In the case of shingles, a qi deficiency is usually detected in the liver meridian and an excess in the gallbladder meridian. Acupuncturists will often provide needle or moxibustion treatment (a technique in which the herb mugwort is burned over specific acupuncture points) around painful areas.

Homeopathy

Few studies have examined the effectiveness of specific homeopathic therapies, however, professional homeopaths may consider the following remedies for the treatment of chickenpox and shingles based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. Your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

Chickenpox:

• 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 cough.
• 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 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.
• Ranunculus 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 postherpetic neuralgia:

• Meditation
• Breathing exercises
• Progressive muscle relaxation
• Biofeedback

People with post herpetic neuralgia have reported some relief from using hypnosis.

Other Considerations

Pregnancy

If you get chickenpox when you are pregnant, the infection may spread to the baby.

Special Populations

If you have a weakened immune system, shingles blisters may spread to other parts of your body and it will likely take longer for the symptoms to heal, maybe lasting for months. Conditions that weaken your immune function include:

• HIV or AIDS
• Organ transplant recipient
• Cancer, especially leukemia, Hodgkin's disease and other lymphomas, or undergoing chemotherapy
• Having an autoimmune disease (such as rheumatoid arthritis, lupus, multiple sclerosis, and Crohn's disease)
• Taking drugs that suppress your immune system

Warnings and Precautions

• Do not give aspirin to children under 19 due to the risk of a rare but serious illness called Reye's syndrome.
• Call your doctor if you experience confusion, vomiting, or weakness, even paralysis, of the arms, legs, trunk, or face during or soon after a chickenpox or shingles infection.

Prognosis and Complications

While chickenpox usually goes away on its own, severe and sometimes fatal infections may occur, particularly in newborn infants, adults, and people whose immune systems are weakened. Potential infections include:

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

Shingles usually clears up in 2 - 3 weeks. Your chance of getting another bout of shingles is only 1 - 5% if you have a healthy immune system. If you have a weakened immune system (see Special Populations), 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.
• Postherpetic neuralgia, 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).

A growing body of research suggests that VZV may lead to a variety of neurologic complications, including encephalitis and meningitis.

Supporting Research

Arvin A. Principles and Practice of Pediatric Infectious Diseases. 4th ed. Philadelphia, PA: Elsevier Saunders; 2012.

Betts RF. Vaccination strategies for the prevention of herpes zoster and postherpetic neuralgia. J Am Acad Dermatol. 2007 Dec;57(6 Suppl):S143-S147.

Black: Obstetric and Gynecologic Dermatology. 3rd ed. Philadelphia, PA: Elsevier Mosby; 2008.

Cohen J. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011.

Davies SJ, Harding LM, Baranowski AP. A novel treatment of postherpetic neuralgia using peppermint oil. Clin J Pain. 2002;18(3):200-2.

Frisch S, Guo A. Diagnostic Methods and Management Strategies of Herpes Simplex and Herpes Zoster. Clinics in Geriatric Medicine. Philadelphia, PA: W.B. Saunders Company. 2013;29(2).

Gould D. Varicella zoster virus: chickenpox and shingles. Nurs Stand. 2014;28(33):52-8.

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

Irwin MR, Olmstead R, Oxman MN. Augmenting immune responses to varicella zoster virus in older adults: a randomized, controlled trial of Tai Chi. J Am Geriatr Soc. 2007 Apr;55(4):511-7.

Johnson RW, Whitton TL. Management of herpes zoster (shingles) and postherpetic neuralgia. Expert Opin Pharmacother. 2004 Mar;5(3):551-9. Review.

Lamont RF, Sobel JD, Carrington D, et al. Varicella-zoster virus (chickenpox) infection in pregnancy. BJOG. 2011;118(10):1155-62.

Nagel MA. Varicella zoster virus vasculopathy: clinical features and pathogenesis. J Neurovirol. 2014;20(2):157-63.

Nagel MA, Gilden D. Neurological complications of varicella zoster virus reactivation. Curr Opin Neurol. 2014;27(3):356-60.

Niv D, Maltsman-Tseikhin A. Postherpetic neuralgia: the never-ending challenge. Pain Pract. 2005 Dec;5(4):327-40.

Pieroni A. Medicinal plants and food medicines in the folk traditions of the upper Lucca Province, Italy. J Etnopharmacol. 2000;70(3):235-73.

Powell DR, Patel S, Franco-Paredes C. Varicella-Zoster Virus Vasculopathy: The Growing Association Between Herpes Zoster and Strokes. Am J Med Sci. 2015;350(3):243-5.

Reilly MP. Clinical applications of acupuncture in anesthesia practice. CRNA. 2000;11(4):173-9.

Roxas M. Herpes zoster and postherpetic neuralgia: diagnosis and therapeutic considerations. Altern Med Rev. 2006 Jun;11(2):102-13. Review.

Silver B, Zhu H. Varicella zoster virus vaccines: potential complications and possible improvements. Virol Sin. 2014;29(5):265-73.

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

Tyring SK. Management of herpes zoster and postherpetic neuralgia. J Am Acad Dermatol. 2007 Dec;57(6 Suppl):S136-S142. Review.

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

Young MK, Wood M, Jean-Noel N. Postherpetic neuralgia in older adults: culture, quality of life, and the use of alternative/complementary therapies. Holist Nurs Pract. 2007 May-Jun;21(3):124-34. Review.