Best Pain Relief For Shingles: Creams And Antiviral Medication

If you've ever had chickenpox, you’ve been infected with the varicella-zoster virus (VCZ). As a child, the concept of the virus remaining in your body forever may not seem very interesting. However, if the virus does reactivate later in life and causes shingles, it can be very painful and serious. 

Your doctor may refer to shingles as herpes zoster (HHV), as the virus is one of the herpes variations that can affect humans, specifically Human Herpesvirus 3 (HHV3). But no matter what it's called, the virus lives in your nerve cells, and when it's reactivated, it can cause a painful skin rash. About 30% of the adult population in the US will have shingles at some point.¹

There is medication to treat shingles, but one of the worst characteristics of the disease is the sometimes debilitating pain that can persist months after the rash has healed. If you catch a shingles outbreak early, your doctor can prescribe antiviral medication to ease the acute symptoms and lower your chances of developing persistent postherpetic neuralgia (PHN).

If you're over 50, the shingles vaccine is recommended to combat the VZV virus — it significantly lowers your risk for both HZ and PHN.

Risks factors for getting shingles

Not everyone who has had chickenpox will get shingles, although there is always that chance. Not remembering you had chickenpox when you were three doesn't mean the virus has been forgotten as well. If you've had the chickenpox vaccine, you may still get shingles later in life, although your risk is lower compared to those that have had chickenpox.

These are some of the risk factors for shingles:

  • Being over 50

  • Being immunocompromised

  • Having certain cancers and treatments

  • Taking immunosuppressant medication

  • Having HIV

  • Being female

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Symptoms of shingles

There are only a few symptoms of shingles — a tingling, itching sensation on one side of your body or face, limited to a single area innervated by a particular nerve termed a dermatome, followed a few days later by a rash in a single stripe in that area. 

If you have a weakened immune system, or in rare cases, the rash can spread over contiguous dermatomes and possibly cross the midline and resemble chickenpox. These are the other signs of shingles onset:

  • Headache

  • Chills and fever

  • Malaise

  • Itching

  • Burning, shooting, pain

  • Pain without rash

Shingles complications

Don't try to treat shingles symptoms on your own — the VCZ virus that causes shingles can have serious complications. 

If the rash is on your face, you're at risk for blisters to form around or in your eyes, which can lead to temporary — or even permanent — vision loss. Ramsay Hunt syndrome is also a possible complication — it is the major otologic complication of VZV reactivation, which typically involves a triad of ipsilateral (same-sided) facial paralysis, ear pain, and vesicles in the ear canal and on the auricle.²

Furthermore, Ramsay Hunt syndrome (herpes zoster oticus) can also cause hearing problems, vertigo, and ipsilateral altered taste perception. 

These are some other possible complications of the shingles virus:

  • Hearing loss

  • Balance issues

  • Bacterial infections, typically Staphylococcus aureus 

  • Inflammation of blood vessels

  • Meningitis, hepatitis, pneumonia

  • Stroke

Treatment for shingles

Treating shingles with antiviral medication reduces the severity of the outbreak. The sooner you start taking prescription meds, the shorter and milder the illness — see your doctor as soon as you have the first signs of the rash. Your doctor will prescribe one of three antivirals — Zovirax (acyclovir), Valtrex (valacyclovir), or Famvir (famciclovir).

Topical adjunctive corticosteroids — can also be prescribed to manage inflammation in the case of herpes zoster ophthalmicus. If you have persistent PHN pain, your doctor may recommend a tricyclic antidepressant or a gabapentinoid to help reduce postherpetic neuralgia symptoms. Opioid analgesics or lidocaine or capsaicin patches can also be used in patients with PHN. 

Topical creams

Creams, lotions, and ointments to treat shingles have a couple of benefits. They usually contain some form of analgesic to relieve the pain and other ingredients to prevent secondary bacterial infection.

Side effects of acyclovir

Acyclovir does have potential side effects. Malaise is common and not serious, but other side effects can create further problems. Here are some of the uncommon but severe side effects of acyclovir:

  • Tissue necrosis (IV use)

  • Toxic epidermal necrolysis

  • Stevens-Johnson Syndrome

  • TTP (immunocompromised pts)

  • Erythema multiforme

Valacyclovir and famciclovir

These are second-generation herpes drugs. Valacyclovir, a prodrug of acyclovir, accelerates both pain relief and persistence in shingles patients. Famciclovir has the benefit of better bioavailability — the concentration of the drug when it reaches the target site, in this case, the inflamed neurons replicating the shingles virus. 

