The varicella-zoster virus (VZV) can cause two diseases: chickenpox (varicella) and shingles (herpes zoster). Before a vaccine was developed in 1994, chickenpox was a common contagious childhood disease that produced itchy. Capsaicin Patch Eases Shingles Pain. MADISON - The chronic pain left behind by shingles causes intense misery, so it sounds a bit like torture to treat it with a high dose of the. Shingles and post-herpetic neuralgia. The Use of Capsaicin for Shingles by PIA GRANT Last Updated: Oct 07, 2015. Research about shingles and capsaicin is inconsistent and success may depend on the individual. George Pasvankas: Managing Pain from Shingles . The burning pain of this condition can be severe, even interfering with appetite and sleep. Hear pain management specialist Dr. George Pasvankas at UCSF Medical Center explain the latest treatment options for shingles, including a new skin patch that contains capsaicin, a hot- pepper compound that's found in jalapenos. Interview Transcript. BACKGROUND: The Centers for Disease Control estimates about 1 million Americans are diagnosed with shingles every year, a painful skin rash caused by the varicella zoster virus -- the same virus that causes chickenpox. Home > Patient Education > Interview with Dr. George Pasvankas: Managing Pain from Shingles. Special Programs; Interview with Dr. Managing Pain from Shingles. Published on August 29, 2011. Biosynthesis of the capsaicinoids occurs in the glands of the pepper fruit where capsaicin synthase condenses vanillylamine. Capsaicin transdermal patch. Introduction. Andrew Schorr: Hello and welcome to Patient Power sponsored by UCSF Medical Center. I'm Andrew Schorr. Pain can be debilitating, and it can be caused by all sorts of things. One cause that many people are not familiar with is a reactivation of chickenpox you may have had as a child. You don't have chickenpox again, but you have another condition called shingles, known as postherpetic neuralgia pain. I understand it affects about 1 million people in America a year. I suffered it, briefly, fortunately, because it can be very severe, when I was going through cancer therapy in my late 4. This can happen to people with weakened immune systems. It also happens as people get older, so we're going to learn all about that and what treatments are available that can help. Our guest is Dr. He's an anesthesiologist who specializes in pain management at the UCSF Pain Management Center. Doctor, am I right, about a million people a year have this reactivation? Dr. George Pasvankas: That's correct. The estimate is an incidence of about a million for reactivation of the chickenpox virus in terms of causing cases of shingles, and the estimate is that about 1. Andrew Schorr: First of all, what's the connection with chickenpox? So, many of us have had it as children, and then we thought that that's the end of it. George Pasvankas: It can be quite dismaying to patients to all of a sudden have a pain problem and have it traced back when they have their conversation with their doctor to an episode of childhood chickenpox which may have happened 5. But essentially while the clinical problems from chickenpox clear up at that time the virus itself never really completely leaves the body. It sort of lies in a dormant state in the nervous system, sitting around, waiting. In some people it never becomes an issue again, but, as you point out, whether it is age or debility or other medical problems or treatments for those medical problems, some people have the unfortunate circumstance where that virus sort of rears its ugly head again and causes an outbreak of shingles. Andrew Schorr: So is it an inflammation of like a nerve root? Is that what it is? Dr. George Pasvankas: Essentially, it's a reactivation of the virus along one of the nerve roots, and inflammation is certainly one of the processes that's going on at that point in time that causes pain in that distribution. Andrew Schorr: What are the symptoms of shingles? Dr. George Pasvankas: It can depend on the individual person. Some people will — before it progresses to a frank painful problem — just start to notice something a little bit off in a sort of single pattern area of the body, and often that's just a clue for people that they're seeing it in such a kind of a cutout or geographic distribution of an area. It can start just with noticing that you don't quite feel things right in that area. The area can just feel a little bit more sensitive if you're brushing over it or putting your clothes on or maybe sensitivity to temperature or something along those lines. For some people, the first thing they notice is the rash that tends to come up in that area. For other people, it will really be a frankly painful sensation in that area as the first thing they notice. Andrew Schorr: When you say ? We've all had poison ivy as a kid. Dr. George Pasvankas: Like many rashes, the first thing somebody may just notice is a color change and a reddening in that area, but typically it will progress to what we call a vesicular rash, which is small eruptions that if it progresses, can become sort of weeping and crusted over and can even leave some permanent discoloration or marking. Andrew Schorr: Now, would this be in straight line, almost like there's a nerve highway underneath, and it's just like a straight line typically? Dr. George Pasvankas: That's exactly how it will appear for people. That highway, as you put it, could be going in many different directions, depending on where that particular nerve root happens to be in the body. For some people, it can be on the face and affect one particular distribution of the face. Often, it will run across a shoulder or down an arm. In the chest area, it will usually run a pattern that circles along the chest wall horizontally, or could run in a pattern for example down towards the groin or down towards the leg. Andrew Schorr: Now, as I was in some cancer