Shingles pain

definition

At Painthat are part of a Shingles occur, it is first the so-called postherpetic neuralgia from the actual "Zoster pain“To distinguish.

Of the "Zoster pain“Is the pain that occurs during a typical course of a shingles infection. This is usually called burning and itchy felt and goes hand in hand with being limited to a certain skin area pustular Rash. Consequently disappears this pain usually too as the rashes healHere, the duration and intensity of the pain can be influenced by suitable measures.

The so-called "postherpetic neuralgia“, The most common complication of shingles. One speaks of her when the pain yet longer than two months after the external skin irritation has subsided remains, i.e. chronified.

root cause

Both the actual "Zoster pain"As well as the"postherpetic neuralgia“Arise in the context of shingles in which Varicella zoster virusesthat are already present in the organism due to a previous infection, reactivated become. During their Migration to the skin along the nerve fibers, which among other things for the Sense of touch are responsible, the viruses get through inflammatory processes the typical Skin changes and the associated "Zoster pain“In the affected areas. In some cases, the pain occurs even before the actual rash appears.

Why the pain persists even after the skin changes have healed and turns into a "postherpetic neuralgia“Can develop is not yet clarified in detail.

One explanation is one permanent damage the affected Nerve fibers by the virus. This damage and subsequent incorrect healing leads to a Hypersensitivityso that signals are constantly sent to the pain-conducting nerve fibers. This also makes the nerve cells in the spinal cord that are addressed by these nerve fibers overexcitable. This is how the nerve cells become active and report information to the brain via Sensation of painwhen the real cause of the pain has long since subsided.

This constantly running Signal cascade but could also run the other way around towards the surface of the skin and there on Pain receptors meet those in turn local a Inflammatory response cause.

Another theory holds Remodeling processescaused by shingles are responsible for the disturbed pain sensation. As a result of these modifications both in the peripheral as well as zentral nervous system Pain-conducting nerve fibers are coupled to those fibers that are responsible for normal touch and tactile sensation. Thus, it is normally from the spinal cord Inhibition of excessive pain sensation bypassed.

Symptoms

Depending on the localization of the nerve damage caused by the varicella zoster virus, this results in postherpetic neuralgia a complex set of symptoms. Therefore, patients mostly describe three different types of pain: a constant oppressive or burning Persistent pain, short ones - shooting in like electric shocks - stabbing (lancinating) Pain and Pain that is touch dependent are (Allodynia, hyperpathia). This touch-dependent pain is sometimes so severe that it is uncomfortable for the patient to have cloth on his body. They are mainly triggered by light touch, while firm pressure on the respective point is not perceived as uncomfortable.
Furthermore can also stress and Temperature changes cause or intensify postherpetic pain.

Itching as a symptom

Another common symptom of shingles is itching, which is often the first symptom of shingles. It typically also occurs in the skin area in which the rash has formed and in which the patient experiences increased pain. As the disease progresses, the itching may increase.
The itching is also due to damage to the nerve by the virus. The nerve damage disrupts the sensitivity of the nerve and the patient feels severe itching. In rare cases, the itching may occur instead of the pain.
The itching usually heals with dehydration and encrustation of the zoster vesicles.
Regular application of a zinc ointment is a good way of helping the skin to dry out quickly. This also leads to a relief of the itching.

Can shingles go away without pain?

As a rule, the damage to the nerve fibers in the context of shingles leads to severe pain. These usually occur in combination with a rash on the skin and itching and are often the first symptom of shingles.
The intensity of the complaints varies from patient to patient. While in some patients the pain symptoms are in the foreground of the disease, the rash in combination with the itching causes more problems for other patients.
In individual cases, however, shingles can pass without the occurrence of pain. Especially within the first few days, the pain is often absent. In some cases, the damage to the nerve is also perceived as burning or itching by those affected.
In this case, however, the early start of pain therapy is also indicated in order to prevent the development of severe pain and possible complications (postherpetic neuralgia) as a prophylactic measure.

therapy

Since the "Zoster pain“Shingles is a symptom of the actual underlying disease, the focus of therapy is the early control of shingles. This is also a prophylactic measure to prevent the development of a "postherpetic neuralgia“Dar.

