Everything you need to know about shingles (varicella zoster) in children and adults

So, what is shingles (varicella zoster)?

Heard of chickenpox? I’m sure you have. If you haven’t or can’t remember what it is, you can read about it here.
The virus that causes chickenpox (and shingles) is called Varicella Zoster Virus (VZV) and it is one of the 8 members found in the family of herpes viruses.
The first time a person catches this virus, he/she develops the characteristic illness that we are all familiar with, chickenpox, or varicella.
After the primary infection has occurred, just like the other members in the herpes family, this virus too remains dormant in our nervous system and can reactivate and cause an illness called shingles at a later time.
Would you like to hear some numbers here? Prior to the development of the vaccine for chickenpox, about 30% of those who had chickenpox (and practically everyone would have had chickenpox) developed shingles at some point in their life, 75% of these occurred after the age of 45.
So let me make this clear – shingles is a secondary illness caused by the same virus. The first time you catch the virus, you develop chickenpox and the second time that same virus reactivates it causes shingles.

How does shingles manifest?

The signs and symptoms of shingles include a vesicular rash in the trunk area that looks like a belt. It is one-sided and usually painful and itchy. See the image attached.
It is interesting that sometimes, especially in adults, the burning pain or the itching sensation precedes the rash by a few hours or days.
A more severe and widespread rash that extends beyond the shape of a belt can occur in immune deficient patients, in all the different age groups.

Can shingles occur without the development of a rash?

Yes, it is not very common for shingles to occur without the appearance of a rash but it can still happen. It is more difficult to diagnose shingles in these cases (also known as Zoster sine herpete).

What are the complications of shingles and who is at higher risk of developing them?

This illness has numerous potential complications.
The first potential complication is a secondary bacterial infection. Since the skin is injured, the bacteria found on our skin can secondarily infect the skin that is affected by the virus. Such cases require antibiotic therapy.
The second important complication that you should be aware of is that sometimes, even after the rash has resolved, there is a chronic pain that remains, and it indicates injury to the nerve in the area. This pain syndrome is referred to as postherpetic neuralgia, and it is defined as a prolonged pain lasting at least 3 months following the resolution of the rash. Its prevalence is 10-13% in people over the age of 50. Fortunately, this pain syndrome is rare, at least in children.
There are additional complications, mainly a disseminated infection including viral meningitis and the involvement of other organs, etc. And again, people who are immune deficient are at higher risk of these complications, regardless of their age.

Recently it turned out that there is a connection between shingles and dementia, more on that in the dedicated chapter about the vaccines.

So, who is at higher risk of getting shingles?

Generally speaking, and as I mentioned before, shingles is an illness that occurs in older adults, usually people over the age of 50.
Theoretically speaking, it can develop at any age, even in adolescents, but this is much less common.
When I see patients over the age of 10 with shingles, they usually have one of two risk factors:
a. They had chickenpox at a very young age, when they were under the age of 1 or 2 years. Chickenpox is quite mild at such a young age and this poses a greater risk of developing shingles in the future. Often the mothers do not even recall their baby having chickenpox at such a young age but remember that the older sibling having it when the younger was a baby (the illness is so mild for babies that it can go unnoticed).
b. Immune deficiency – not only do we tend to see more shingles in children who are immune suppressed, but their illness is usually more stubborn and widely spread.
However, usually, it is hard to know why a child randomly develops shingles one day. In summary, most cases occur in adults over the age of 50, without any particular reason and without a hidden underlying disease.

But children these days are vaccinated for chickenpox, so how does this affect shingles?

This is an additional benefit that the vaccine offers. It is not that the chickenpox vaccine prevents shingles from occurring whatsoever, but the prevalence of shingles in those who are vaccinated for chickenpox is lower than in those who aren’t.

Is shingles contagious?

Okay, try to focus because I get asked this question a lot and people tend to get confused with the answer.
The only people who can get infected from a person who has shingles are those who never had chickenpox or never got the chickenpox vaccine and have come into direct contact with the vesicles of the ill person. For these people, this will be the first exposure to the virus and they will develop chickenpox.
If a person has widespread shingles (which isn’t very common) they can transmit the infection through aerosols.
Keep in mind that shingles cannot cause shingles in someone else, because it is always caused by a reactivation of a virus found in the person’s body.

Is there any treatment for shingles after the rash has erupted?

Yes. Rapid treatment with one of the three antivirals: acyclovir, valacyclovir or famciclovir can shorten the course of the illness.
A few therapeutic concepts that you should be familiar with:
1. Start as soon as possible – starting the treatment after you’ve had the rash for 3 days is not very helpful, if at all. So, try to see a doctor as soon as the rash appears so you can start the antivirals as soon as possible.
2. Make sure you get the correct dose – unfortunately, there is great confusion when it comes to dosing of these drugs. The correct dose for adults is 800mg of acyclovir 5 (yes 5!) times a day for 5-7 days or 1 gram of valacyclovir 3 times a day for 7 days. You need to be monitored by a physician that knows how to treat shingles and what the benefits of each one of these antivirals are.
3. Immunodeficient people – usually require intravenous medication due to the concern for widespread illness.
4. Treatment of children who do not have any underlying medical conditions – it is not mandatory to treat these children because they tend to develop mild illness, without complications. However, each case should be considered for treatment individually.
5. Keep in mind that the earlier you start the treatment, the shorter the course of the illness. However, there is no evidence that antiviral medications reduce the risk of development of postherpetic neuralgia. It would make sense that the shorter the illness, the milder the pain syndrome, but this has not been proven in the medical literature.
6. Instead of treating a disease that has already erupted, let’s remember that preventing the illness is always better than catching the disease itself.

Is there a way to prevent shingles?

Yes, there is. You can get vaccinated. Make sure children get their chickenpox vaccines and adults get their shingles vaccines.
You’ll have to go to this link to learn more about the shingles vaccines.

In summary, shingles is a very unpleasant illness, more common in adults than it is in children, and it can leave behind neurologic effects that manifest with a very painful syndrome, especially in elders.

We have now learned what treatments are available once the disease has already erupted. In this next chapter, we will learn how to prevent shingles using a specific vaccine.

Good luck!