treatment years ago receiving some pretty heavy- duty medicines and certainly my immune system was weakened both from the cancer or even from the drugs trying to fight the cancer, I noticed one day sitting at lunch with a friend that I had a sensitivity in a straight line down the left side of my chest. And in mentioning it to this friend, who happened to be a physician, he said sounds like shingles to me, and I was put on an antiviral. We'll talk about that in a minute. Is that sensitivity what you're talking about? It could be just as subtle as that? Because I'd never experienced anything like that before. Dr. George Pasvankas: It can absolutely be as subtle as that. Again, for some people it will depend on the order of things. Some people will have the symptoms before the rash, some people will have the rash before the symptoms. I would say in your particular circumstance, you'd call it lucky that you had a vague sense and a sensitivity there before you ended up with a full- blown rash eruption or what sounds like a full- blown really neurologic pain going on. Early Treatment With Antivirals. Andrew Schorr: Now, that physician, a primary care doctor, prescribed an antiviral medicine. A lot of us are used to the fact that when you're told you have a virus like a cold or something like that, they say, . George Pasvankas: That's correct. Most of these patients are presenting to their primary care physicians or to urgent care centers or emergency rooms perhaps more than they're presenting to a pain management doctor, but the tendency for certain, since this is a circumstance where we know that this can progress to cause a chronic problem like this, and since it is a circumstance where we do have a medication that's effective against this particular virus, that most patients will be treated from the outset with an antiviral medication if it's caught early. Andrew Schorr: Let's talk about early. So for somebody like me who got this early warning sign or somebody who started to see a rash, getting medical attention quickly is important. Otherwise, how severe the pain can be? Dr. George Pasvankas: I think it's very important to get started on treating the discomfort and treating the underlying problem as early as possible. Andrew Schorr: So antivirals, do they always work? Dr. George Pasvankas: I think like any treatment, it's variable, and I think in particular what we have to think about is we don't know for certain that you can catch the process at this exact point in time and prevent it from becoming X amount of pain or reduce the chances that it's going to become a chronic pain problem by Y amount or something along those lines. I would put it more broadly into the picture of it's important to start treating it early, and anything that we can point to would tell us that the earlier is better and whatever effect you are able to get from it by treating it early is better. Unfortunately, we can't say that there's a particular cutoff or a particular level of efficacy that's going to prevent this particular pain problem. Andrew Schorr: A couple of things before we go on to other treatments. I know pain — perception of pain — varies by people. Pain doctors often say, . George Pasvankas: We do a lot of after- the- fact talking with people about what was going on during their initial phase of things since we're mostly seeing people with the chronic problem, and we'll have people tell us that it is among the most difficult and painful things that they've gone through. There's something about the neurologic character of this pain that's so burning, so intense and so electric shooting that it tends to get high pain scores. I think there's that hypersensitivity. As opposed to a pain that's maybe severe but going on somewhere where there's not a lot external that's making it worse, this is something where simple things like showers or socks or clothes or just somebody bumping into them by accident can really cause things to go off the charts. So it's absolutely possible to see numbers up at the top of the pain scale for the acute events, and even for the worst cases of chronic ones. Andrew Schorr: Let's talk about chronic shingles. People may have seen their primary care doctor but now you say there is a percentage of the time when it becomes chronic, and I imagine they get referred to a center such as yours, the UCSF Pain Management Center, and a specialist such as you. What's going on when it becomes chronic? What does that mean? Dr. George Pasvankas: Well, that's a great question. Just the simple definition of when does a pain problem become a chronic pain problem has its own large debate and its own investigation. Certainly, as we talked about, the expectation is that the disease process should run its course. After the reactivation of the virus runs its course and goes away, the pain problem should typically wind its way down as well, and in a span of weeks to a month or a month and change, similarly disappear. When do we have a chronic pain problem that hasn't resolved appropriately? Certainly when you're looking at, I'd say, six months to a year, everybody is in agreement you're really looking at a problem that's probably unlikely to fully resolve on its own and stay a chronic pain problem. Capsaicin patch: Indications, Side Effects, Warnings. Generic Name: capsaicin (kap- SAY- sin)Brand Name: Qutenza. Capsaicin patch is used for: Treating a certain type of nerve pain caused by the shingles (postherpetic neuralgia). It may also be used for other conditions as determined by your doctor. Capsaicin patch is a TRVP1 channel agonist. It works by decreasing certain pain receptors on some nerve endings. Do NOT use capsaicin patch if: you are allergic to any ingredient in capsaicin patch. Contact your doctor or health care provider right away if any of these apply to you. Before using capsaicin patch: Some medical conditions may interact with capsaicin patch. Tell your doctor or