Shingles (Herpes Zoster) Treatment in Ankara, Turkey

Shingles, medically known as herpes zoster, is an infection caused by the reactivation of the chickenpox virus (Varicella zoster). It generally progresses with painful rashes that are unilateral and show a dermatomal distribution. Early diagnosis and appropriate treatment are of great importance in preventing complications.

The main aim of shingles treatment is to stop the virus from multiplying and to relieve pain. Antiviral medications (acyclovir, valacyclovir, famciclovir), when started early, reduce the duration and severity of the disease. Treatment should be started within the first 72 hours after the onset of the rash.

Pain control is an important part of shingles treatment. Paracetamol, nonsteroidal anti-inflammatory drugs, or, if necessary, neuropathic pain medications (gabapentin, pregabalin) may be used. In severe cases, short-term opioid analgesics may also be preferred.

In order to reduce the risk of postherpetic neuralgia that may develop after shingles, in addition to early antiviral treatment, nerve-supporting vitamins (B1, B6, B12) and local care are recommended. In older individuals and those with weakened immune systems, vaccination provides effective protection in preventing recurrence.

What Is Shingles?

Shingles is a viral infection involving the nerves and causing painful rashes on the skin, which occurs when the varicella-zoster virus, the chickenpox virus, becomes reactivated in the body. It generally progresses with unilateral rashes limited to a specific area of the body. It is seen more frequently in individuals with weakened immune systems.

What are the first symptoms of shingles (before the rash), and why are they so important?

Although shingles is generally recognized by its rash, the real story begins a few days before the rash appears. This initial period is called the “prodromal phase” and is of vital importance for the course of the disease.

Patients begin to experience a strange and unexplained sensation in the area where the rash will later appear, usually only on one side of the body (for example, half of the chest, part of the back, or one side of the face). The sensations in this prodromal phase are generally as follows:

• Stinging
• Burning
• Itching
• Tingling
• Tickling
• Severe sensitivity (even the touch of clothing may be disturbing)
• Deep, gnawing pain
• Sudden stabs like an electric shock

This pain can sometimes be so misleading that it may be confused with another emergency condition (heart attack, kidney stone, appendicitis). These initial symptoms may sometimes also be accompanied by fever, headache, and a general feeling of weakness.

This stage is a critical warning for the first 72 hours, which is the “golden window” of treatment. The period when antiviral (anti-virus) medications are most effective is the first three days after the rash begins. If this prodromal pain (especially if it is unilateral and band-like) is noticed and a dermatologist is consulted as soon as the rash appears, treatment can be started within this golden window. This allows the disease to progress much more mildly and significantly reduces the risk of the most feared complication, long-term pain (PHN).

What do the typical shingles rashes look like, and how long do they last?

One to three days after the prodromal pain and burning sensation, red spots or small bumps (papules) begin to appear on the skin in that area. The most distinctive feature of this rash is that it does not cross the midline of the body (the spinal or sternum line) and follows a single nerve area. It appears like a “band” or “belt” (the word zona means “belt” in Greek).

These red papules rapidly turn into fluid-filled blisters (vesicles). They look just like chickenpox blisters. Within a few days, the clear fluid inside these vesicles becomes cloudy and may turn into pustules (yellowish, inflamed-looking blisters). New vesicle formation generally continues for another 3 to 5 days.

In the next stage (generally within 7-10 days), these blisters rupture, dry out, and form crusts. These crusts also fall off over time. This entire process, that is, the period from the onset of the rash until the crusts have completely fallen off, generally lasts 2 to 4 weeks in uncomplicated cases. This period may be somewhat longer in elderly patients or those with weakened immune systems.

Where on the body is shingles most commonly seen?

Although the virus can awaken in any nerve root, the areas where shingles is most commonly seen are:

• Thoracic (Chest and back – the most common area)
• Cervical (Neck, shoulder, and arm)
• Trigeminal (Face, forehead, and scalp)
• Lumbosacral (Waist, hip, and leg)

Special attention should be paid especially to shingles involving the face (trigeminal). Because one branch of this nerve supplies the eye and may lead to a serious condition requiring emergency intervention, called “Herpes Zoster Ophthalmicus,” which can even result in blindness. Bilateral shingles, affecting both sides of the body at once, is extremely rare and generally indicates a very serious underlying immune system problem.

Why does shingles occur, and who is at higher risk?

The answer to the question “why now?” in shingles is almost always related to the immune system. The main trigger for the virus awakening is the weakening of the specific cellular immunity against the virus.

The most common factors that weaken the immune system and increase the risk of shingles are:

• Advancing age (being over 50 is the most important factor)
• Intense and chronic stress
• Cancer treatments (chemotherapy, radiotherapy)
• Medications used after organ transplantation
• Autoimmune diseases (Rheumatoid arthritis, Lupus)
• Immunosuppressive medications used for these diseases
• HIV/AIDS infection
• Major surgeries or severe physical traumas

Patients with weakened immune systems are more prone not only to having shingles but also to having a more severe course of the disease (more widespread rash, internal organ involvement) and to developing complications.

