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98-528: Shingles , also known as herpes zoster or zona , is a viral disease characterized by a painful skin rash with blisters in a localized area. Typically the rash occurs in a single, wide mark either on the left or right side of the body or face. Two to four days before the rash occurs there may be tingling or local pain in the area. Other common symptoms are fever, headache, and tiredness. The rash usually heals within two to four weeks, but some people develop ongoing nerve pain which can last for months or years,

196-465: A CNS infection caused by VZV. Since 2000, PCR testing has become more widely used, and the number of diagnosed cases of CNS infection has increased. Classic textbook descriptions state that VZV reactivation in the CNS is restricted to immunocompromised individuals and the elderly; however, studies have found that most participants are immunocompetent, and younger than 60 years old. Historically, vesicular rash

294-1046: A benign condition called dermatographic urticaria . Hives can also be classified by the purported causative agent. Many different substances in the environment may cause hives, including medications, food and physical agents. In perhaps more than 50% of people with chronic hives of unknown cause, it is due to an autoimmune reaction. Risk factors include having conditions such as hay fever or asthma . Drugs that have caused allergic reactions evidenced as hives include codeine , sulphate of morphia , dextroamphetamine , aspirin , ibuprofen , penicillin , clotrimazole , trichazole, sulfonamides , anticonvulsants , cefaclor , piracetam , vaccines , and antidiabetic drugs . The antidiabetic sulphonylurea glimepiride , in particular, has been documented to induce allergic reactions manifesting as hives. The most common food allergies in adults are shellfish and nuts . The most common food allergies in children are shellfish , nuts, eggs , wheat , and soy . One study showed Balsam of Peru , which

392-403: A condition called postherpetic neuralgia (PHN). In those with poor immune function the rash may occur widely . If the rash involves the eye, vision loss may occur. Shingles is caused by the varicella zoster virus (VZV) that also causes chickenpox . In the case of chickenpox, also called varicella, the initial infection with the virus typically occurs during childhood or adolescence. Once

490-407: A few days and without leaving any long-lasting skin changes. Cases of long duration are more common in females. Cases of short duration are more common among children while cases of long duration are more common among those who are middle aged. Fewer than 5% of cases last for more than six weeks. The condition frequently recurs. In half of cases of hives, the cause remains unknown . Angioedema

588-540: A first line therapy as they block both brain and peripheral H1 receptors, causing sedation. Second-generation antihistamines , such as loratadine , cetirizine , fexofenadine or desloratadine , selectively antagonize peripheral H1 receptors, and are less sedating, less anticholinergic , and generally preferred over the first-generation antihistamines. Fexofenadine, a new-generation antihistamine that blocks histamine H1 receptors, may be less sedating than some second-generation antihistamines. People who do not respond to

686-425: A hard surface, etc. The areas of the body most commonly affected are the hands, feet, trunk, abdomen, buttocks, legs and face. Although this appears to be very similar to dermatographism, the cardinal difference is that the swelled skin areas do not become visible quickly and tend to last much longer. This form of the skin disease is, however, rare. Cholinergic urticaria (CU) is one of the physical urticaria which

784-428: A hasty drop in body temperature. Regular antihistamines are not generally efficacious. One particular antihistamine, cyproheptadine (Periactin), has been found to be useful. The tricyclic antidepressant doxepin has been found to be effective blocking agents of histamine. Finally, a medication named ketotifen, which keeps mast cells from discharging histamine, has also been employed with widespread success. This form of

882-464: A higher hospitalization rate; the difference may be due to the prevalence of HIV in the earlier study, or to the introduction of antivirals in California before 1994. Shingles has a long recorded history, although historical accounts fail to distinguish the blistering caused by VZV and those caused by smallpox , ergotism , and erysipelas . In the late 18th century William Heberden established

980-418: A link to family history. A 2008 study showed that people with close relatives who had shingles were twice as likely to develop it themselves, but a 2010 study found no such link. Adults with latent VZV infection who are exposed intermittently to children with chickenpox receive an immune boost. This periodic boost to the immune system helps to prevent shingles in older adults. When routine chickenpox vaccination

1078-502: A lower risk of contamination. They also have more sensitivity than viral cultures . Shingles can be confused with herpes simplex , dermatitis herpetiformis and impetigo , and skin reactions caused by contact dermatitis , candidiasis , certain drugs and insect bites. Shingles risk can be reduced in children by the chickenpox vaccine if the vaccine is administered before the individual gets chickenpox. If primary infection has already occurred, there are shingles vaccines that reduce

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1176-711: A painful condition called postherpetic neuralgia , which is often difficult to manage. In some people, shingles can reactivate presenting as zoster sine herpete : pain radiating along the path of a single spinal nerve (a dermatomal distribution ), but without an accompanying rash . This condition may involve complications that affect several levels of the nervous system and cause many cranial neuropathies , polyneuritis , myelitis , or aseptic meningitis . Other serious effects that may occur in some cases include partial facial paralysis (usually temporary), ear damage, or encephalitis . Although initial infections with VZV during pregnancy, causing chickenpox, may lead to infection of

