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2017 HCHB_digital

Shingles Shingles

Shingles Shingles (herpes zoster) is a reactivation of the varicella zoster virus – also called herpesvirus 3, the same virus that causes chickenpox (see Childhood Diseases and Immunisation). Chickenpox generally occurs in children and young people. However, once an episode of chickenpox has resolved, the virus is not eliminated from the body but lies dormant in nerve cells close to the spinal cord. Many years later it can reactivate to cause shingles, an infection with symptoms vastly different from the original chickenpox infection. Exactly how the virus remains latent in the body, and subsequently reactivates, is not understood. Shingles occurs only in people who have had chickenpox, and people whose immune systems are impaired due to ill health, medications, or diseases that lower the immunity (eg, cancer, HIV) are most at risk. Occasionally, trauma (eg, a surgical scar) may trigger shingles at the site of the injury. Contact with somebody who currently has varicella or herpes zoster may also cause reactivation. Shingles can occur at any age but is more common in adults aged over 60. Rarely, shingles may occur in young children who were either born with chickenpox or had it soon after birth. Most people get shingles only once in their lifetime. Symptoms of shingles Early symptoms may include non-specific complaints, such as headache, fever and malaise, which may be easily misdiagnosed. After a couple of days, itching, tingling, numbness or burning, and/or a stabbing pain may develop in the affected dermatome (an area of skin supplied by one spinal nerve). Usually, after one or two days (but sometimes as long as three weeks), the initial phase is followed by the appearance of the characteristic skin rash. The pain and rash most commonly occur on the areas of skin supplied by the thoracic (chest), cervical (neck), ophthalmic (forehead), and lumbar (torso) nerves. The rash usually starts as a crop of red papules and may look like hives but, since the virus spreads along certain nerves located off the spinal cord, it typically has a stripe-like and usually unilateral presentation, unlike hives which are usually widespread. Within a few days, the papules form small, painful, exudate-filled blisters, which may persist for up to seven to 10 days before they crust over and heal. Once the blisters have appeared, and until the rash has developed crusts, a person is extremely contagious and transmission of the virus can occur to people without immunity to the virus. These people may then develop chickenpox but will not immediately develop shingles. Shingles may be associated with serious complications including postherpetic neuralgia, bacterial superinfection, infection of internal organs, visual impairment, hearing loss and death. Sometimes after severe blistering, scarring and discoloured skin may remain. Initial assessment Avoid close contact with somebody with suspected shingles if you have never TREATMENT OPTIONS Category Examples Comments Oral analgesics Topical pain relievers Varicella vaccine Natural / herbal products / supplements [GENERAL SALE] eg, paracetamol (Panadol, Paracare), ibuprofen up to 25s (Advil, Nurofen) [PHARMACY ONLY MEDICINE] eg, paracetamol – greater than 20 tablets, suspension (Pamol All Ages, Paracare, Panadol), ibuprofen >25s (Advil, Nurofen), ibuprofen + paracetamol (Maxigesic, Nuromol) [GENERAL SALE] eg, capsaicin cream (Zostrix HP*), lignocaine preparations (Soov cream/spray) [PHARMACY ONLY MEDICINE] eg, lignocaine/prilocaine (Emla), aspirin (

CONTINUING OTC EDUCATION had chickenpox or been vaccinated against chickenpox. Refer any customers with suspected shingles to a doctor as prompt treatment with antiviral medicine can help reduce symptoms and complications. Treatment Antiviral drug treatment prescribed by a doctor can reduce the severity of the attack and incidence of nerve pain that can persist long after the attack has resolved (post-herpetic neuralgia), if started within 72 hours of the rash appearing. The treatment options table lists over-the-counter agents that may also be considered. Prevention Vaccination against the herpes zoster virus with the vaccine Zostavax may be considered in people older than 50 because they are more at risk of severe complications from shingles. Zostavax is indicated for the: • prevention of herpes zoster (shingles) and post-herpetic neuralgia • reduction of acute and chronic zoster-associated pain. This vaccine reduces the incidence of shingles by 50% and, in people who do get shingles despite being vaccinated, the symptoms are usually less severe and post-herpetic neuralgia is less likely to develop. The vaccine is currently unfunded, but may be administered by registered pharmacists who have successfully completed an approved vaccinator training course. Post-herpetic neuralgia This is defined as pain that persists or recurs more than a month after the onset of shingles. It is more common in people older than 40 and is more likely in people with facial shingles infections. The pain may be burning and continuous, Refer to PHARMACIST Customers with suspected shingles should be referred to a doctor. For people with previously diagnosed shingles, the pharmacist should ask the following specific questions to help decide whether the person needs referring back to a doctor: • has the rash persisted, despite a course of antiviral treatment? • does the person appear to be getting worse, not better, despite ongoing treatment? • is the person still in pain? • does the person appear depressed or are they having trouble sleeping? • has the rash now appeared on the forehead or spread into the eye? • has the person previously been treated for shingles but is now having severe post-herpatic neuralgia? • has the customer had any reactions to products previously prescribed for shingles? or spasmodic and shooting, or, rarely, an itchy, crawling variety. The overlying skin may feel numb or extremely sensitive to touch. Topical pain relievers including capsaicin cream may help, but some people may require further referral for ongoing assessment and management with prescription medicines, acupuncture or transcutaneous electrical nerve stimulation (TENS) therapy. Advice for customers • Early treatment from a doctor will reduce the severity and duration of shingles. • Rest and take pain relief (eg, paracetamol). • Apply a bland, protective cream to the rash, and wear loose clothing. • If the pain persists following treatment return to your doctor. • Warn customers that they are highly contagious until the rash crusts over. Page 133

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