What does the ‘Golden 72 Hours’ rule mean in shingles treatment?

The cornerstone of shingles treatment is stopping the virus from multiplying (replication). The effectiveness of the antiviral medications used for this purpose is like a race against time. Clinical studies clearly show that starting antiviral treatment within the first 72 hours (3 days) from the onset of the rash has the greatest impact on the course of the disease.

The virus goes through its fastest replication period just before the rash appears and in the first 72 hours after it appears. Starting treatment within this “golden window” limits the damage the virus will cause to the nerves and skin from the very beginning.

The benefits of starting treatment within this ‘golden window’ are:

• It reduces the severity and duration of acute pain
• It accelerates the healing of the rashes
• It prevents the formation of new rashes
• It reduces the risk of damage to organs such as the eye

Most importantly: It significantly reduces the risk of developing PHN (long-term pain)

Is antiviral treatment not started after 72 hours? Of course it is, especially in patients in the risk group (elderly, immunosuppressed) or if new rash formation is still continuing, treatment is still started. However, the benefit provided by treatment started within 72 hours is much greater than that of delayed treatment.

Which antiviral medications are used in shingles treatment?

The main systemic (oral) antiviral agents used in acute shingles treatment to prevent the virus from multiplying are:

• Acyclovir
• Valacyclovir
• Famciclovir

These medications prevent viral replication by disrupting the virus’s DNA synthesis. The standard treatment duration is generally 7 days.

So, is there any difference between these medications? Acyclovir is an effective and reliable medication that has been used in shingles treatment for years. However, its most important disadvantage is that its absorption into the bloodstream (bioavailability) is low when taken orally. For this reason, it must be taken frequently, such as 5 times a day, to achieve an effective level, which may make patient compliance more difficult.

Valacyclovir and Famciclovir, on the other hand, are newer-generation molecules called “prodrugs.” After entering the body, they rapidly convert into their active forms (Valacyclovir to acyclovir, Famciclovir to penciclovir). Thanks to this feature, they pass into the bloodstream much more efficiently and can be used with a simpler dosage such as 3 times a day.

The most important difference is that comprehensive clinical studies have shown that Valacyclovir and Famciclovir may be superior to Acyclovir in reducing the risk of chronic pain (PHN) developing after shingles. For these reasons, especially in patients over the age of 50 and at high risk of PHN, one of these two medications is generally preferred.

How should shingles rash care be done at home?

While antiviral treatment stops the virus from the inside, proper care of the rash area is also very important in preventing secondary bacterial infections, reducing pain, and accelerating healing.

The steps to be taken for wound care at home are:

• Clean the area gently (with fragrance-free, non-drying soap and lukewarm water)
• Dry gently (not by rubbing but by patting lightly with a clean towel)
• Apply a thin layer of clean, pure petroleum jelly (Vaseline)
• Cover with a sterile, non-stick bandage
• Apply a cool and moist compress for itching (with a clean cloth)
• Use calamine lotion for itching after crusting has started

Cleanliness is the key during this process. Hands should always be washed before and after touching the area. The towels and sheets used should not be shared with others and should be washed with hot water. Remember, the fluid inside the vesicles can transmit chickenpox to people who have not had chickenpox before (or are unvaccinated).

Which creams should NEVER be applied to shingles rashes?

This is one of the most critical points of dermatological management and one of the most common mistakes made by patients. Topical corticosteroids (cortisone creams) should NEVER be applied to acute shingles rashes, especially while the vesicles are active.

So why are these creams, which suppress itching and inflammation, prohibited?

Because cortisone strongly suppresses the local immune system of the skin. Shingles is already a viral infection that occurs at a time when the immune system is weakened. When you apply cortisone to the rash, it is as if you are telling the cells of the skin that fight the virus to “take a break.”

This may cause the virus to multiply much more aggressively in that area, the infection to spread, the healing time to be prolonged, and potentially more serious skin damage (scarring). This is literally like pouring gasoline on a fire. Skin care should be supportive (such as Vaseline) and protective, not immunosuppressive.

Why is shingles pain so severe, and how is it managed?

Shingles pain is not a simple skin pain. It is a neuropathic pain. In other words, the source of the pain is not the wound on the skin, but the nerve fibers themselves that have been invaded and destroyed by the virus. The virus starts a kind of “fire” in the nerves. Therefore, the pain is felt as burning, stinging, electric shock, or throbbing, and it does not always respond well to standard painkillers.

Acute pain management is as important as antiviral treatment and requires a multifaceted approach.

• Simple analgesics (Paracetamol, Ibuprofen)
• Neuropathic pain agents (Gabapentin, Pregabalin)
• Tricyclic antidepressants (at low doses for pain modulation)
• Opioids for severe pain (short-term and under doctor supervision)
• Systemic corticosteroids (cortisone tablets)

If it is forbidden to apply cortisone cream to the shingles rash, why does your doctor sometimes give you cortisone tablets (such as Prednisone)?