1274-402: A parasitic infection, such as blastocystosis and strongyloidiasis among others. The rash that develops from poison ivy , poison oak , and poison sumac contact is commonly mistaken for urticaria. This rash is caused by contact with urushiol and results in a form of contact dermatitis called urushiol-induced contact dermatitis . Urushiol is spread by contact but can be washed off with

1372-455: A person with cholinergic urticaria will develop the characteristic small hives, especially on the neck and chest. The immediate symptoms of this type are treated with antihistamines, epinephrine and airway support. Taking antihistamines prior to exercise may be effective. Ketotifen is acknowledged to stabilise mast cells and prevent histamine release, and has been effective in treating this hives disorder. Avoiding exercise or foods that cause

1470-453: A rash in such a pattern (zosteriform herpes simplex). When the rash is absent (early or late in the disease, or in the case of zoster sine herpete ), shingles can be difficult to diagnose. Apart from the rash, most symptoms can occur also in other conditions. Laboratory tests are available to diagnose shingles. The most popular test detects VZV-specific IgM antibody in blood; this appears only during chickenpox or shingles and not while

1568-415: A reduction in their symptoms. Those with a longer disease duration typically have a worse prognosis, with greater symptom severity. Chronic urticaria is often accompanied by an intense pruritus, and other symptoms associated with a reduced quality of life and a high burden of co-morbid psychiatric conditions such as anxiety and depression. Chronic urticaria is usually seen in those older than 40 years, it

1666-520: A strong grease- or oil-dissolving detergent and cool water and rubbing ointments. Dermatographic urticaria (also known as dermatographism or "skin writing") is marked by the appearance of weals or welts on the skin as a result of scratching or firm stroking of the skin. Seen in 4–5% of the population, it is one of the most common types of urticaria, in which the skin becomes raised and inflamed when stroked, scratched, rubbed, and sometimes even slapped. The skin reaction usually becomes evident soon after

1764-516: A strong indicator of VZV encephalitis, was absent in half of a group of people diagnosed with VZV encephalitis by PCR. Viral disease A viral disease (or viral infection ) occurs when an organism's body is invaded by pathogenic viruses , and infectious virus particles (virions) attach to and enter susceptible cells. Examples are the common cold , gastroenteritis and pneumonia . Basic structural characteristics, such as genome type, virion shape and replication site, generally share

1862-460: A strong relationship with increasing age. The incidence rate of shingles ranges from 1.2 to 3.4 per 1,000 person‐years among younger healthy individuals, increasing to 3.9–11.8 per 1,000 person‐years among those older than 65 years, and incidence rates worldwide are similar. This relationship with age has been demonstrated in many countries, and is attributed to the fact that cellular immunity declines as people grow older. Another important risk factor

1960-613: A trigger. In half of cases the cause remains unknown . Risk factors include having conditions such as hay fever or asthma . Diagnosis is typically based on appearance. Patch testing may be useful to determine the allergy. Prevention is by avoiding whatever it is that causes the condition. Treatment is typically with antihistamines , with the second generation antihistamines such as fexofenadine , loratadine and cetirizine being preferred due to less risk of sedation and cognitive impairment. In refractory cases, corticosteroids or leukotriene inhibitors may also be used. Keeping

2058-490: A vibrating device such as a laboratory vortex machine against the forearm for four minutes. Speedy swelling of the whole forearm extending into the upper arm is also noted later. The principal treatment is avoidance of vibratory stimulants. Antihistamines have also been proven helpful. The mainstay of therapy for both acute and chronic hives is education, avoiding triggers and using antihistamines. Chronic hives can be difficult to treat and lead to significant disability. Unlike

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2156-506: A way to differentiate shingles and smallpox, and in the late 19th century, shingles was differentiated from erysipelas. In 1831 Richard Bright hypothesized that the disease arose from the dorsal root ganglion, and an 1861 paper by Felix von Bärensprung confirmed this. Recognition that chickenpox and shingles were caused by the same virus came at the beginning of the 20th century. Physicians began to report that cases of shingles were often followed by chickenpox in younger people who lived with

2254-453: A wide adoption of zoster vaccination could dramatically reduce the incidence rate. In one study, it was estimated that 26% of those who contract shingles eventually present complications. Postherpetic neuralgia arises in approximately 20% of people with shingles. A study of 1994 California data found hospitalization rates of 2.1 per 100,000 person-years, rising to 9.3 per 100,000 person-years for ages 60 and up. An earlier Connecticut study found

2352-463: Is immunosuppression . Other risk factors include psychological stress . According to a study in North Carolina, "black subjects were significantly less likely to develop zoster than were white subjects." It is unclear whether the risk is different by sex. Other potential risk factors include mechanical trauma and exposure to immunotoxins . There is no strong evidence for a genetic link or

2450-419: Is a concern in severe cases, as angioedema of the throat can be fatal. This very rare form of angioedema develops in response to contact with vibration. In vibratory angioedema, symptoms develop within two to five minutes after contact with a vibrating object and abate after about an hour. People with this disorder do not experience dermographism or pressure urticaria. Vibratory angioedema is diagnosed by holding