Consequently, the aim of this therapy is to prevent the virus from spreading, relieve acute pain and prevent postherpetic neuralgia. First, antivirals such as Acyclovir and Brivudine to contain virus activity. This means that the skin changes also heal faster. In addition, local anesthetics are used to reduce pain and itching.

In some cases, however, the measures taken to combat acute shingles are not prophylactically effective enough to prevent the development of postherpetic neuralgia.

The treatment of postherpetic neuralgia differs from the treatment of acute shingles. Antiviral drugs are usually no longer administered because the actual viral infection has usually long since subsided.

Instead, the following other types of medication are used to relieve pain:

• Anticonvulsants

• Opioids

• tricyclic antidepressants

Also read our article on that Shingles medication!

Anticonvulsants were primarily developed for the treatment of epilepsy, but are now also mainly used in pain therapy. The active ingredients Gabapentin and Carbamazepine are often used in the treatment of postherpetic pain.

Opioids are commonly used to treat severe pain, e.g. used for tumors and, due to their strong effect, partly falls under the Narcotics Act. There are therefore special guidelines for taking and carrying these products.

Antidepressants are primarily drugs used to treat depression or other illnesses that trigger anxiety. The so-called tricyclic antidepressants, however, also work against chronic pain symptoms. The most commonly used active ingredients are of these Amitriptyline, Desipramine, Imipramine and Doxepin. Even in small doses, they have a pain-relieving effect and also have a positive effect on sleep and mood. Some of these drugs are also used to relieve the pain of shingles of the head (see also: Shingles on the head - you should definitely consider this!)

Local anesthetics are also used in some cases. These are, for example, lidocaine plasters or capsaicin creams.

By blocking sodium channels, lidocaine reduces the excitability of pain-conducting nerve fibers.

Capsaicin is a herbal extract made from cayenne pepper and is used for external use, among other things, to relieve muscle tension. Its pain-relieving effect is based on the one hand on the biochemical mechanism of inhibiting the resumption of the mediator substance P at nerve endings. This reduces the transmission of the pain stimulus. On the other hand, capsaicin causes local irritation to widen the blood vessels, which leads to increased blood flow and heat development. However, the irritant effect can lead to sensitivity reactions and side effects such as intense burning sensation and itching.

If the postherpetic neuralgia has only existed for less than six weeks, a sympathetic block can also reduce the pain.

However, if the pain persists for a long time and cannot be adequately alleviated by other drugs, acupuncture treatments and so-called transcutaneous electrical nerve stimulation, or TENS for short, are used as alternatives. Light stimulation current impulses are transmitted to the nerve fibers by electrodes attached to the skin. This suppresses the transmission of pain and thus also the perception of the pain. However, it is often necessary to get used to the current impulses, so that TENS is not yet a long-term therapy option. Gentler measures are also helpful for some patients. Psychotherapy or relaxation techniques help to process the pain and deal with it on a mental level.

Surgical measures are only considered in rare cases. For example, there is the option of an anterolateral chordotomy. This means that the nerve tracts in the spinal cord that are responsible for the conduction of pain are surgically cut.

As with all surgical measures, the possible complications due to damage to other nerve tracts or the surgical intervention in general must be taken into account.

What is the best way to relieve pain?

In addition to the classic pain medication (e.g. ibuprofen or paracetamol), numerous other preparations, so-called co-analgesics, are also available for treating the pain that occurs as part of shingles.
This is because the virus damages the nerve in the area of ​​the nerve fiber. The above-mentioned pain medication, however, mainly works at the nerve endings in the skin area and must therefore be supplemented with the co-analgesics.
Depending on the intensity of the pain, the therapy is initially carried out with paracetamol or ibuprofen in combination with weak opioid analgesics (e.g. codeine).
If the symptoms persist or postherpetic neuralgia, strong opioids (morphine) or co-analgesics (anticonvulsants, antidepressants, local anesthetics) are often prescribed as a result. Therapy with ibuprofen or paracetamol is usually sufficient for children.
In addition to drug pain therapy, there are other methods available that can accompany pain therapy.
Often, transcutaneous electrical nerve stimulation (TENS) is used, in which electrical stimulation in the area of ​​the painful area generates abnormal sensations that can alleviate the local pain.
Alternatively, physical therapy, occupational therapy or psychotherapy can also relieve the pain.

Which drugs work best?

