Shingles on right arm 68 year old female, need any suggestions from knowledgeable people.

Infections
1

Shingles is covering at least half of arm from forefinger to high on shoulder. Slight pain for 2 days before rash started 5 days ago (couple pink spots) and has continued to expand to present along with pain. Shingles was diagnosed 4 days ago and anti-viral was prescribed, but pills were so big (1gm) they couldn’t be swallowed and now way pass 72hrs recommend time frame for start. Pain is extreme to point arm and hand cannot be used at all. Vicodin doesn’t relieve pain only allows 2-3 hours of sleep (which does help some). A melanoma was removed from forearm with 4 lymph nodes removed in arm pit 7 years ago.

All ready understand Shingles process but have questions that can’t seem to get answers about.

1)      How long does the rash normally keep spreading?

2)      At what point does the most severe pain slack off?

3)      Any recommendations for pain relief?

4)      Does anybody know if complications could happen because of lymph nodes removed?

2

We contacted doctor again about anti-viral med being later than 72 hrs. She suggested taking anyway and gave a prescription for Valtrix 500 mg to lower pill size. If anybody has taken this medication, we would appreciate knowing any side effects you experienced.

Also as indicated in first post hand is involved. It has extreme swelling of thumb and forefinger; we would like to know if this is normal when hand is involved.

May have noticed I’ve been saying WE. That’s because it’s my wife that has the shingles and unable to use computer. I wanted to edit first post to add that info but haven’t found way to edit yet. Thanks for any help in advance.

3

Hi Don

I sympathize with you and your wife.

I might not be of much help. I had shingles two years ago on my shoulder and face.  I did find a lot of help on this site, which you will find too.

I didnt like the drugs at all, and managed with paracetamol mostly . I was inbed for 6 weeks. I have had a fuzzy head and balance problems ever since. I think because it was close to my head and ear. I also got bells palsy

the pain seems to lessen after the blisters stop.

I am thinking you will hear from Merry, a lovely nurse who helps on this site

I was so greatful for her help at the time.

I wish you luck and hope your wife gets better soon

Christine NZ

4

It's very important that you immediately receive a Shingles vaccination. I had it after I broke out with shingles. After I received the vaccine it has lessened the severity and recurrence of the virus.

For pain lidocaine prescription and ice helps. Ask your doctor about bio drugs that can also help with relief. 

I

 

5

Thanks Christine

She is in major pain and like you she hates taking any medication, even has hard time swallowing pills. I assume you mean when blisters dry and crust over, does look like the spreading may have stopped for now (hopefully).

Sorry about what you went through because of wife’s situation I can now appreciate how it has affected those with shingles in past.

Don

6

Thanks for reply, I have heard you have to wait awhile after active episode of Shingles to get vaccine, I’ll have to check into that.

I’ll check about bio drugs and about lidocaine for pain. I’m going shortly for something to relieve her pain or she’s will probably end up in emergency room.

7

Dear Don,

I am so sorry your wife is going through this excruciating experience. Your wife had her lymph nodes resected from her axilla. Does she suffer from lymphedema, now? Does she always get her BP and blood draws done on the opposite arm? Is she considered "cured"

regarding the melanoma?

The risk increases for Herpes Zoster-Shingles on a traumatized body part, and the risk for lymphedema might rise slightly with Herpes Zoster-Shingles.

I have/had breast cancer with lymph node resection (excellent prognosis), but I never allow BPs, IVs, or blood draws in that arm, ever.

I would ask for the antiviral, Famciclovir 500mg three times daily for seven more days, starting now.

It is the newest and most efficacious drug, and the tablets are smaller than Valcyclovir-Valtrex 1000mg. Valtrex is based on Acyclovir, the oldest antiviral, which is less effective. Varicella is somewhat resistant to Acyclovir. Frankly, Valtrex stopped working on me, and I have difficulties swallowing the large capsules as Herpes Zoster-Shingles affects my ear and throat. She is not getting an effective dose with Valtrex 500 mg. 3x daily, so she should change STAT to Famciclovir 500 mg 3x daily to achieve the effective dose to stop the viral replication.

In a textbook case, the vesicle-blisters occur in crops over a period of five days. Please remember that this nasty virus does not read the textbook.

I am concerned that your wife has a history of malignant melanoma. If she is having metastatic disease, Herpes Zoster-Shingles could be a portent of metastasis. She needs to see her oncologist for follow-up.

The pain usually gets worse after the first couple of days. As your wife has an extensive case with severe pain, I would be assertive and request (demand nicely) oxycodone 10 mg every 6 hours for pain. I know the lancinating pain where a mere wisp of breeze sets off paroxysms of agony again and again, with no sleep night after night.