2548-461: Is a life-threatening condition. Treatment guidelines for the management of chronic hives have been published. According to the 2014 American practice parameters, treatment involves a stepwise approach. Step 1 consists of second generation, H1 receptor blocking antihistamines. Systemic glucocorticoids can also be used for episodes of severe disease but should not be used for long term due to their long list of side effects. Step 2 consists of increasing

2646-408: Is a related condition (also from allergic and nonallergic causes), though fluid leakage is from much deeper blood vessels in the subcutaneous or submucosal layers. Individual hives that are painful, last more than 24 hours, or leave a bruise as they heal are more likely to be a more serious condition called urticarial vasculitis . Hives caused by stroking the skin (often linear in appearance) are due to

2744-419: Is a sulfone antimicrobial agent and is thought to suppress prostaglandin and leukotriene activity. It is helpful in therapy-refractory cases and is contraindicated in people with G6PD deficiency. Sulfasalazine, a 5-ASA derivative, is thought to alter adenosine release and inhibit IgE mediated mast cell degranulation, Sulfasalazine is a good option for people with anemia who cannot take dapsone. Hydroxychloroquine

2842-836: Is an antimalarial agent that suppresses T lymphocytes. It has a low cost however it takes longer than dapsone or sulfasalazine to work. Omalizumab was approved by the FDA in 2014 for people with hives 12 years old and above with chronic hives. It is a monoclonal antibody directed against IgE. Significant improvement in pruritus and quality of life was observed in a phase III, multicenter, randomized control trial. Immunosuppressants used for CU include cyclosporine, tacrolimus, sirolimus, and mycophenolate. Calcineurin inhibitors, such as cyclosporine and tacrolimus, inhibit cell responsiveness to mast cell products and inhibit T cell activity. They are preferred by some experts to treat severe symptoms. Sirolimus and mycophenolate have less evidence for their use in

2940-433: Is defined as more than 20 skin lesions appearing outside either the primarily affected dermatome or dermatomes directly adjacent to it. Besides the skin, other organs, such as the liver or brain , may also be affected (causing hepatitis or encephalitis , respectively), making the condition potentially lethal. The causative agent for shingles is the varicella zoster virus (VZV)—a double-stranded DNA virus related to

3038-436: Is diagnosed by applying pressure by stroking or scratching the skin. The hives should develop within a few minutes. Unless the skin is highly sensitive and reacts continually, treatment is not needed. Taking antihistamines can reduce the response in cases that are annoying to the person. This type of hives can occur right away, precisely after a pressure stimulus or as a deferred response to sustained pressure being enforced to

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3136-405: Is followed by the appearance of the characteristic skin rash. The pain and rash most commonly occur on the torso but can appear on the face, eyes, or other parts of the body. At first, the rash appears similar to the first appearance of hives ; however, unlike hives, shingles causes skin changes limited to a dermatome, normally resulting in a stripe or belt-like pattern that is limited to one side of

3234-540: Is hereditary and becomes evident as hives all over the body 9 to 18 hours after cold exposure. The common form of cold urticaria demonstrates itself with the rapid onset of hives on the face, neck, or hands after exposure to cold. Cold urticaria is common and lasts for an average of five to six years. The population most affected is young adults, between 18 and 25 years old. Many people with the condition also have dermographism and cholinergic hives. Severe reactions can be seen with exposure to cold water; swimming in cold water

3332-480: Is identified. Diagnosis is typically based on the appearance. The cause of chronic hives can rarely be determined. Patch testing may be useful to determine the allergy. In some cases regular extensive allergy testing over a long period of time is requested in hopes of getting new insight. No evidence shows regular allergy testing results in identification of a problem or relief for people with chronic hives. Regular allergy testing for people with chronic hives

3430-411: Is in many processed foods, to be the most common cause of immediate contact urticaria. Another food allergy that can cause hives is alpha-gal allergy , which may cause sensitivity to milk and red meat. A less common cause is exposure to certain bacteria, such as Streptococcus species or possibly Helicobacter pylori . Hives including chronic spontaneous hives can be a complication and symptom of

3528-472: Is less well understood than that of the herpes simplex virus. Virus-specific proteins continue to be made by the infected cells during the latent period, so true latency, as opposed to chronic , low-level, active infection , has not been proven to occur in VZV infections. Although VZV has been detected in autopsies of nervous tissue, there are no methods to find dormant virus in the ganglia of living people. Unless

3626-416: Is limited evidence for their efficacy. Oral glucocorticoids are effective in controlling symptoms of chronic hives. However, they have an extensive list of adverse effects, such as adrenal suppression, weight gain, osteoporosis, hyperglycemia, etc. Therefore, their use should be limited to a couple of weeks. In addition, one study found that systemic glucocorticoids combined with antihistamines did not hasten

