Online Health Chat with Robert Bolash, MD
Thursday, May 7, 2015
Shingles affects one out of every three people in the United States. More than one million cases of shingles are diagnosed every year. The risk of shingles increases as you get older, and about half of the cases occur in men and women ages 50 and older. Shingles develops in about 10 percent of people who have had chickenpox at an earlier time in their life. People at risk for shingles are those who have a weakened immune system (such as people with cancer or HIV), are over the age of 50, have been ill or are under stress or experiencing trauma. People who are diagnosed with shingles usually have only one episode in their lifetime, but a person can have a second or third episode.
About the Speaker:
From Cleveland Clinic’s Department of Pain Management, Robert Bolash, MD, is board-certified in anesthesiology and pain medicine and sees patients at Cleveland Clinic. He is also an assistant professor of anesthesiology at the Cleveland Clinic Lerner College of Medicine. His specialty interests include arachnoiditis, arthritis, back pain in athletes, bursitis, chronic back pain, chronic myofascial pain (CMP), chronic neuropathic pain, coccydynia, herniated discs, knee injuries, musculoskeletal pain, myofascial pain syndrome, neck pain, nerve injuries, neuropathy, diabetic neuropathy, occipital headaches, radiculopathy, Raynaud’s phenomenon, sciatica, shingles (varicella-zoster virus), spinal fractures, spondylitis, spondylosis, spinal stenosis and whiplash. A graduate of University of Miami Medical School in Miami, Florida, Dr. Bolash completed his residency at St. Luke’s Roosevelt Hospital in New York, New York, and a fellowship in pain management at Cleveland Clinic.
Let’s Chat About Shingles Myths and Facts
Moderator: Welcome to our chat about Shingles with Cleveland Clinic interventional pain specialist Dr. Robert Bolash. Thank you, Dr. Bolash, for taking the time to be with us to share your expertise and answer our questions.
Let’s get started with our questions.
Tulla: Can you have a shingles outbreak more than once?
Robert_Bolash,_MD: Unfortunately you can. They say that lightning never strikes the same place twice, but one of the biggest myths about shingles is that you can be unlucky and have the outbreak more than once.
pilatesgirl: Do you know why shingles occurs on a certain area of the body versus another area? My brother got it on his skull. I have seen it on arms and backs as well.
Robert_Bolash,_MD: The torso is a common area, as is the face. The virus travels in specific nerves, so you will see shingles occur in a band on one side of the body. This band corresponds to the area where the nerve transmits signals, and we can often map these out.
Shar: Is there a way that I can prevent shingles?
Robert_Bolash,_MD: The vaccine prevents shingles in 51 percent of patients. The number isn't great, but it means that half the people who may have had shingles will not suffer with the outbreak.
paddy: Is shingles contagious like chickenpox?
Robert_Bolash,_MD: Someone with shingles can't spread shingles, but they can spread chickenpox. The virus is released from the oozing lesions of the rash. If you have a rash with open sores, you should stay away from those who haven't had chickenpox, or wait until the lesions scab over.
LOLlady: Chickenpox goes away after a couple of weeks. Is it the same with shingles? Does it ever completely go away?
Robert_Bolash,_MD: Unfortunately, up to 40 percent of people who have shingles go on to develop the painful condition. This persistent pain is called "post-herpetic neuralgia." The area can become so sensitive that even wearing a soft undershirt can cause pain as the cloth rubs against the chest.
laura628: I'm a 70 year-old healthy female. I had chickenpox as a child and a mild case of shingles in 1992. Are my chances of contracting shingles a second time greater or less because I've already had shingles? I have not had the shingles vaccine.
Robert_Bolash,_MD: Laura, it is a good question that I am not sure we have the answer to. I would consider having the discussion with your doctor to see if you are a candidate for the vaccine to help lessen your likelihood of getting shingles a second time.
Signs and Symptoms
Marey: Are there any symptoms you would have/receive prior to the outbreak of the shingles?
Robert_Bolash,_MD: Shingles often starts as a headache, nausea, fevers or chills. Some patients then experience tingling, itching, burning or stabbing pain before the rash shows up. On occasion, some patients don't even get the typical shingles rash.
Dannyboy: Is a rash the first sign of shingles?
Robert_Bolash,_MD: The rash often takes two days to develop. As the virus becomes reactivated in the nerves, there may be pain, tingling or burning in advance of the rash. People who have developed this on the chest have even mistaken this pain for a heart attack.
Marey: Is this part of shingles: you mention a tingling, is there an itching sensation felt on the inside of your body you cannot get to?
Robert_Bolash,_MD: Marey, itching may be a part of shingles as well. Similar nerves that play a role in shingles also are involved with the sensation of "itch." This phenomenon is actually an area of research in several pain conditions.
