Is Your Medication Raising Your Risk for Shingles?

Certain medications, particularly immunosuppressive drugs used in the treatment of autoimmune conditions, like prednisone, increase the risk of shingles in susceptible individuals by affecting the immune system. ¹ Antonelli MA, Moreland LW, Brick JE. Herpes zoster in patients with rheumatoid arthritis treated with weekly, low-dose methotrexate. Am J Med. 1991;90(3):295-298. ^{, 2} Atzeni F, Gozza F, Riva A, Alciati A, Galloway J. Conventional, biological disease-modifying anti-rheumatic drugs and Janus kinase inhibitors and varicella zoster virus. Expert Opin Pharmacother. 2023;24(6):679-689. doi:10.1080/14656566.2023.2195050

Keep reading to find out if your medications are increasing your risk of shingles and what steps you can take to prevent the condition.

Your immune system and shingles

Shingles (also referred to as herpes zoster) is an infection caused by the varicella-zoster virus – the same virus that causes chickenpox. Shingles is characterized by a painful, blistering rash that appears on the face and body. ³ Patil A, Goldust M, Wollina U. Herpes zoster: A Review of Clinical Manifestations and Management. Viruses. 2022;14(2):192. Published 2022 Jan 19. doi:10.3390/v14020192

When someone gets chickenpox, the immune system kicks in to fight the infection and clear symptoms, but the virus stays in the body in an inactive (dormant) state and hides in nerve cells near the spinal cord and brain. ³ Patil A, Goldust M, Wollina U. Herpes zoster: A Review of Clinical Manifestations and Management. Viruses. 2022;14(2):192. Published 2022 Jan 19. doi:10.3390/v14020192

The occurrence of shingles is closely linked to one's immune status. When the immune system's ability to control the dormant replication of the virus is compromised, it results in shingles. ⁴ Nair PA, Patel BC. Herpes Zoster. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441824/

Individuals with robust immunity seldom experience shingles. ⁴ Nair PA, Patel BC. Herpes Zoster. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441824/

Medications that lower immune function

Medications that suppress T-cell-mediated immunity – the body’s ability to recognize and eliminate foreign antigens – increase the risk of developing shingles. ⁵ Tran CT, Ducancelle A, Masson C, Lunel-Fabiani F. Herpes zoster: Risk and prevention during immunomodulating therapy. Joint Bone Spine. 2017;84(1):21-27. doi:10.1016/j.jbspin.2016.04.001 These medications are called immunosuppressant drugs and include:

• Drugs used in the management of rheumatic conditions, such as rheumatoid arthritis:
  • Non-biologic disease-modifying antirheumatic drugs (DMARDs), including methotrexate, hydroxychloroquine, and sulfasalazine. ¹ Antonelli MA, Moreland LW, Brick JE. Herpes zoster in patients with rheumatoid arthritis treated with weekly, low-dose methotrexate. Am J Med. 1991;90(3):295-298.  
  • Corticosteroids, including prednisone, methylprednisolone, and triamcinolone. ⁵ Tran CT, Ducancelle A, Masson C, Lunel-Fabiani F. Herpes zoster: Risk and prevention during immunomodulating therapy. Joint Bone Spine. 2017;84(1):21-27. doi:10.1016/j.jbspin.2016.04.001
  • Tumor necrosis factor (TNF) inhibitors, including adalimumab (Humira) and infliximab (Remicade). 
  • Janus kinase (JAK) inhibitors, including tofacitinib (Xeljanz) and upadacitinib (Rinvoq) ² Atzeni F, Gozza F, Riva A, Alciati A, Galloway J. Conventional, biological disease-modifying anti-rheumatic drugs and Janus kinase inhibitors and varicella zoster virus. Expert Opin Pharmacother. 2023;24(6):679-689. doi:10.1080/14656566.2023.2195050
• Medication used in the treatment of cancer and organ transplant, such as ⁴ Nair PA, Patel BC. Herpes Zoster. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441824/ : 
  • Chemotherapy agents 
  • Anti-rejection drugs (eg, cyclosporine)

Established research supports changes in the gut microbiome (good bacteria that live in the gastrointestinal tract) and reduced immunity with excessive use of antibiotics. ⁷ Ramirez J, Guarner F, Bustos Fernandez L, Maruy A, Sdepanian VL, Cohen H. Antibiotics as Major Disruptors of Gut Microbiota. Front Cell Infect Microbiol. 2020 Nov 24;10:572912. doi: 10.3389/fcimb.2020.572912. While inconclusive, there is ongoing research to determine a possible connection between the antibiotic-related decline in immunity and the potential risk for shingles. ⁸ Armstrong D, Dregan A, Ashworth M, White P. Prior antibiotics and risk of subsequent Herpes zoster: A population-based case control study. PLoS One. 2022;17(10):e0276807. Published 2022 Oct 27. doi:10.1371/journal.pone.0276807

