Herpes zoster, or shingles, is a viral infection that affects at least one in three Americans at some point in their lives. This infection triggers a painful rash, which typically starts as a stripe of blisters on one side of your torso, but it can appear anywhere on the body.
The same virus that causes chickenpox causes shingles. The varicella-zoster virus, also known as Herpes zoster (HZ), is a painful acute infection caused by the reactivation of the dormant Herpes zoster virus, in an individual who has previously had chicken pox, which is caused by the varicella zoster virus (VZV). New onset Acute Herpes zoster (AHZ) can be extremely painful even after prompt treatment with standard oral antiviral medication, which include Acyclovir (Zovirax®), valacyclovir (Valtrix®) and famciclovir (Famvir®). None of these rapidly eliminate severe shingles pain. Severe Herpes zoster infections of the face can require intravenous narcotics. The chronic, unremitting pain of postherpetic neuralgia (PHN) can be devastating and incapacitating.
Although shingles doesn’t threaten your life, this condition is typically quite painful. Unfortunately, the pain of shingles can persist long after the blisters heal. When this happens, you’re diagnosed with a condition called chronic postherpetic neuralgia.
Vaccines exist to lower your risk of getting shingles, and there are steps you can take to manage your symptoms should you develop this condition. Dr. Jeffrey Klein and our team of providers at HK Dermatology in San Juan Capistrano, California offer expert diagnosis and management of shingles.
Keep reading to learn our top shingles management tips!
Shingles may not be a life-threatening condition, but that doesn’t mean you shouldn’t get medical help. If you suspect you have shingles, schedule an appointment within 2-3 days. If you’re struggling with shingles pain, don’t hesitate to talk to your provider. With many treatment options, there’s no need to stay in pain.
At HK Dermatology, our team uses Dr. Klein’s radical new treatment to slow the development of painful blisters and lower your chances of getting chronic postherpetic neuralgia.
TELBAT (Tumescent Lidocaine Epinephrine, B12 vitamin, Acyclovir, Triamcinolone)
TELBAT (pronounced “Tell -Bat”) is a new treatment for severely painful Herpes infection invented by Dr. Jeffrey Klein, (US Patent 10,493,024 B2. Klein. Tumescent infiltration drug delivery of high subcutaneous drug concentrations with prolonged local and systemic effects and minimal local or systemic toxicity (Dec 3, 2019). TELBAT is treats the most severe forms of Herpes zoster pain. TELBAT treatment consists of the painless injection of a relatively large volume of the relatively dilute TELBAT solution directly within and beneath the skin affected by the painful shingles rash.
The name TELBAT is an acronym for Tumescent (means swollen and firm), Epinephrine (capillary vasoconstrictor), Lidocaine (local anesthetic), vitamin B12 (an essential agent for health of nerves), Acyclovir (anti-Herpes virus drug), and Triamcinolone (anti-inflammatory corticosteroid). TELBAT may also be effective in treating a Herpes simplex (cold sore) virus eye infection.
Acute Herpes zoster (AHZ) is characterized by the new onset of intense skin pain caused by the Herpes zoster virus infection. AHZ typically involves 3 sequential stages: 1) abrupt onset of pain affecting a localized area of skin (dermatome) on one sideonly of the body, 2) soon afterward, typically within 1 to 3 days, a rash with vesicles and blisters appears in that same area, and, 3) gradual resolution of the rash and pain over 3 to 4 weeks. Subacute Herpes zoster describes the condition of Herpes zoster pain which persists for more than a month but less than 3 months after the onset of AHZ.
Chronic Postherpetic neuralgia (PHN) is a chronic form of zoster pain that persists for 3 months or more. PHN is the most common complication of shingles. In some patients PHN can be severely incapacitating and can last for years. The risk of developing PHN is increased with age, with impaired immunity, and with inadequate (insufficient or delayed) treatment with shingles-specific oral antiviral drugs. The debilitating pain of PHN often results in impaired physical function and mobility, chronic depression, emotional and physical isolation, and marked reduction in quality of life. PHN also results in significant costs to patients, their care givers and the healthcare system.
There are at least distinct types of pain associated with nerve injury caused by shingles.
1) Sharp-Stabbing Sudden Pains (Intensity and Frequency can vary)
2) Constant Deep Aching-Burning Pain
3) Pain caused by Light Touch of the affected area (Allodynia)
4) Exaggerated pain caused by a direct touch to the affected area (Hyperalgesia)
5) Constant deep painful itch
6) Persistent bothersome numbness
Dilute Epinephrine in the TELBAT solution produces local capillary vascular constriction in the subcutaneous tissue underlying the painful shingles rash. This vaso-constriction delays the systemic absorption of the TELBAT drugs into the blood stream from under the skin, which thereby prolongs the local effects of all the drugs in the TELBAT solution.