Cool compresses help decrease the pain. Heat worsens the pain!!!

Bactine or Solarcaine with Aloe both contain Lidocaine to numb the nerve endings topically. These can be used as an adjunct to the oxycodone 10mg. The arm should be elevated above the heart to prevent swelling. Absolutely no scratching or picking allowed as you do not want a secondary bacterial infection. If your wife does not have good pain control, she runs the risk of developing Post Herpetic Neuralgia PHN. This is why it is essential to get her on Famciclovir, and Oxycodone, a much stronger analgesic, and use a Lidocaine spray on her arm. Nothing will totally alleviate the pain, but these measures, and your comforting her, will help markedly.

The pain might lessen after 3 weeks, if she is lucky...

I am a Nurse Practitioner in the States. I have had Herpes Zoster-Shingles in my right ear every three to five weeks for the past twenty-one years and twice in my right eye. I am 66 years old.

I am so sorry I didn't respond sooner, but I just received your post in my email.

Best Wishes

Merry Juliana

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Also, Don, your wife just needs to rest and sleep. Any activity will worsen the pain.

Merry Juliana

9

Also, Don, your wife just needs to rest and sleep. Any activity will worsen the pain.

Merry Juliana

10

Don,

To reduce the swelling in the fingers and hand, her hand should be placed higher than her elbow, which should be higher than her shoulder, which is higher than her heart.

In other words, she should NOT lie on her right side.

She can lie on her back with a pillow on her abdomen/chest, and her arm resting on the pillow. She also can lie on her left side with a pillow on her right side, and her right arm elevated on top.

Ice and elevation will decrease the swelling, which will also decrease the pain.

I hope this makes sense.

She has more swelling probably due to the excision of the four lymph nodes.

Best Regards

Merry Juliana

11

Hi Merry,

First thanks for reply and information. Yes lymph nodes where from axilla, had to look it up not good with medical terms. She doesn’t suffer from lymphedema now and never had BPs, IVs, or blood draws at all but she does protect the right arm from things she can control. Did have compression therapy shortly after operation 7yrs ago because of questionable lymphedema diagnoses. Yes she is considered cured as far as melanoma is concerned and has been followed by dermatologist that originally found it.

I’ll see about requesting Famciclovir 500mg antiviral. I’m picking up Percocet 5/325mg (IIRC) tomorrow for pain relief, had some confusion today at pharmacy over prescription doctor wrote. Would the oxycodone 10 mg be better than the Percocet? Also have Methypred (Medrol) 4mg pack told to use more if nothing else seem to help.

She has never been diagnosed with metastatic disease. But was wondering about risk from lymph node removal, which you have certainly help about possibility of Post Herpetic Neuralgia PHN.

Thank you so much, I’ll have to go through every detail of all your post more than once to implement as much as I can. I’m late today because of overload with wife’s needs her and my chores. It’s a burden I gladly accept but I worry might not be doing enough for her health.

Please excuse my grammar and spelling, you’ve probably already noticed it’s not one of my strong points. Being this late at night doesn’t help either.

Thanks, Don

P.S. Just as I was finishing typing this (one finger typist L), had to stop wife up sick and vomiting I hope not from Vicodin or something worse.

12

Don,

Vicodin (Hydocodone) is known to cause nausea and vomiting. I never prescribed it as it is a horrible drug for that reason.

2 tablets of Percocet 5/325mg is the same as one tablet of Oxycodone 10mg plus acetominophin 650mg.

The Medrol pack can't hurt, and might help with the pain and inflammation.

I know how difficult it is to see someone you love in agony. You are priceless! May I ask your wife's name? Please send her my love and tell her I do care for her in her anguish!

All my best to the both of you!

Merry Juliana

13

Merry,

Another busy day that stared around midnight with trip to ER, after second round of vomiting and another crying pain episode I just couldn’t stand to watch again (something had to be done).

ER nurse and doctor realized how badly off she was upon examination. Setup med regiment tailored to use medications currently on hand while adding couple more. This process happened so fast I hadn’t had time to document name of antiviral you suggested, all I could remember it started with an “F”. That wasn’t enough for them to figure out or maybe they thought I was just senile (which might be correct) or maybe even drug addict after I mentioned 10mg oxycodone. I guess I didn’t do good sales job, might have to do your modified 10mg process if she needs it.

This is what we ended with.

Percocet 5/325 mg       1 ea - ever 4 hrs

Valtrex 500 mg 2 ea - 3 x day

Medrol 4 mg                per schedule

Zofran 4 mg                  1 ea - ever 8 hrs

Colace 100 mg 1 ea – 2 x day

They started all ~ 2 am monitor long enough for stability. After returning home and a little sleep she had improved noticeably and now 8:30 pm even more improved after more sleep. At lease looks bearable at this point and time to follow more of your suggestion. That’s after I get some sleep tonight smile.