3724-438: Is not recommended. Acute and chronic hives are visually indistinguishable on visual inspection alone. Angioedema is similar to hives, but in angioedema, the swelling occurs in a lower layer of the dermis than in hives, as well as in the subcutis. This swelling can occur around the mouth, eyes, in the throat, in the abdomen, or in other locations. Hives and angioedema sometimes occur together in response to an allergen , and

3822-633: Is not the causative factor. The condition was first distinguished in 1980. People with exercise urticaria (EU) experience hives, itchiness, shortness of breath and low blood pressure five to 30 minutes after beginning exercise. These symptoms can progress to shock and even sudden death. Jogging is the most common exercise to cause EU, but it is not induced by a hot shower, fever, or with fretfulness. This differentiates EU from cholinergic urticaria. EU sometimes occurs only when someone exercises within 30 minutes of eating particular foods, such as wheat or shellfish. For these individuals, exercising alone or eating

3920-440: Is not the same as herpes simplex virus , although they belong to the same family of herpesviruses . Shingles vaccines reduce the risk of shingles by 50 to 90%, depending on the vaccine used. Vaccination also decreases rates of postherpetic neuralgia, and, if shingles occurs, its severity. If shingles develops, antiviral medications such as aciclovir can reduce the severity and duration of disease if started within 72 hours of

4018-670: Is offered by the National Health Service (NHS) to all people in their 70s. As of 2021 Zostavax is the usual vaccine, but Shingrix vaccine is recommended if Zostavax is unsuitable, for example for those with immune system issues. Vaccination is not available to people over 80 as "it seems to be less effective in this age group". By August 2017, just under half of eligible 70–78 year olds had been vaccinated. About 3% of those eligible by age have conditions that suppress their immune system, and should not receive Zostavax. There had been 1,104 adverse reaction reports by April 2018. In

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4116-443: Is provoked during sweating events such as exercise, bathing, staying in a heated environment, or emotional stress. The hives produced are typically smaller than classic hives and are generally shorter-lasting. Multiple subtypes have been elucidated, each of which require distinct treatment. The cold type of urticaria is caused by exposure of the skin to extreme cold, damp and windy conditions; it occurs in two forms. The rare form

4214-769: Is termed scombroid food poisoning . Ingestion of free histamine released by bacterial decay in fish flesh may result in a rapid-onset, allergic-type symptom complex which includes hives. However, the hives produced by scombroid is reported not to include wheals. Chronic idiopathic hives has been anecdotally linked to stress since the 1940s. A large body of evidence demonstrates an association between this condition and both poor emotional well-being and reduced health-related quality of life . A link between stress and this condition has also been shown. Some cases have been thought to be due to stress, including an association between post-traumatic stress and chronic idiopathic hives. In most cases of chronic idiopathic urticaria , no cause

4312-494: Is the most common cause of a severe reaction. This can cause a massive discharge of histamine, resulting in low blood pressure, fainting, shock and even loss of life. Cold urticaria is diagnosed by dabbing an ice cube against the skin of the forearm for 1 to 5 minutes. A distinct hive should develop if a person has cold urticaria. This is different from the normal redness that can be seen in people without cold urticaria. People with cold urticaria need to learn to protect themselves from

4410-616: Is the most commonly involved nerve, of which the ophthalmic division is the most commonly involved branch. When the virus is reactivated in this nerve branch it is termed zoster ophthalmicus . The skin of the forehead, upper eyelid and orbit of the eye may be involved. Zoster ophthalmicus occurs in approximately 10% to 25% of cases. In some people, symptoms may include conjunctivitis , keratitis , uveitis , and optic nerve palsies that can sometimes cause chronic ocular inflammation, loss of vision, and debilitating pain. Shingles oticus , also known as Ramsay Hunt syndrome type II , involves

4508-400: The ear . It is thought to result from the virus spreading from the facial nerve to the vestibulocochlear nerve . Symptoms include hearing loss and vertigo (rotational dizziness). Shingles may occur in the mouth if the maxillary or mandibular division of the trigeminal nerve is affected, in which the rash may appear on the mucous membrane of the upper jaw (usually the palate, sometimes

4606-503: The herpes simplex virus . Most individuals are infected with this virus as children which causes an episode of chickenpox . The immune system eventually eliminates the virus from most locations, but it remains dormant (or latent ) in the ganglia adjacent to the spinal cord (called the dorsal root ganglion ) or the trigeminal ganglion in the base of the skull. Shingles occurs only in people who have been previously infected with VZV; although it can occur at any age, approximately half of

4704-426: The immune system is compromised, it suppresses reactivation of the virus and prevents shingles outbreaks. Why this suppression sometimes fails is poorly understood, but shingles is more likely to occur in people whose immune systems are impaired due to aging, immunosuppressive therapy , psychological stress , or other factors. Upon reactivation, the virus replicates in neuronal cell bodies, and virions are shed from

4802-539: The "peculiar age distribution of zoster may in part reflect the frequency with which the different age groups encounter cases of varicella and because of the ensuing boost to their antibody protection have their attacks of zoster postponed". Lending support to this hypothesis that contact with children with chickenpox boosts adult cell-mediated immunity to help postpone or suppress shingles, a study by Thomas et al. reported that adults in households with children had lower rates of shingles than households without children. Also,