Studies comparing valacyclovir and famciclovir were inconclusive regarding superiority and found no differences in endpoints. However, a systematic review of high-quality trials established that famciclovir and valacyclovir were superior to acyclovir in reducing the possibility of prolonged pain.³

Capsaicin

Recent research indicates that capsaicin — the chemical compound that gives cayenne pepper its heat — can help with postherpetic neuralgia pain. Capsaicin can be a double-edged sword, unlike other topical shingles solutions, such as lidocaine or aloe vera.

While it does reduce substance P in the neurons by inhibiting the pain impulses between the peripheral and central nervous system, it can also make your skin burn wherever it's applied. You can ease the burning by applying a thin layer of Salonpas or another analgesic to the area before the capsaicin. 

Capsaicin also has these possible side effects: 

  • Dry, red skin

  • High blood pressure

  • Nausea and vomiting

  • Respiratory symptoms — sinusitis, bronchitis, cold, cough

  • Dizziness and headache

  • Limb pain

EMLA

EMLA, or a eutectic mixture of local anesthetics, is a combination of prilocaine and lidocaine. Studies indicate that applying EMLA cream to the shingles rash "significantly" improved the patient's pain levels.⁴

Patches for PHN

A lidocaine patch (Dermalid, Lidoderm, Ztido) is available with a prescription. The patch is a 5% concentration, but patients can use up to three patches on a single area at any given time for pain management for up to 12 hours daily. Capsaicin patches have also shown positive outcomes in several studies.⁵

Whereas a cream must be applied several times daily to be effective, patients wear the patch for several hours, guaranteeing the constant transmission of the capsaicin chemicals. 

What are the best over-the-counter creams for shingles?

Choosing the right OTC shingles cream is largely a matter of personal preference. There is a range of ingredients, effectiveness, and cost of the different creams. Some creams contain natural ingredients, while others have analgesics that control pain. 

There isn't a lot of research on which creams are most effective. Online reviews may be the best place to get unbiased information on OTC cream results. Expense is another consideration — some are quite expensive.

Lidocaine

Lidocaine is a topical anesthetic that numbs the skin and underlying nerve tissue when applied. Prescription-strength lidocaine has better results for shingles pain, but it can ease some itching and burn in an OTC cream.⁶

The highest concentration you can get without a prescription is 5%. Whereas, as a prescription, the cream can be compounded as high as 10%. Some OTC medications with lidocaine include Aspercreme, Absorbine jr, and Salonpas.⁷

Calamine

You probably have some calamine lotion handy for treating poison ivy and mosquito bites, but you can also apply it to open lesions to reduce pain and pruritus.

Hydrocortisone/steroids

Hydrocortisone/steroid creams may seem like a good idea to stop the blister's itching. But they don't help with skin infections and would be contraindicated as they may suppress the immune system reacting to the infection.

Natural remedies

You can get past shingles without medical intervention — people have been doing it for thousands of years. But they also had no recourse to manage complications and would have probably welcomed a pill to ease the pain. You can do some things to alleviate the symptoms while dealing with the infection, but they are not great substitutes for going to the doctor. 

Acupuncture

The Chinese have been using acupuncture for thousands of years. Although studies have not demonstrated a benefit for acupuncture in both shingles and PHN, you may still decide to try acupuncture.⁷

Honey

Clover and Manuka honey have significant antiviral properties that can combat the shingles virus, and they can be useful in managing the rash when applied topically. Citizens in developing nations use honey as a home remedy, and studies have shown that medical-grade honey is beneficial when treating cold sores — another herpes virus. 

The lowdown

There's nothing wrong with trying home remedies to manage some of your shingles symptoms, but you should not attempt to "cure" an outbreak on your own. Shingles, like any other herpes virus, can't be cured, only tamped down until it returns to a latent state. If you have shingles, you can transmit it to someone who's never had chickenpox, and they'll get that and be susceptible to shingles later. 

See your doctor if you think you're getting shingles. Most people only have one outbreak in their lifetime, but some immunocompromised patients run the risk of recurrent infections. 

Before you begin self-treatment for shingles, consult your doctor for advice on the best OTC remedies.

  1. Shingles (Herpes zoster) | Centers for Disease Control and Prevention

  2. Ramsay hunt syndrome | Rare Disease Database

  3. Antivirals for management of herpes zoster including ophthalmicus: A systematic review of high-quality randomized controlled trials (2012)

  4. EMLA cream in the treatment of post-herpetic neuralgia. Efficacy and pharmacokinetic profile (1989)

  5. The effectiveness and safety of topical capsaicin in postherpetic neuralgia: A systematic review and meta-analysis (2016)

  6. Lidocaine | NIH: National Library of Medicine

  7. Lidocaine- lidocaine ointment amneal pharmaceuticals LLC | Daily Med

Other sources:

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