Thanks again,

Don

14

Merry,

I did past along your love and fact you care for her in her anguish. She and I thank you for that. Her name is Pat (Patricia), sorry I overlooked  that.

We've tried different pillow options to elevate arm you suggested. She's maybe half way to correct elevation because of sever pain in shoulder joint, but she's still working to get optimum level as pain allows. Thanks again for your time and help.

I did get Bactine spray containing Lidocaine but we've held back using it because it says not to use on blisters which she still has, she's certain she can't stand to apply a lotion. We're also concerned about her not having a bowel movement in over week now even though she's been taking Colace 100 mg 1 ea – 2 x day as prescribed by ER doctor for last 3 days. The instructions that came with Colace indicates 3 times a day. What is your feeling about the Colace?

Don

15

Finally got to wife’s PCP today about getting more Percocet, which might have been a mistake. They are against those type medications and only gave prescription for 12 more Percocets only as needed. They gave prescription for Gabapentin 300 mg 3 times daily for nerve pain and damage repair. Also prescription for Mupirocin Oinment 2 %.

Does anybody have opinion on effectiveness of Gabapentin?

Should Mupirocin be applied over areas that still have liquid blisters?

16

Hi Don

Mupirocin can be applied over the open blisters.

I would consider switching PCPs if the Physician is being that stingy with the Opioid.

I feel that for acute pain, Opioids are better suited, and Gabapentin as an adjunct. I certainly am helped slightly by my anticonvulsant, but not nearly enough.

For chronic pain, the anticonvulsants are better suited. It is unconscionable that these Physicians are making patients suffer.

Merry Juliana

17

Marry

After this is over we are considering looking into switching PCP’s. Another indicator this morning PCP called indicating they had made a mistake, the Gabapentin should have been 100mg instead of 300mg. Ask if Pat had taken any yet, if so did she have any problems. Indicating they would send new prescription for 100mg. I let them know she had taken two and she had mentioned a twitchy like quivering feeling also seemed she had hard time focusing her eyes, so send new prescription. She didn't take any more 300mg and tomorrow she will start the 100mg with the 300mg on hand if needed.

I have everything you suggested saved so if this should occur again to Pat or Me we’ll be better prepared.

Do you think a dermatologist might be more knowledgeable and understanding with a Shingles case?

Don

18

An update with few questions. Rash on wife's arm has mostly crusted over except for couple blisters near wrist. Thumb still swollen and immobile. Arm pit, right upper chest, shoulder and breast area (mostly around area where lymph nodes removed years ago) swollen with pain which is still keeping her from elevating arm completely above heart.

Her most troubling pain is now mostly skin (surface area) which has been deep pain prior. She swears the Gabapentin has caused the surface pain to be more severe, now on 300mg 3 x daily for 900mg daily total. Realizing this may just be a stage type process or confidential timing brings up following questions.

Does Gabapentin have any other benefit  than pain relief?

Like does it help minimize long term effect of PHN?

Could this just be normal for surface pain to increase prior to get better?

We're debating stepping her down slowly and stopping Gabapentin completely. Looking for advice concerning this as it doesn't seem her PCP has a clue.

19

Don,

The Gabapentin does help with acute pain relief and also does help prevent Post Herpetic Neuralgia PHN. The pain of Herpes Zoster-Shingles gets worse often the second and third weeks before it gets better. As your wife was unable to receive more Opioids, I am certain the pain is worse, but not due to the Gabapentin, but not having any Opioids to take.

I take Topamax, a similar anticonvulsant. I am certain I would have been suicidal with pain without the Topamax, and definitely would have Post Herpetic Neuralgia PHN without the Topamax.

I strongly advise to stay on the Gabapentin. I am sorry to hear that she is suffering so.

Best Regards

Merry Juliana

20

I guess shingles doesn't observe Christmas, but it does appear there may be slight improvement in pain intensity today. Blisters and rash area of entire arm has dried and crusty, skin extremely dry (cracked) looking almost like alligator skin. Hopefully a sign pain level might be heading down hill.

Hand, elbow and front shoulder area still swollen (7+ days now) with pain. However we're now able to concentrate more on ice pack application and better elevation methods to reduce swelling as suggested by Merry along with other great advice from her. Thanks from the heart to Merry, christine76458 and hope4cure who have offered great advice to this point.

To all here my wife and I would like to wish you all a very Merry Christmas and Happy New Year.

Pat & Don