4900-456: The 1940s the disease was considered benign, and serious complications were thought to be very rare. However, by 1942, it was recognized that shingles was a more serious disease in adults than in children and that it increased in frequency with advancing age. Further studies during the 1950s on immunosuppressed individuals showed that the disease was not as benign as once thought, and the search for various therapeutic and preventive measures began. By

4998-864: The US National Institutes of Health , the number of new cases per year ranges from 1.2 to 3.4 per 1,000 person-years among healthy individuals to 3.9 to 11.8 per 1,000 person-years among those older than 65 years of age. About half of those living to age 85 will have at least one attack, and fewer than 5% will have more than one attack. Although symptoms can be severe, risk of death is very low: 0.28 to 0.69 deaths per million. The earliest symptoms of shingles, which include headache, fever, and malaise, are nonspecific, and may result in an incorrect diagnosis. These symptoms are commonly followed by sensations of burning pain, itching, hyperesthesia (oversensitivity), or paresthesia ("pins and needles": tingling, pricking, or numbness). Pain can be mild to severe in

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5096-452: The US, it is recommended that healthy adults 50 years and older receive two doses of Shingrix, two to six months apart. The aims of treatment are to limit the severity and duration of pain, shorten the duration of a shingles episode, and reduce complications. Symptomatic treatment is often needed for the complication of postherpetic neuralgia. However, a study on untreated shingles shows that, once

5194-411: The acute form, 50–80% of people with chronic hives have no identifiable triggers. But 50% of people with chronic hives will experience remission within 1 year. Overall, treatment is geared towards symptomatic management. Individuals with chronic hives may need other medications in addition to antihistamines to control symptoms. People who experience hives with angioedema require emergency treatment as this

5292-412: The affected dermatome , with sensations that are often described as stinging, tingling, aching, numbing or throbbing, and can be interspersed with quick stabs of agonizing pain. Shingles in children is often painless, but people are more likely to get shingles as they age, and the disease tends to be more severe. In most cases, after one to two days—but sometimes as long as three weeks—the initial phase

5390-402: The appearance of the rash. Evidence does not show a significant effect of antivirals or steroids on rates of postherpetic neuralgia. Paracetamol , NSAIDs , or opioids may be used to help with acute pain. It is estimated that about a third of people develop shingles at some point in their lives. While shingles is more common among older people, children may also get the disease. According to

5488-449: The body and does not cross the midline. Zoster sine herpete ("zoster without herpes") describes a person who has all of the symptoms of shingles except this characteristic rash. Later the rash becomes vesicular , forming small blisters filled with a serous exudate , as the fever and general malaise continue. The painful vesicles eventually become cloudy or darkened as they fill with blood, and crust over within seven to ten days; usually

5586-591: The cases in the United States occur in those aged 50 years or older. Shingles can recur. In contrast to the frequent recurrence of herpes simplex symptoms, repeated attacks of shingles are unusual. It is extremely rare for a person to have more than three recurrences. The disease results from virus particles in a single sensory ganglion switching from their latent phase to their active phase. Due to difficulties in studying VZV reactivation directly in humans (leading to reliance on small- animal models ), its latency

5684-434: The cells and carried down the axons to the area of skin innervated by that ganglion. In the skin, the virus causes local inflammation and blistering. The short- and long-term pain caused by shingles outbreaks originates from inflammation of affected nerves due to the widespread growth of the virus in those areas. As with chickenpox and other forms of alpha-herpesvirus infection, direct contact with an active rash can spread

5782-459: The characteristic belt-like dermatomal rash. The common name for the disease, shingles , derives from the Latin cingulus , a variant of Latin cingulum , meaning "girdle". Until the mid-1990s, infectious complications of the central nervous system (CNS) caused by VZV reactivation were regarded as rare. The presence of rash, as well as specific neurological symptoms, were required to diagnose

5880-488: The chickenpox has resolved, the virus can remain dormant (inactive) in human nerve cells ( dorsal root ganglia or cranial nerves ) for years or decades, after which it may reactivate and travel along nerve bodies to nerve endings in the skin, producing blisters. During an outbreak of shingles, exposure to the varicella virus found in shingles blisters can cause chickenpox in someone who has not yet had chickenpox, although that person will not suffer from shingles, at least on

5978-857: The common cold. They usually appear three to five days after the cold has started, and may even appear a few days after the cold has resolved. Mechanisms other than allergen-antibody interactions are known to cause histamine release from mast cells. Many drugs, for example morphine , can induce direct histamine release not involving any immunoglobulin molecule. Also, a diverse group of signaling substances called neuropeptides , have been found to be involved in emotionally induced hives. Dominantly inherited cutaneous and neurocutaneous porphyrias ( porphyria cutanea tarda , hereditary coproporphyria , variegate porphyria and erythropoietic protoporphyria ) have been associated with solar urticaria . The occurrence of drug-induced solar urticaria may be associated with porphyrias. This may be caused by IgG binding, not IgE. This