Marey: So, if someone does not get the typical rash, how would someone know it was a case of shingles versus perhaps another illness?
Robert_Bolash,_MD: Great question. This is when it becomes somewhat tricky, and we utilize our understanding (and perhaps diagnostic tests) to rule out other conditions that can look similar. If you have warning signs of shingles (even without a rash), I would see a family doctor sooner rather than later, because we have effective treatments that can be given early in the disease.
Various Virus Thoughts
Magnet: Shingles is caused by the chickenpox virus. I do not understand why having chickenpox when younger does not provide immunity to shingles later. Measles is also a virus, but once you have measles, you are immune. Please explain. This really confuses me.
Robert_Bolash,_MD: After having the chickenpox, your body does not rid your system of the virus. Instead, the virus stays in a portion of the spinal nerve root called the dorsal root ganglion. For the majority of people, the virus simply stays there quietly and doesn't cause problems. We aren't always sure why the virus gets reactivated, but this typically occurs at times of stress.
sassykat: I have encountered more young adults under the age of 30 with shingles, and they are having more devastating effects, such as effects on hearing, eyesight etc. Do you have an opinion on this, and why it has become more common in this age group?
Robert_Bolash,_MD: I can theorize that perhaps we are seeing more and more young people with complex diseases that can result from stress, which reactivates the virus. That is an excellent question, but I am not sure we have the answer for it yet.
Wain: If I get shingles, do I just let it run its course like you have to do with other viruses, or should I see the doctor?
Robert_Bolash,_MD: I would see a doctor at the first suspicion that you have shingles. Starting antiviral medications early can ease symptoms.
trust: Is there anything to help the healing of nerves due to shingles? I am three months from a shingles outbreak in my left thigh. I had an anti-viral medication, Lyrica® and was hospitalized for five days due to excruciating pain. (It felt like the muscles and bones in my thigh were twisting and breaking my leg. I screamed for two weeks.) After lots of narcotics, I finally stopped screaming, but pain would still occur. I’m off of the narcotics now and taking 600 mg gabapentin every eight hours. I’m trying capsaicin 0.1 percent, but still having pain. Am I a GBM patient (glioblastoma IV)?
Robert_Bolash,_MD: You have tried some of the medications we use for this condition, and I am sorry you haven't obtained much relief yet. We still have a large number of other options, including other medications, various interventions and more advanced procedures. I would welcome the opportunity to see you in consultation to evaluate what the next step should be. Feel free to make an appointment at your convenience at 216.444.3134.
FORQUER: If a 70 year-old female has shingle pain TWO YEARS after onset, is there anything that can be done to stop the pain.
Robert_Bolash,_MD: There are a number of treatments, from medications, injections, topical agents or implantable devices that can help with the painful condition that follows a shingles outbreak. I would be happy to discuss the options with you in consultation. Feel free to make an appointment with one of our pain specialists at 216.444.3134.
bbofranpd: Do you recommend the shingle shot for someone 84 years old who has had the shingles?
Robert_Bolash,_MD: In most cases, we do recommend it, as does the CDC (Centers for Disease Control and Prevention). This is to decrease the chances of getting shingles more than once. I would urge you to have this conversation with your family physician who knows the other medical problems you have and can help you with this decision.
ClevelandNoodge: If you have already had shingles (or had them twice in my case) but have never been vaccinated, will the vaccine prevent you from having future outbreaks?
Robert_Bolash,_MD: Great question. I am sorry to hear you were unlucky twice. The CDC does recommend considering the vaccine, EVEN if you have already had shingles. This is to prevent further outbreaks.
jlp152: I had shingles when I was 5 years old. I believe I also had the chickenpox but only one pox when I was a toddler. Should I get the shingles vaccine? I am 55 years old.
Robert_Bolash,_MD: The shingles vaccine is typically recommended for people aged 60 and older, though there are exceptions to give the vaccine to people aged 50 and older. This becomes more important when we consider the other medical problems you have. It is a discussion I would have with your physician who knows your entire medical history.
miamickey: Is it safe to get the shingles vaccine while on Coumadin, methotrexate, prednisone, Voltaren®, clobetasol and folic acid (I am a female 61 years old)?
Robert_Bolash,_MD: The CDC recommends caution for people who are receiving steroids or other agents that lower the immune system. I would have a conversation with your rheumatologist specific to your condition and these medications. The benefits may outweigh the risks.
Alice: Is the shingles vaccine covered yet by Medicare? And what if you are not yet eligible for Medicare?
Robert_Bolash,_MD: Medicare Part B does not cover the vaccine. Medicare Part D does pay for the vaccine, but the amount of coverage varies dependent upon the insurer. There may be a copay, or you may have to purchase the vaccine and have the cost reimbursed. If you have Part D, I would ask your health insurer what your coverage is.