Drug pain therapy for shingles is intended to both relieve acute pain and reduce the risk of complications (postherpetic neuralgia). Various drug classes with different modes of action are available for this purpose.
In the case of mild pain and in children, therapy with NSAIDs lasting several days, e.g. Ibuprofen or paracetamol. If the pain gets worse, the medication can be supplemented with weak opioids (e.g. codeine).
In the case of very severe pain or in the treatment of postherpetic neuralgia, however, other drugs are in the foreground. In addition to the use of strong opioids (e.g. morphine), so-called co-analgesics play an important role, as they suppress the development of pain directly on the damaged nerve fiber compared to other preparations.
The tricyclic antidepressant amitriptyline or various epilepsy drugs (gabapentin, pregabalin) are often used. These block various channels in the nerve fiber, which means that the pain stimulus cannot be passed on.
An alternative is the local application of local anesthetics (lidocaine, capsaicin) in the form of plasters, which can also reduce pain.

Read our article about this Shingles medication! and Zostex and shingles - is that compatible?

How long does the pain last?

The pain that occurs in the context of shingles is differentiated between a so-called zoster pain, which occurs in combination with the skin rash as part of the disease, and postherpetic neuralgia, which occurs as a complication when the nerve pain becomes chronic.
The zoster pain that occurs with shingles usually subsides after the disease heals after 3-4 weeks at the latest. If prophylactic pain therapy is started early, the pain can subside within a few days.
On the other hand, there is an increased risk of persistence of pain, especially in older people. If the pain persists for more than four weeks, it is called postherpetic neuralgia.
Post-herpetic neuralgia is a complication of shingles. It is a chronic, recurring pain sensation due to nerve damage caused by shingles. This pain can sometimes last for months and years. Older people with shingles in the head and neck area are particularly at risk. The treatment of postherpetic neuralgia requires individual pain therapy.

Why is the pain worse at night?

Often times, patients with shingles report that the pain increases during the night. As a result, sleep disorders often occur, which delay the further healing of the disease.
One cause of the pain, which gets worse at night, can be the patient's lying position. Additional pressure on the affected skin area while lying down can increase the pain. There is also the risk of rubbing the pustules of the rash while you sleep, causing the pain to increase briefly.

Home remedies

Numerous home remedies can also be used as part of symptomatic pain therapy for shingles. In addition to suppressing the sensation of pain, these also serve to combat the viral pathogens and heal the rash. However, they are only intended as an accompanying support for drug treatment.
Quark and healing earth wraps are suitable for relieving pain, as they have an antiseptic effect in addition to pain relief.
In addition, chilli patches and local application of magnesium are effective in treating pain associated with shingles.

Homeopathic remedies for the treatment of shingles

In addition to home remedies, various homeopathic preparations are also effective in the symptomatic therapy of shingles. However, these should also only be used to support drug treatment and are not an alternative. If there is no improvement, a doctor should be consulted in any case.
Frequently used homeopathic preparations are Mezerum (D6) and Rhus toxicodendron (D12). While Mezerum is particularly suitable for very severe pain, which occurs mainly at night and when in contact with water or when it is touched, Rhus toxicodendron is mainly used for stabbing and burning pain.

forecast

Round 20% of shingles patients develop a postherpetic neuralgia. It manifests itself particularly often after infections and mostly affects elderly and / or immunocompromised patients. One too existing polyneuropathye.g. a disease with diabetes can be another factor in the development of postherpetic neuralgia.

A spontaneous regression postherpetic neuralgia within a year exists at every second patient and at every fourth leads a therapy to decline.

However, the wide range of therapy methods show that treating this form of chronic pain is not easy. Therefore, the main focus is mainly on the early detection of shingles to prevent the development of postherpetic neuralgia.

Pain recurs after years

In rare cases, the pain may recur months or years after shingles.
These pains are also classified as postherpetic neuralgia. They arise from the severe damage to the nerves caused by the virus and the nerves' lack of regenerative capacity. This pain should also be treated in order to prevent further persistence of the pain.
In very rare cases, shingles can recur in patients with a severely weakened immune system (e.g. with tumor diseases, HIV, multiple sclerosis, very old people). Then the new pain stimulus can be the first symptom of shingles.

Read our topic: Post-zoster neuralgia