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6076-403: The crusts fall off and the skin heals, but sometimes, after severe blistering, scarring and discolored skin remain. The blister fluid contains varicella zoster virus, which can be transmitted through contact or inhalation of fluid droplets until the lesions crust over, which may take up to four weeks. Shingles may have additional symptoms, depending on the dermatome involved. The trigeminal nerve

6174-509: The disease occurs on areas of the skin exposed to the sun; the condition becomes evident within minutes of exposure. This type of urticaria is also termed rare and occurs upon contact with water. The response is not temperature-dependent and the skin appears similar to the cholinergic form of the disease. The appearance of hives is within one to 15 minutes of contact with the water and can last from 10 minutes to two hours. This kind of hives does not seem to be stimulated by histamine discharge like

6272-642: The dose of the current antihistamine, adding other antihistamines, or adding a leukotriene receptor antagonist such as montelukast. Step 3 consists of adding or replacing the current treatment with hydroxyzine or doxepin. If the individual doesn't respond to steps 1–3 then they are considered to have refractory symptoms. At this point, anti-inflammatory medications (dapsone, sulfasalazine), immunosuppressants (cyclosporin, sirolimus) or other medications like omalizumab can be used. These options are explained in more detail below. First generation antihistamines, such as diphenhydramine or hydroxyzine , are not recommended as

6370-573: The environmental temperature cool is also useful. For cases that last more than six weeks long term antihistamine therapy is indicated. Immunosuppressants such as omalizumab or cyclosporin may also be used. About 20% of people are affected at some point in their lives. Cases of short duration occur equally in males and females while cases of long duration are more common in females. Cases of short duration are more common among children while cases of long duration are more common among those who are middle aged. Hives have been described at least since

6468-431: The fetus and complications in the newborn, chronic infection or reactivation in shingles are not associated with fetal infection. There is a slightly increased risk of developing cancer after a shingles episode. However, the mechanism is unclear and mortality from cancer did not appear to increase as a direct result of the presence of the virus. Instead, the increased risk may result from the immune suppression that allows

6566-412: The first infection. How the virus remains dormant in the body or subsequently re-activates is not well understood. The disease has been recognized since ancient times . Risk factors for reactivation of the dormant virus include old age, poor immune function , and having contracted chickenpox before 18 months of age. Diagnosis is typically based on the signs and symptoms presented. Varicella zoster virus

6664-546: The gums of the upper teeth) or the lower jaw (tongue or gums of the lower teeth) respectively. Oral involvement may occur alone or in combination with a rash on the skin over the cutaneous distribution of the same trigeminal branch. As with shingles of the skin, the lesions tend to only involve one side, distinguishing it from other oral blistering conditions. In the mouth, shingles appears initially as 1–4 mm opaque blisters (vesicles), which break down quickly to leave ulcers that heal within 10–14 days. The prodromal pain (before

6762-409: The incidence of varicella decreased, and the occurrence of shingles among adults increased by 90%. The results of a further study by Yawn et al. showed a 28% increase in shingles incidence from 1996 to 2001. It is likely that incidence rate will change in the future, due to the aging of the population, changes in therapy for malignant and autoimmune diseases, and changes in chickenpox vaccination rates;

6860-449: The injuring food without exercising produces no symptoms. EU can be diagnosed by having the person exercise and then observing the symptoms. This method must be used with caution and only with the appropriate resuscitative measures at hand. EU can be differentiated from cholinergic urticaria by the hot water immersion test. In this test, the person is immersed in water at 43 °C (109.4 °F). Someone with EU will not develop hives, while

6958-413: The lesions have crusted over, capsaicin cream (Zostrix) can be used. Topical lidocaine and nerve blocks may also reduce pain. Administering gabapentin along with antivirals may offer relief of postherpetic neuralgia. Antiviral drugs may reduce the severity and duration of shingles; however, they do not prevent postherpetic neuralgia . Of these drugs, aciclovir has been the standard treatment, but

7056-482: The maximum dose of H1 antihistamines may benefit from increasing the dose further, then to switching to another non-sedating antihistamine, then to adding a leukotriene antagonist , then to using an older antihistamine, then to using systemic steroids and finally to using ciclosporin or omalizumab . Steroids are often associated with rebound hives once discontinued. H2-receptor antagonists are sometimes used in addition to H1-antagonists to treat urticaria, but there

7154-442: The mentioned symptoms is very important. In particular circumstances, tolerance can be brought on by regular exercise, but this must be under medical supervision. The skin lesions of urticarial disease are caused by an inflammatory reaction in the skin, causing leakage of capillaries in the dermis , and resulting in an edema which persists until the interstitial fluid is absorbed into the surrounding cells. Hives are caused by

7252-433: The mid-1960s, several studies identified the gradual reduction in cellular immunity in old age, observing that in a cohort of 1,000 people who lived to the age of 85, approximately 500 (i.e., 50%) would have at least one attack of shingles, and 10 (i.e., 1%) would have at least two attacks. In historical shingles studies, shingles incidence generally increased with age. However, in his 1965 paper, Hope-Simpson suggested that