Dilute Lidocaine in the TELBAT solution is a local anesthetic that provides immediate and profound local anesthesia that eliminates Herpes zoster pain for 8 to 18 hours or more.
Vitamin B12 reduces shingles pain, but the mechanism by which B12 achieves this effect is not precisely known. B12 may function by aiding the repair and healing of nerve cells damaged by Herpes virus infection.
Dilute Acyclovir: Acyclovir is an antiviral drug that stops the replication (proliferation) of the Herpes zoster virus, thereby slowing the progression and reducing the intensity of shingles pain and rash. There are three FDA-approved oral drugs for treating shingles: acyclovir, valacyclovir and famciclovir. Valacyclovir (Valtrex®) is transformed into acyclovir after it is absorbed into the body.
Dilute Triamcinolone is an effective, mid-potency corticosteroid anti-inflammatory drug. The triamcinolone in the TELBAT solution reduces the local inflammatory response to the Herpes zoster virus (HZV), thereby reducing nerve injury caused by the virus, shingles pain, blistering, tissue damage, and the risk of scaring caused by the severe inflammation.
Normal saline (0.9% physiologic sodium chloride) is the solvent or vehicle into which the TELBAT drugs are dissolved. By mixing the TELBAT drugs into a relatively large volume of saline, the drugs are relatively dilute, which eliminates the risk of drug-related local tissue toxicity.
If the first dose of TELBAT is given within 4 to 7 days of the first of the shingles outbreak, most patients only require 3 daily TELBAT injections.
Acyclovir is the only one of these antiviral drugs that is available in liquid form for intravenous (IV) injection. The liquid form of Acyclovir is available commercially at a concentration of 1gm/20ml. Undiluted acyclovir is only approved for IV infusion. Undiluted commercial acyclovir, when injected into the skin, is toxic to the skin, causing pain and necrosis. Dr. Klein discovered that when acyclovir is significantly diluted, it can be safe and effective when injected into and under the skin
The effectiveness of any anti-shingles drug depends on its concentration in the skin at the site of the shingles infection. TELBAT treatment maximizes its concentration of acyclovir in the skin (to optimize therapeutic effect) and simultaneously minimize its concentration in the blood (to minimize the risk of toxicity). For both acute and chronic (PHN) pain, lidocaine in the TELBAT solution reliably eliminates shingles pain for 8 to 18 hours.
Acute H zoster pain responds rapidly to a TELBAT injection. In more than 90% of patients TELBAT completely eliminating severe shingles pain (both acute and chronic). In the remaining patients, shingles pain is reduced by 75% almost instantly. Without exception, every patient has confirmed that their decrease in pain is “like night and day.”
For some patients, a single treatment permanently eliminated all shingles pain. Other patients require 2 to 5 consecutive, daily TELBAT treatments to achieve permanent success. The sooner TELBAT treatments can be initiated the better.
For acute H zoster of less than 4days duration, two to four TELBAT treatments can permanently eliminate the pain, and dramatically shorten the healing process. It is important to initiate TELBAT treatment of acute shingles as soon as possible. With delayed treatment, acute Herpes zoster become more resistant to treatment.
The chronic PHN pain is more resistant to TELBAT treatment. Nevertheless, some PHN patients do achieve a significant long-term reduction in pain levels.
In our experience with TELBAT, the subcutaneous infiltration of tumescent acyclovir is safe and without evidence of any significant adverse effects. Patients who are taking anticoagulant blood thinners such as Xarelto® (rivaroxaban) or Eliquis® (apixaban) may experience some bruising at the injection sites.
When a specific use of a drug has been approved by the FDA, the “instructions for use” for the drug are printed on a package label that is inserted into each box containing the drug. When a particular use of the drug is not explicitly described on this printed label, the use is considered “off-label”.
All of the individual drugs in the TELBAT solution have FDA approval to be sold commercially. However, the combination of these drugs has yet to be approved by the FDA, and therefore a TELBAT solution for treating Herpes virus infection is considered to be “off-label” and cannot be sold commercially. Importantly, the FDA does not object to a physician using TELBAT solution to treat his/her own patients. Similarly, the subcutaneous injection of acyclovir is “off-label”.