pharmacist if you have any medical conditions, especially if any of the following apply to you: if you are pregnant, planning to become pregnant, or are breast- feedingif you are taking any prescription or nonprescription medicine, herbal preparation, or dietary supplementif you have allergies to medicines, foods, or other substancesif you have broken or damaged skin at the application siteif you have a history of high blood pressure, other heart problems, or recent heart attack or stroke. Some MEDICINES MAY INTERACT with capsaicin patch. However, no specific interactions with capsaicin patch are known at this time. Ask your health care provider if capsaicin patch may interact with other medicines that you take. Check with your health care provider before you start, stop, or change the dose of any medicine. How to use capsaicin patch: Use capsaicin patch as directed by your doctor. Check the label on the medicine for exact dosing instructions. Capsaicin patch is usually applied at your doctor's office, hospital, or clinic. If you will be using capsaicin patch at home, a health care provider will teach you how to use it. Be sure you understand how to use capsaicin patch. Follow the procedures you are taught when you use it. Contact your health care provider if you have any questions. Do not remove the patch from the sealed pouch until right before use. You may receive other medicine to treat pain that occurs during and after your treatment with capsaicin patch. Discuss any questions or concerns with your doctor. Do not touch the patch while it is on your skin. Burning or stinging may occur. If you miss a dose of capsaicin patch, contact your doctor right away. Ask your health care provider any questions you may have about how to use capsaicin patch. Important safety information: Do not use capsaicin patch on the face or scalp. Do not get it in the eyes, nose, mouth, or genital area. If you get capsaicin patch in any of these areas, rinse right away with cool water. Do not inhale any of capsaicin patch. It may cause shortness of breath, coughing, or sneezing. Tell your health care provider if any of these symptoms occur. Do not get capsaicin patch on skin that is not being treated. Tell your health care provider if capsaicin patch comes into contact with skin that is not being treated. The treated area may be sensitive to heat (eg, hot showers or baths, direct sunlight, strong exercise) for a few days after capsaicin patch is applied. Lab tests, including blood pressure, may be performed while you use capsaicin patch. These tests may be used to monitor your condition or check for side effects. Be sure to keep all doctor and lab appointments. Capsaicin patch should be used with extreme caution in CHILDREN younger than 1. PREGNANCY and BREAST- FEEDING: If you become pregnant, contact your doctor. You will need to discuss the benefits and risks of using capsaicin patch while you are pregnant. It is not known if this medicine is found in breast milk. Do not breast- feed on the day of treatment after you have received your treatment with capsaicin patch. Possible side effects of capsaicin patch: All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome: Mild pain, redness, burning, or itching at the application site; mild sore throat; nausea. Seek medical attention right away if any of these SEVERE side effects occur: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); blisters or swelling at the application site; severe or persistent dizziness or headache; severe or persistent pain, redness, burning, or itching at the application site; shortness of breath, coughing, or sneezing. This is not a complete list of all side effects that may occur. If you have questions about side effects, contact your health care provider. Call your doctor for medical advice about side effects. To report side effects to the appropriate agency, please read the Guide to Reporting Problems to FDA. If OVERDOSE is suspected: Contact 1- 8. American Association of Poison Control Centers), your local poison control center, or emergency room immediately. Proper storage of capsaicin patch: Store capsaicin patch between 6. F (2. 0 and 2. 5 degrees C). Brief storage at temperatures between 5. F (1. 5 and 3. 0 degrees C) is permitted. Store away from heat, moisture, and light. Do not store in the bathroom. Keep capsaicin patch out of the reach of children and away from pets. General information: If you have any questions about capsaicin patch, please talk with your doctor, pharmacist, or other health care provider. Capsaicin patch is to be used only by the patient for whom it is prescribed. Do not share it with other people. If your symptoms do not improve or if they become worse, check with your doctor. Check with your pharmacist about how to dispose of unused medicine. This information should not be used to decide whether or not to take capsaicin patch or any other medicine. Only your health care provider has the knowledge and training to decide which medicines are right for you. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about capsaicin patch. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to capsaicin patch. This information is not specific medical advice and does not replace information you receive from your health care provider. You must talk with your healthcare provider for complete information about the risks and benefits of using capsaicin patch. Review Date: August 8, 2. Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only your health care provider has the knowledge and training to decide which medicines are right for you. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from your health care provider. You must talk with your healthcare provider for complete information about the risks and benefits of using this medicine. More about capsaicin topical Consumer resources Professional resources Related treatment guides.
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