The notorious pain that comes with the eruption of shingles is notably external. But it can be quite nasty internally if it follows the distribution of the sensory nerve the shingle viruses are affecting.
Shingles, or herpes zoster, is a re-activation of the chickenpox viruses that took up residence in the nerve roots of your central nervous system during a past chicken pox infection.
The viruses are somehow arrested in an incomplete form, usually in the sensation part of the nerve root, until somehow the arrest becomes defective and the viruses migrate along the nerve to pop out in skin along that nerve’s distribution.
All cases of shingles do not cause pain, but an inflammatory reaction to the viruses on the loose always happens. It’s assumed that this creates the pain experience. Yet, some patients don’t read the book and happily develop just the rash — if only it were so in all cases.
In the stereotypical cases, the pain can be wretched, disabling and, unfortunately, long lasting — the reason for their much-dreaded reputation. The pain can be experienced beneath the skin along the nerve’s path, either preceding or accompanying the eruption of tiny blister clusters in the nerve’s anatomical pattern.
The reason for this column is that I received a call from a patient who knew she was having shingles. She had gone to the emergency room twice in misery. She had the external exquisitely sensitive skin rash and pain, but also a feeling of deeper, duller pain along the nerve’s path on her torso.
The emergency room physician told her that that kind of internal pain did not happen with shingles. He had her get a CAT scan, fearing some internal problem, but the scan was quite normal. The patient was convinced the inner pain was part of the larger shingles picture. Narcotics in any form gave her no relief.
Why the viruses break out of confinement is often a mystery. What is known is that their migration from the root stimulates a host inflammatory response. White blood cells, attracted to the site, track along the nerve with the viral flow. It is felt that this somehow generates the nerve’s pain.
It makes sense that the inflamed nerve could and would be the source of both internal and/or external pain as it wends its way outward from the root. Not only might it happen simultaneously with the skin eruption, but it may also occur mysteriously preceding the blistery rash and lead to a host of wrong diagnoses.
This has fostered legendary erroneous estimates of pleurisy, abdominal organ rupture, all sorts of back syndromes and leg blood clots until the rash finally erupts, clarifying the cloudy causation of the angst.
The “cyclovirs,” medicines now given for shingles, are most effective taken early in a shingles outbreak. Before they were available, the recommended treatment was anti-inflammatory cortisone in industrial strength doses by mouth, injection or both, with mostly modest success. The idea was to control the inflammation around and in the nerve and stop the pain.
After the “cyclovir” she took did not help, the above patient got both injectable and oral cortisone. It did modify the pain measurably so she could function. Her skin oddly is and was unresponsive, and will heal as well as possible on its own.
While the emergency room physician had a valid point, the information she got was not entirely accurate. The message is that shingles can cause internal pain to a devilish degree and not represent any other disease.
Listening to the patient’s history is an old, sort of quaint approach, especially in an age where business and production trumps medicine. But, it works more often than not. I hasten to add that I tell some patient almost every day that I only walk on water when it’s frozen.
Frank Bures is a Winona dermatologist.