When high-dose oral cortisone is given together with antiviral medication, it suppresses that severe inflammation in the nerve root very quickly. It reduces the pain in this acute period to a statistically significant degree and rapidly improves the patient’s quality of life. However, there is no strong evidence that systemic cortisone also prevents PHN (long-term pain). Its purpose is only to make the acute phase more comfortable, and it should be used carefully in conditions such as diabetes and hypertension.

What is pain continuing despite the rashes disappearing (PHN)?

PHN (Postherpetic Neuralgia) is the most feared and most common complication of shingles. It is the name given to chronic neuropathic pain continuing in that area even after the rashes have completely healed (generally 1 to 3 months later). This pain may last for months, and in some unfortunate cases, even for years.

The reason for this is that the virus causes permanent damage to the nerve fibers during the acute infection. The nerves begin to continuously send pain signals to the brain that are in the nature of a “false alarm.” There is no longer a virus or rash in the area, but the nerve’s “short circuit” continues. The risk of PHN increases dramatically with age. While it is rare under the age of 50, some degree of PHN may develop in a significant portion of shingles patients over the age of 70.

How is this long-term pain (PHN) that does not go away after shingles treated?

PHN treatment is completely different from acute shingles treatment, is more difficult, and requires patience. At this stage, antiviral medications or standard painkillers no longer provide any benefit. The goal of the treatment is to calm the pain signals sent by the damaged nerves.

The cornerstones of PHN treatment are:

• Gabapentinoids (Gabapentin, Pregabalin)
• Tricyclic Antidepressants (Amitriptyline, Nortriptyline)
• Lidocaine patches (especially for allodynia – the condition where even the rubbing of clothing causes pain)
• Capsaicin creams or patches (desensitizing nerve endings with the substance obtained from hot pepper)
• Opioids (in resistant cases not responding to other treatments)

In order for these medications (especially the first two) to be effective, they should be used according to the principle of “start low, increase slowly” (titration). Because they may cause side effects such as dizziness and drowsiness, especially in elderly patients. The dose should be adjusted by finding a balance between effectiveness and side effects.

When is shingles an emergency, and which complications are serious?

Although most cases of shingles can be managed on an outpatient basis, some situations require emergency intervention and referral to the relevant specialist. The two most serious complications are:

• Herpes Zoster Ophthalmicus (Eye Shingles)
• Ramsay Hunt Syndrome (Ear Shingles / Facial Paralysis)

Eye Shingles (Herpes Zoster Ophthalmicus):

If shingles rashes have appeared on your forehead, scalp, and especially on the tip of your nose, this is a very serious alarm indicating that the virus has involved the nerve branch supplying the eye. By involving the cornea, retina, and other important structures of the eye, the virus may lead to keratitis, glaucoma (eye pressure), and permanent vision loss. Every patient with suspected shingles around the eye or on the tip of the nose, even if the complaints are mild, must be referred URGENTLY and MANDATORILY to an eye doctor (ophthalmologist).

Ear Shingles (Ramsay Hunt Syndrome):

This is the involvement of the facial nerve and the hearing/balance nerve by the virus. Its symptoms are painful rashes on the auricle or inside the ear canal, severe ear pain, sudden facial paralysis on that side, loss of taste, dizziness (vertigo), and hearing loss. Very rapid and aggressive treatment is required to prevent the facial paralysis from becoming permanent. This condition is managed differently from normal shingles; in addition to antiviral treatment, high-dose systemic corticosteroid (Prednisone) treatment is essential to reduce edema and damage in the nerve. These patients should also be referred quickly to an ENT or Neurology specialist.

Is there a vaccine to protect against shingles?

Yes, there is a very effective way to protect against shingles and its most feared complication, PHN: Vaccination.

The modern vaccine used today is known as the Recombinant Zoster Vaccine (RZV – trade name Shingrix). This vaccine is a genetically engineered vaccine that does not contain live virus. It has shown tremendous success in clinical studies: it is 97% effective in preventing shingles in adults aged 50 and older, and 91% effective even over the age of 70. Most importantly, it provides over 90% effectiveness in preventing PHN (chronic pain).

To whom is the vaccine recommended?

• All healthy adults aged 50 and over
• Immunosuppressed individuals aged 19 and over

The vaccine is administered as a total of 2 doses intramuscularly in the arm, 2 to 6 months apart.

“I had shingles before, should I still get vaccinated?” Yes. Having shingles does not mean you will not get it again. The vaccine also greatly reduces this recurrence risk.

“I had the old (Zostavax) vaccine, should I get the new vaccine (Shingrix)?” Yes. The old vaccine (live vaccine) was less effective and its effect diminished over time. It has been proven that the new RZV (Shingrix) vaccine provides much superior and longer-lasting protection. For physicians in dermatology practice who frequently see both acute shingles rashes and the chronic helplessness brought by PHN, primary prevention through vaccination is one of the most critical steps to be taken in protecting the patient’s long-term health.