7350-524: The newer drugs valaciclovir and famciclovir demonstrate similar or superior efficacy and good safety and tolerability. The drugs are used both for prevention (for example in people with HIV/AIDS ) and as therapy during the acute phase . Complications in immunocompromised individuals with shingles may be reduced with intravenous aciclovir. In people who are at a high risk for repeated attacks of shingles, five daily oral doses of aciclovir are usually effective. Corticosteroids do not appear to decrease

7448-494: The nucleus. This group of analysts defined multiple categories of virus. Groups: The clinical characteristics of viruses may differ substantially among species within the same family: Vertical and sexual Varicella : Zoster : Varicella : Zoster : Hives Hives frequently occur following an infection or as a result of an allergic reaction such as to medication, insect bites , or food. Psychological stress , cold temperature, or vibration may also be

7546-470: The other physical hives. Most researchers believe this condition is actually skin sensitivity to additives in the water, such as chlorine. Water urticaria is diagnosed by dabbing tap water and distilled water to the skin and observing the gradual response. Aquagenic urticaria is treated with capsaicin (Zostrix) administered to the chafed skin. This is the same treatment used for shingles . Antihistamines are of questionable benefit in this instance since histamine

7644-484: The person with shingles. The idea of an association between the two diseases gained strength when it was shown that lymph from a person with shingles could induce chickenpox in young volunteers. This was finally proved by the first isolation of the virus in cell cultures , by the Nobel laureate Thomas Huckle Weller , in 1953. Some sources also attribute the first isolation of the herpes zoster virus to Evelyn Nicol . Until

7742-514: The rash has cleared, postherpetic neuralgia is very rare in people under 50 and wears off in time; in older people, the pain wore off more slowly, but even in people over 70, 85% were free from pain a year after their shingles outbreak. People with mild to moderate pain can be treated with over-the-counter pain medications . Topical lotions containing calamine can be used on the rash or blisters and may be soothing. Occasionally, severe pain may require an opioid medication, such as morphine . Once

7840-755: The rash) may be confused with toothache . Sometimes this leads to unnecessary dental treatment. Post-herpetic neuralgia uncommonly is associated with shingles in the mouth. Unusual complications may occur with intra-oral shingles that are not seen elsewhere. Due to the close relationship of blood vessels to nerves, the virus can spread to involve the blood vessels and compromise the blood supply, sometimes causing ischemic necrosis . In rare cases, oral involvement causes complications such as osteonecrosis , tooth loss , periodontitis (gum disease), pulp calcification, pulp necrosis , periapical lesions and tooth developmental anomalies. In those with deficits in immune function, disseminated shingles may occur (wide rash). It

7938-443: The reactivation of the virus. Although shingles typically resolves within 3–5 weeks, certain complications may arise: Varicella zoster virus (VZV) has a high level of infectivity and has a worldwide prevalence. Shingles is a re-activation of latent VZV infection: zoster can only occur in someone who has previously had chickenpox (varicella). Shingles has no relationship to season and does not occur in epidemics. There is, however,

8036-680: The release of histamine and other mediators of inflammation ( cytokines ) from cells in the skin. This process can be the result of an allergic or nonallergic reaction, differing in the eliciting mechanism of histamine release. Histamine and other proinflammatory substances are released from mast cells in the skin and tissues in response to the binding of allergen -bound IgE antibodies to high-affinity cell surface receptors. Basophils and other inflammatory cells are also seen to release histamine and other mediators, and are thought to play an important role, especially in chronic urticarial diseases. Over half of all cases of chronic idiopathic hives are

8134-513: The result of an autoimmune trigger. Roughly 50% of people with chronic urticaria spontaneously develop autoantibodies directed at the receptor FcεRI located on skin mast cells. Chronic stimulation of this receptor leads to chronic hives. People with hives often have other autoimmune conditions, such as autoimmune thyroiditis , celiac disease , type 1 diabetes , rheumatoid arthritis , Sjögren's syndrome or systemic lupus erythematosus . Hive-like rashes commonly accompany viral illnesses, such as

8232-542: The risk of long-term pain . Side effects however appear to be minimal. Their use in Ramsay Hunt syndrome had not been properly studied as of 2008. Treatment for zoster ophthalmicus is similar to standard treatment for shingles at other sites. A trial comparing aciclovir with its prodrug , valaciclovir, demonstrated similar efficacies in treating this form of the disease. The rash and pain usually subside within three to five weeks, but about one in five people develop

8330-501: The risk of developing shingles or developing severe shingles if the disease occurs. They include a live attenuated virus vaccine, Zostavax, and an adjuvanted subunit vaccine, Shingrix. A review by Cochrane concluded that Zostavax was useful for preventing shingles for at least three years. This equates to about 50% relative risk reduction . The vaccine reduced rates of persistent, severe pain after shingles by 66% in people who contracted shingles despite vaccination. Vaccine efficacy

