ASK THE GP: I had shingles two years ago – so why am I still itchy? Dr Martin Scurr answers your health questions
Two years ago, I had a very bad attack of shingles in my right eye and scalp. I was in such agony I went to hospital and was put on a morphine drip for three days. My right eye and scalp now feel constantly irritated and itchy. I’ve been told there’s nothing I can do about it, but it drives me crazy. I’m 79 and otherwise fit and active.
Shiela Peczenik, Andover, Hants.
What you describe is known as postherpetic neuralgia, a sensation triggered by nerve damage following shingles.
Shingles is caused by the varicella-zoster virus, the same virus that causes chickenpox. Like most of us, you probably have had chickenpox in childhood — after you recovered, the virus will have gone into hibernation in nerve tissue close to the brain or spinal cord.
Fact: Shingles is caused by the varicella-zoster virus, the same virus that causes chickenpox
Your immune system will have kept it under control for all that time until two years ago, when, for some reason, your immunity waned, allowing the virus to reactivate wherever it had been lurking for all those years. In your case, it was possibly in a branch of the trigeminal nerve, which is responsible for sensation in the forehead and eye region (the upper third of the face).
As well as the painful blistering rash of shingles, this will have caused an inflammatory response around your right eye and scalp.
The pain usually dissipates after several weeks, but in some people it can persist, and this is termed postherpetic neuralgia; essentially the nerve cells that were damaged by inflammation continue to send pain signals to the brain.
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The damage may also cause areas of numbness and abnormal sensation when the skin is touched or something cold or warm is applied — in your case, this has triggered a persistent itching.
There are drugs that can reduce the abnormal sensations, but treatment may have to continue for many months — with the occasional review by your doctor or a pain clinic specialist to fine-tune the correct dose. The two drugs of choice are gabapentin and pregabalin. These are anticonvulsant medicines which are also proven to be useful in the treatment of nerve-derived pain — they effectively dampen the pain signals.
The other option — with a similar mechanism — is taking a tricyclic antidepressant such as amitriptyline. This should be started at the dose of 10 mg taken at night (by comparison, as a treatment for depression the dose is much higher, 75 mg to 150 mg).
Did you know? The pain of shingles usually dissipates after several weeks, but in some people it can persist, and this is termed postherpetic neuralgia
Even at that low dose, sleepiness and dry mouth may be troublesome side-effects, particularly in the first week or two, and it may take up a month to notice any improvement.
One other suggestion to discuss with your GP is the prescription-only capsaicin cream, which contains a purified version of the ingredient in chilli peppers that makes them taste hot.
Research has shown this can help relieve nerve pain in the skin. It must be applied four times daily to the skin only (not the eye) and can cause a burning discomfort — which up to a third of users may find is worse than the symptom they are hoping to treat — but it might be worth a try. You have already suffered the complication for two years and I think there’s a strong case for talking to your GP about further treatment, or asking for a referral to a specialist pain clinic.
Since returning from a holiday four years ago, my feet have ached. At first I thought it was because I’d been wearing flip-flops, but I’ve had a number of different diagnoses and treatments.
After a second MRI scan, I’ve now been told it’s arthritis. I had steroid injections three weeks ago but, to my dismay, my feet are no better. I’m 84 and very healthy otherwise. My toes are fine — it’s my insteps and ankles that hurt.
Name and address supplied.
I sense your frustration and disappointment — in your longer letter you detail a saga of different clinicians (including a podiatrist, two orthopaedic surgeons, and your GP), and now you feel that, despite treatment, the pain has not changed.
I note that the pain, under the instep of each foot as well as around the ankle, came on suddenly, and that you suspect it was triggered by wearing flip-flops.
It may be a cliche to blame walking in such unsupportive shoes, but it’s something I’ve seen several times, and on every occasion the diagnosis was plantar fasciitis.
Write to Dr Scurr
To contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email [email protected] — including contact details.
Dr Scurr cannot enter into personal correspondence.
His replies cannot apply to individual cases and should be taken in a general context.
Always consult your own GP with any health worries.
This affects the soft tissues of the underside of the foot, specifically the ligaments that attach muscles of the underside of the foot to the underside of the heel bone. It’s caused by inflammation triggered by overuse (like a repetitive strain injury).
It may be that using your toes to grip on to the flip-flops to keep them on might have upset the usual muscle function of the underside of the foot — especially if doing more walking than usual when on holiday.
The condition is more common in older people, but affects both feet in only 10 per cent of cases.
The diagnosis is based upon the symptoms, with the pain often being most severe with the first steps of the day — and the point where the instep meets the heel bone feeling acutely tender when pressed.
Plantar fasciitis may not show up on scans, and these may even be misleading because if they reveal any arthritic change, this could be misdiagnosed as the cause of the pain.
The treatment includes rest, wearing supportive, well-cushioned shoes with good arch and heel support and, often, an orthotic in the shoe (a wedge-shaped one that raises the heel slightly). It usually takes six to 12 months to recover.
The question to ask your GP or orthopaedic specialist is whether your pain might be due to plantar fasciitis.
IN MY VIEW…GPs SHOULD BE IN HOSPITALS
GENERAL practice is in real trouble — with a perfect storm of soaring demand, cuts in funding, staff shortages and ever more red tape.
The Daily Mail’s resident GP: Dr Martin Scurr
No wonder patients struggle to get appointments. No wonder GPs feel disillusioned, their jobs no longer seen as fulfilling, leading in turn to difficulty recruiting and retaining them.
Part of the problem lies with the independent subcontractor status of GPs, an historic arrangement dating from the start of the NHS in 1948. It means GPs are effectively small businesses ‘hired in’ by the health service. But this model is no longer fit for purpose: a recent survey revealed that only one GP in five sees partnership as the most attractive career option. General practice is losing 100 partners every month.
One of my friends, an experienced GP in her late 40s, is typical. She recently resigned from her partnership and is happily working as a locum. A single mother of two teenage boys, she has more freedom, less administrative burden and is able to concentrate on patient care. What she misses is being able to provide continuity of care, which we all acknowledge improves outcomes and is more satisfying for both patient and doctor.
But the cavalry is riding to the rescue: a West Midlands hospital trust has announced it’s taking over 18 practices covering 100,000 patients, with the GP partners giving up their independent status to become salaried employees.
This will enable them to concentrate on care and relinquish the burden of management. It also has the potential to reduce the divide between general practice and hospital care.
Patients and medical staff alike can only benefit when GPs are able to work alongside their specialist colleagues, ideally participating in the care of their patients when they’re in hospital, with access to hospital record systems and the ability to freely investigate their patients using hospital facilities.
It’s time the walls came down: I hope we see more such schemes soon.
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