Jul 30, 2012

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

My sister-in-law, Anja, was in grade school with Olympian Clara Hughes. Ive even seen the Grade 1 photo with both of them in it. I heard a recent interview with Clara Hughes where she described some of her training races to prepare for the London Olympics. In some of these races, she beat the male cyclists. Her male competitors were not happy, and contemplated leaving the sport. They had a term for being beaten by a girl. They called it Being Chicked. Clara attributed her success in both cycling and speed skating to her big heart. No we are not talking about all her charitable work, apparently she has a physically large strong heart. She also says she loves the pain of training. While the pain of training for the Olympics may provide our athletes with a path to victory, the pain of shingles is nothing but misery.


Shingles is a condition caused by the same virus that causes chickenpox, varicella-zoster. This virus does not leave your body when the red itchy spots of chickenpox go away. Instead, it becomes the inactive in the nerve cells of your body. In some people, the virus reactivates later life and causes another rash. This time though, instead of being itchy, the rash is usually painful. This condition is known as shingles. The medical term for it is herpes zoster.


Doctors talk about two main things when they talk about shingles or herpes zoster. They talk about the reinfection of nerve cells by the virus and its accompanying rash, and they talk about postherpetic neuralgia. Postherpetic neuralgia is nerve damage pain that remains after the shingles rash is gone. In Canada each year, there are 130 000 new cases of shingles, 17000 cases of postherpetic neuralgia and 20 deaths. Postherpetic neuralgia can result in severe pain. Common sites of postherpetic neuralgia pain are the torso and the face. Sometimes the pain is so severe patients are unable to wear clothing that comes in contact with the lesions or to be outside in the wind because of the sensitivity of the skin on the torso and face. There have even been cases of loss of vision and facial scarring. Shingles and postherpetic neuralgia will probably increase as the population ages. The number of people with shingles who get postherpetic neuralgia rises from 10% among people of all ages to as high as 40% among those 50 years and older.


There are three main ways to treat shingles and postherpetic neuralgia. If someone already has the painful postherpetic neuralgia, the doctor will usually start with starting with a tricyclic antidepressant like amitriptylline or a medication like gabapentin. These medications will hopefully decrease the pain signals from the damaged nerves. Sometimes the doctor will add a narcotic painkiller like codeine or morphine as well. Unfortunately, randomized controlled trials have shown only a 20%40% reduction in severity of pain.. Often the doctor will have to throw several medications from several different nerve pain categories at postherpetic neuralgia. That is one of the places the Dauphin Clinic Pharmacy shines. We can make a topical ointment with up to 4-5 different nerve pain medications in it that can help the postherpetic neuralgia quite a bit. All in all, though, postherpetic neuralgia can be very difficult and painful to treat.


If we could reduce or eliminate the initial shingles rash, that would be better, right? Well, if you get to your doctor within 72 hours of the first sign of shingles, we can do something more. The first sign of shingles is often a tingling or burning sensation in the skin. This sensation may become quite painful and accompanied by fever and headache. The skin over the burning area then begins to redden and fluid filled blisters develop after two or three days. The blisters continue to form until the rash reaches its peak in three to seven days. Gradually, the blisters will break and form small ulcers which dry to form scabs. The scabs usually fall off into three weeks. If you see the doctor within 72 hours of that tingling, burning and reddening, the doctor can give you an antiviral like famciclovir. There is evidence that the early use of antivirals will provide relief for acute pain and hasten healing of the rash. We hope this will also reduce the chance of postherpetic neuralgia, but the evidence for using antivirals to prevent postherpetic neuralgia is weak.


The best option would be to prevent the shingles infection altogether. Now there is a shingles vaccine that been approved in Canada for people 50 years of age and older. It is called Zostavax and it prevents the shingles infection in 50% of the people who get it and postherpetic neuralgia in 67% of the people who receive the vaccine. It is believed that if someone who got the vaccine gets postherpetic neuralgia it may not be as painful. Something I learned when researching this article was that you can get shingles more than once. So, even if you have had shingles before, it is still reasonable to get the shingles vaccine.


The interesting thing about the shingles vaccine, Zostavax, is its storage requirements. It has to be stored frozen (below -15C) and it has to be injected within 30 minutes of being mixed. So you need to have a pharmacy with a freezer very close to a clinc where the injection can be given. This means the Dauphin Clinic Pharmacy is the only pharmacy I know of in the Parkland that has the Zostavax shingles vaccine in the Parkland.

The best way to prevent the pain of shingles is to get the vaccine. And now sit back, relax and watch our Olympic athletes do us proud in London. Go Canada Go!


The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional


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