Shingles has been in the public discourse recently after singer Justin Bieber, and senator Dianne Feinstein said they had it.
Shingles is caused by the varicella-zoster virus and requires speedy treatment to avoid complications.
It can occur in people of any age. Risk factors also include those who are immunocompromised, on certain medications, or have high-stress levels.
People are talking about shingles a lot lately—especially as recent news reports revealed that pop star Justin Bieber, 29, and senator Dianne Feinstein, 89, were both diagnosed with the infection. Shingles is caused by the varicella-zoster virus (VZV), which is also often referred to as herpes zoster. 
Bieber was also diagnosed with Ramsay Hunt syndrome (or herpes zoster oticus), which can cause facial paralysis and hearing damage. Bieber told his fans in a video that his facial paralysis affected his eye, nostril, and mouth on one side—but that it would get better. Ramsay Hunt syndrome is a complication of shingles.
A shingles overview
Shingles is a viral infection caused by the varicella-zoster virus, which lies dormant in the dorsal root ganglia in people who’ve had chickenpox. Later in life, it can re-emerge—not as chickenpox but as shingles.
It’s marked by a burning or stinging sensation, as well as a cutaneous eruption of red blisters. The rash typically emerges in a strip formation, wrapping around one side of the torso—although it can occur on the face or on other body parts. It can present bilaterally, but this is atypical.
If you suspect your patient has shingles, it’s worth asking them if they recall having chicken pox as a child. According to the CDC, 99.5 percent of Americans born before 1980 had chickenpox, so even if many of your adult patients don’t recall having had chickenpox, there’s a good chance they have. The first symptom that patients may notice is a sensation of slight pain, burning, or tingling—typically on only one side of the body. They may also present with a slight reddish mark or spot. Within one to five days, they may see a larger rash bloom. Afterwards, the rash usually turns to fluid-filled blisters, which dry up within a week to 10 days. All in all, shingles symptoms last about two weeks, with the virus retreating again to the ganglia.
It’s important that patients with shingles prevent spreading the virus to others. Someone with shingles cannot give shingles per se to another person, but direct contact with the rash can lead to chickenpox in people who haven’t had chickenpox already.
It’s crucial that your patients are told to cover the rash, wash their hands often, and avoid contact with others, especially pregnant women who haven't had chickenpox, premature infants, and immunocompromised people—including those on immunosuppressive medications. Patients with shingles must avoid people with HIV.
Risk factors associated with shingles
Shingles is an opportunistic virus, says Stella Bard, M.D., It is associated with age, certain health conditions, medications that suppress the immune system (like biologics or steroids), or a weakened immune system.
According to research in the British Journal of Dermatology, stress may also be a culprit. “High levels of psychological stress,” the study’s authors write, are associated with increased risk of herpes zoster. Bard agrees.
One of the major misconceptions about shingles is that it only occurs in older patients. Perhaps you’ve even had a younger patient surprised by their shingles diagnosis. As seen in Bieber’s case, this is not accurate.
According to Dina D. Strachan, M.D., director of Aglow Dermatology, “Traditionally, shingles would occur in people over 50 or those with compromised immunity. With vaccination against chickenpox in childhood, there seems to be a reduced immune response or opportunity for naturally boosted exposure, so it is now more common for younger, healthy people to develop shingles.” Nevertheless, shingles' risk increases with age, according to the Centers for Disease Control and Prevention. Incidences jump from five cases per every 1,000 adults between the ages of 50 and 59 to eleven cases per every 1,000 adults over the age of 80.
Shingles can cause complications, including pneumonia, hearing loss, or encephalitis, although the most common complication is postherpetic neuralgia (PHN), which occurs in about 10 percent-18 percent of individuals who have shingles. The likelihood of PHN increases in people over 40.
PHN can take several forms, including a “constant deep, aching, or burning pain; a paroxysmal, lancinating pain; hyperalgesia (painful stimuli are more painful than expected); and allodynia (pain associated with typically non-painful stimuli),” according to research in Current Pain and Headache Reports.
Another potentiality? Recurrent shingles. For some time, it was thought that shingles only occurs once in a lifetime. That is not accurate. In fact, recurrent shingles does occur, and it’s largely associated with age: it occurs more frequently in people over the age of 50. Recurrence is also more common in women and people with hematologic malignancies and autoimmune diseases.
Patients presenting with shingles need to be treated quickly. “Treatment with antiviral drugs and analgesics within 72 hours of rash onset has been shown to reduce severity and complications associated with herpes zoster and PHN,” according to the Indian Journal of Dermatology, Venereology, and Leprology. Treatments include acyclovir, famciclovir, and valacyclovir.
To prevent shingles and any risk of future complications, vaccination against both shingles and chickenpox is wise, says Bard.
The CDC recommends Shingrix, the recombinant zoster vaccine, for
Adults over 50 years (two doses, separated by 2 to 6 months)
Anyone over 19 with a compromised immune system due to disease or medication (two doses)
You should be aware of contraindications before encouraging your patients to get the vaccine, including pregnancy, current moderate illness, and fever, or allergy to the vaccine.
“The vaccine offers percent protection against shingles. It is both easily available and accessible to patients, as it is administered at their local pharmacy. It is prudent for anyone who has had chickenpox or shingles in the past to be vaccinated,” Bard says.