Because TELBAT is a patented composition, it is illegal for any physician to provide TELBAT and charge a fee for the service unless the physician has a licensed to do so. An FDA requirement for approval of TELBAT to be sold commercially is a clinical trial of TELBAT that establishes safety and efficacy of TELBAT. Dr. Klein is in the process of requesting FDA approval of an Investigational New Drug (IND) application for permission to conduct a clinical trial of TELBAT for treating the most severe shingles pain. In pilot studies of TELBAT for treating shingles Dr. Klein has shown that highly dilute acyclovir solution can be injected subcutaneously without toxicity.
For acute Herpes zoster (AHZ), when TELBAT treatments are initiated within four days of the onset of the AHZ pain, usually 2 to 4 treatments are sufficient to arrest all progression of the shingles rash and permanently eliminate the zoster pain. Of course, once blistering has occurred, it takes 7 days or more for the crusted blisters to dry up and fall off. Exceptionally severe cases of shingles may require additional TELBAT treatments. In our experience, prompt treatment of acute shingles with TELBAT significantly reduces the risk of developing chronic PHN or other HZ complications. All acute shingles patients do take the usual anti-shingles tablets (Valtrex, acyclovir or famciclovir) for a total of 10 days.
Subacute Herpes zoster patients have persistent moderate to severe shingles pain which has lasted for more than 8 weeks. These patients often require receive 6 to 10 or more TELBAT treatments before the pain is eliminated. Subacute shingles can be expected to respond well to TELBAT.
TELBAT is less consistently successful. PHN is a chronic disease, like diabetes, that can require regular TELBAT treatments once every week or two. A few PHN patients experience long term improvement with only 6 to 12 treatments. For some PHN patients, TELBAT treatments are not sufficiently helpful to justify long term repeated treatments. Currently there is no reliably effective commercially available treatment for PHN. The drugs that are typically used for this condition often have significant side effects. The current consensus, among those who specialize in treating PHN, is that PHN cannot be cured. However, for some PHN patients, TELBAT can provide definite long-term improvement. PHN is more resistant to TELBAT than acute shingles. PHN patients often receive regular TELBAT treatments, every 4 to 14 days.
Dr. Klein is Clinical Professor of Dermatology, UC Irvine. He is Certified by the American Board of Dermatology (UC Irvine), American Board of Internal Medicine (UCLA0, and the American Board of (MOHS) Micrographic Dermatologic Surgery. His training includes an NIH Clinical Pharmacology Research Fellowship (UCSF), MPH Biostatistics (UC Berkeley)
When you have shingles, anything touching or rubbing the blisters can cause significant pain. Wearing clothes with a relaxed fit and made from natural materials, such as cotton, can help keep you more comfortable.
You can help reduce the pain caused by clothes and other things touching your blisters by covering the blisters with bandages, if possible. Be sure to use bandages that won’t stick to your rash. Sometimes the stripe of blisters is too big for coverage, however, so be sure to talk to your provider at HK Dermatology before covering up.
You might remember taking an oatmeal bath to alleviate the itching caused by chickenpox. This same treatment can ease the discomfort of shingles. By adding colloidal oatmeal, a fine powder made of specially ground oats, to a cool or lukewarm bath, you can find relief from itching and mild pain. Calamine lotion can also be used to help manage itching.
The blisters that shingles cause can break and ooze pus and other fluids. This can make your skin itchy or uncomfortable. To ease this discomfort, place a washcloth soaked in cool water directly on the blisters. This also helps lower your risk of infection.
Don’t leave the compress on your skin for longer than 20 minutes at a time. Also be sure not to use a compress at the same time you have a patch, treatment cream, or bandage in place.
You can manage your symptoms and help speed healing by practicing good self-care while you have shingles. Be sure to get plenty of rest and focus on eating healthy, nutritious foods so your body can fight the infection. Avoid stress, too, as this can make shingles worse, and use distractions, like reading, watching TV, or doing activities you enjoy to help take your mind off your discomfort.
Prevention is the best medicine, and it’s possible to get shingles more than once. To lower your risk of getting shingles again, talk to your HK Dermatology provider about getting vaccinated.
In 2017, the Food and Drug Administration (FDA) approved a new shingles vaccine, and only your doctor can tell you if it’s right for you. Generally speaking, however, you may be eligible for this vaccine if you’re over 50 or have a weakened immune system. It’s also possible to get the vaccine even if:
If you’re concerned about shingles, or you want to learn more about the shingles vaccine, schedule an appointment online or over the phone with a provider at HK Dermatology.