Shbway: A friend (approximately age 58) had the shingles vaccine and still contracted a mild case of shingles during a time of extreme stress. Does the vaccine work well, or can one expect to contract a mild case of shingles?
Robert_Bolash,_MD: The vaccine works to prevent shingles 51 percent of the time. It prevents the painful condition that follows shingles 67 percent of the time. At first glance, you may be discouraged by these numbers, but the vaccine has cut down the number of people with shingles by half and the number of people with the painful condition that follows by two-thirds.
Jack_in_Florida: Two years ago I had a "shingles shot" that was quite expensive (insurance did not cover it). About six months later, I developed a rash on the underside of my arm. I stopped at a walk-in clinic and was told it was shingles, not severe, but blisters that eventually dried up. My question is: are shingles shots worth the investment?
Robert_Bolash,_MD: That’s a challenging question, Jack, because it is somewhat of a gamble to know if you are going to get shingles. You may invest the money and not get shingles or invest the money and not get the benefit of the vaccine. I can tell you that each and every patient who develops the painful condition that follows the shingles outbreak, "post-herpetic neuralgia," would certainly tell you it’s worth the investment.
mini: Is there only one shingles vaccine? Are others being researched that might have a better track record for prevention?
Robert_Bolash,_MD: I don't have any insider information, but I am sure that companies who make vaccines will find this area to be of interest. With more and more Americans living longer, unfortunately shingles may be a growing problem.
DebNsatx: Thanks for having this webchat. Can a person get a slight case of the shingles after getting the shingles vaccine? I'm referring to the vaccine itself; basically, if it can cause you to have some symptoms afterward? I have a weakened immune system already and am 54 years of age (F), so I'm trying to weigh out the pros versus the cons in my case. Any advice? Note that I had a mild case of the shingles back in my late thirties and get a tingling feeling every now and then in my back while I'm under stress. Thanks for your response in advance.
Robert_Bolash,_MD: Great question, Deb. The shingles vaccine is typically recommended for people aged 60 and older. It is approved for patients aged 50 and older. Since you fall between the 50 to 60 age range, I would have a conversation with your family physician about the risks/benefits of the vaccine now versus waiting another six years. Your conversation will center around the other medical problems you have and when the timing is best.
pilatesgirl: Are there any new treatments on the horizon?
Robert_Bolash,_MD: With more and more people getting shingles, there are some emerging medications and technologies. One technique we used in advanced cases of pain that persists after shingles is "spinal cord stimulation." There is technology being developed to help target the stimulation to the painful area with more precision. The field is evolving almost monthly.
pilatesgirl: Are there ways to boost the immune system to help lessen the chances of an outbreak of shingles when under stress?
Robert_Bolash,_MD: Avoiding stressors is always the best way to prevent shingles. That being said, some of these stressors cannot be avoided. Commonly, shingles can begin in cancer patients who are receiving chemotherapy and HIV patients with disease progression, as well as many other advanced illnesses.
loveisthegreatest: Are there any new treatments for shingles? Years ago, it was complex.
Robert_Bolash,_MD: Great question. There are a number of medications, injections, interventions and advanced treatments that can help the painful condition that comes from shingles. Compared with other pain conditions, it is a tough type of pain to treat, but there are advances for these types of pain almost every year, and likely many therapies that were not available years ago.
MaxinMO: What types of therapies are there for dealing with the pain associated with shingles?
Robert_Bolash,_MD: Pain-relieving medications taken orally or applied topically are typically the first option. We then consider more invasive options such as injections in proximity to the area where the nerves exit the spine. More advanced implantable devices are options for very refractory pain.
Moderator: That is all the time we have for questions today. Thank you, Dr. Bolash, for taking time to educate us about shingles.
On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative.
If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.
Robert_Bolash,_MD: Thank you all for the wonderful questions. We had a great discussion. My parting advice: (1) if you suspect shingles, have an evaluation early. (2) If you are left with pain after shingles, there are many options, and I would welcome having a discussion with anyone left with persistent pain.
To make an appointment with Robert Bolash, MD, or any of the other pain management specialists, please call 216.444.PAIN (7246) or visit us at clevelandclinic.org/painmanagement for more information.
For More Information
Cleveland Clinic’s Department of Pain Management offers many safe, proven, effective treatments designed to eliminate or reduce chronic pain. Board-certified physicians are dedicated to the goal of helping people with chronic pain return to a normal, productive lifestyle. Our specialists are among the most experienced in the world, treating more than 10,000 new patients each year. Using the latest in diagnostic technology paired with medical and interventional therapeutics, they will work with you to identify the source of the pain, eliminate or reduce the pain and teach you to manage it.
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Learn more about symptoms, causes, diagnostic tests and treatments for shingles:
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