8428-452: The same features among virus species within the same family. Human-infecting virus families offer rules that may assist physicians and medical microbiologists / virologists . As a general rule, DNA viruses replicate within the cell nucleus while RNA viruses replicate within the cytoplasm . Exceptions are known to this rule: poxviruses replicate within the cytoplasm and orthomyxoviruses and hepatitis D virus (RNA viruses) replicate within

8526-405: The scratching and disappears within 30 minutes. Dermatographism is the most common form of a subset of chronic hives, acknowledged as "physical hives". It stands in contrast to the linear reddening that does not itch seen in healthy people who are scratched. In most cases, the cause is unknown, although it may be preceded by a viral infection, antibiotic therapy, or emotional upset. Dermatographism

8624-524: The skin. In the deferred form, the hives only appear after about six hours from the initial application of pressure to the skin. Under normal circumstances, these hives are not the same as those witnessed with most urticariae. Instead, the protrusion in the affected areas is typically more spread out. The hives may last from eight hours to three days. The source of the pressure on the skin can happen from tight fitted clothing, belts, clothing with tough straps, walking, leaning against an object, standing, sitting on

8722-476: The study by Terada et al. indicated that pediatricians reflected incidence rates from 1/2 to 1/8 that of the general population their age. The family name of all the herpesviruses derives from the Greek word έρπης herpēs , from έρπω herpein ("to creep"), referring to the latent, recurring infections typical of this group of viruses. Zoster comes from Greek ζωστήρ zōstēr , meaning "belt" or "girdle", after

8820-738: The time of Hippocrates . The term urticaria is from the Latin urtica meaning " nettle ". Hives, or urticaria, is a form of skin rash with red, raised, itchy bumps. They may also burn or sting. Hives can appear anywhere on the surface of the skin. Whether the trigger is allergic or not, a complex release of inflammatory mediators, including histamine from cutaneous mast cells , results in fluid leakage from superficial blood vessels. Hives may be pinpoint in size or several inches in diameter, they can be individual or confluent, coalescing into larger forms. About 20% of people are affected. Cases of short duration occur equally in males and females, lasting

8918-614: The time to symptom control compared with antihistamines alone. Leukotrienes are released from mast cells along with histamine. The medications, montelukast and zafirlukast block leukotriene receptors and can be used as add on treatment or in isolation for people with CU. It is important to note that these medications may be more beneficial for people with NSAID induced CU. Other options for refractory symptoms of chronic hives include anti-inflammatory medications, omalizumab, and immunosuppressants. Potential anti-inflammatory agents include dapsone, sulfasalazine, and hydroxychloroquine. Dapsone

9016-406: The treatment of chronic hives but reports have shown them to be efficacious. Immunosuppressants are generally reserved as the last line of therapy for severe cases due to their potential for serious adverse effects. In those with chronic urticaria, defined as either continuous or intermittent symptoms lasting longer than 6 weeks, 35% of people are symptom free 1 year after treatment, while 29% have

9114-480: The two studies that showed no increase in shingles incidence were conducted among populations where varicella vaccination was not as yet widespread in the community. A later study by Patel et al. concluded that since the introduction of the chickenpox vaccine, hospitalization costs for complications of shingles increased by more than $ 700 million annually for those over age 60. Another study by Yih et al. reported that as varicella vaccine coverage in children increased,

9212-543: The virus is dormant. In larger laboratories, lymph collected from a blister is tested by polymerase chain reaction (PCR) for VZV DNA, or examined with an electron microscope for virus particles. Molecular biology tests based on in vitro nucleic acid amplification (PCR tests) are currently considered the most reliable. Nested PCR test has high sensitivity , but is susceptible to contamination leading to false positive results . The latest real-time PCR tests are rapid, easy to perform, and as sensitive as nested PCR, and have

9310-528: The virus to a person who lacks immunity to it. This newly infected individual may then develop chickenpox, but will not immediately develop shingles. The complete sequence of the viral genome was published in 1986. If the rash has appeared, identifying this disease (making a differential diagnosis ) requires only a visual examination, since very few diseases produce a rash in a dermatomal pattern (sometimes called by doctors on TV "a dermatonal map"). However, herpes simplex virus (HSV) can occasionally produce

9408-449: Was considered a characteristic finding, but studies have found that rash is only present in 45% of cases. In addition, systemic inflammation is not as reliable an indicator as previously thought: the mean level of C-reactive protein and mean white blood cell count are within the normal range in participants with VZV meningitis. MRI and CT scans are usually normal in cases of VZV reactivation in the CNS. CSF pleocytosis, previously thought to be

9506-416: Was introduced in the United States, there was concern that, because older adults would no longer receive this natural periodic boost, there would be an increase in the incidence of shingles. Multiple studies and surveillance data, at least when viewed superficially, demonstrate no consistent trends in incidence in the U.S. since the chickenpox vaccination program began in 1995. However, upon closer inspection,

9604-460: Was maintained through four years of follow-up. It has been recommended that people with primary or acquired immunodeficiency should not receive the live vaccine. Two doses of Shingrix are recommended, which provide about 90% protection at 3.5 years. As of 2016, it had been studied only in people with an intact immune system. It appears to also be effective in the very old. In the UK, shingles vaccination

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