See 5 Types of Medication That Treat Rheumatoid Arthritis (RA)

Additional factors that may increase your risk for shingles

Even if you are not taking an immunosuppressant, you may still be at risk for developing shingles if any of the following factors apply to you ⁴ Nair PA, Patel BC. Herpes Zoster. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441824/ :

• Age. Adults aged 50 years and older have a higher risk of shingles, which continues to increase due to the natural decline of immune function over time. ⁹ Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103–108. doi: 10.15585/mmwr.mm6703a5
• Stress. Prolonged, high levels of stress, including physical trauma and emotional stress, can weaken the immune system and trigger shingles. ³ Patil A, Goldust M, Wollina U. Herpes zoster: A Review of Clinical Manifestations and Management. Viruses. 2022;14(2):192. Published 2022 Jan 19. doi:10.3390/v14020192
• Compromised immunity. Medical conditions that impact immune function include ³ Patil A, Goldust M, Wollina U. Herpes zoster: A Review of Clinical Manifestations and Management. Viruses. 2022;14(2):192. Published 2022 Jan 19. doi:10.3390/v14020192 ^{, 4} Nair PA, Patel BC. Herpes Zoster. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441824/ :
  • Autoimmune disease
  • Human immunodeficiency virus (HIV)
  • Solid organ and stem cell transplant
  • Chronic lung or kidney disease

It is important to note that not everyone with these risk factors will develop shingles, and the presence of these risk factors only increases the likelihood of developing shingles.

Next steps if you are at a higher risk for shingles

While some risk factors, such as age or a chronic medical condition, cannot be changed, there are a few steps you can take to help lower your risk of shingles and its related complications (eg, the persistence of nerve pain and vision or hearing problems ⁴ Nair PA, Patel BC. Herpes Zoster. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441824/ ).

• Get vaccinated. Vaccination is the most effective strategy for lowering your risk of shingles. The recombinant zoster vaccine (Shingrix) is recommended for anyone over 50, regardless of health status, or for anyone over 18 who is immunocompromised. ⁹ Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103–108. doi: 10.15585/mmwr.mm6703a5 ^{, 10} Shingrix. Package Insert. GlaxoSmithKline Biologicals SA; 2023
• Explore alternative medication. Some newer drugs for autoimmune conditions (eg, Cosentyx, Tremfya, and Skyrizi) target more specific proteins and receptors within the immune system and are associated with a lower risk of infections. ¹¹ Wu KK, Lee MP, Lee EB, Wu JJ. Risk of herpes zoster with IL-17 inhibitor therapy for psoriasis and other inflammatory conditions. J Dermatolog Treat. 2020;31(4):359-365. doi:10.1080/09546634.2019.1597246 ^{, 12} Din S, Selinger CP, Black CJ, Ford AC. Systematic review with network meta-analysis: Risk of Herpes zoster with biological therapies and small molecules in inflammatory bowel disease. Alimentary Pharmacology & Therapeutics. Published online December 31, 2022. doi: 10.1111/apt.17379
• Maintain a healthy lifestyle. Adequate nutrition, hydration, exercise, and stress management contribute to the optimal function of the immune system.
• Consider vitamins and supplements. Certain vitamins and supplements, such as vitamin C, zinc, echinacea, and turmeric, are associated with boosting immunity and may help enhance your immune system's strength. ¹³ Read SA, Obeid S, Ahlenstiel C, Ahlenstiel G. The Role of Zinc in Antiviral Immunity. Adv Nutr. 2019;10(4):696-710. doi:10.1093/advances/nmz013 ^{, 14} Crawford C, Brown LL, Costello RB, Deuster PA. Select Dietary Supplement Ingredients for Preserving and Protecting the Immune System in Healthy Individuals: A Systematic Review. Nutrients. 2022;14(21):4604. Published 2022 Nov 1. doi:10.3390/nu14214604 It is important to talk with your doctor before trying a new diet, home remedy, or supplement to make sure it does not adversely interfere with your health or current medications.

If you have questions or concerns about your risk of shingles, talk to your doctor about which strategies might be right for you to lower your overall risk.

Medications for treating shingles

While there are several strategies for reducing the risk, individuals who are susceptible may still find themselves developing shingles.

Medications that are prescribed and/or recommended for treating shingles include ⁴ Nair PA, Patel BC. Herpes Zoster. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441824/ ^{, 15} Gruver C, Guthmiller KB. Postherpetic Neuralgia. [Updated 2023 Apr 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493198/ ^{, 16} Minor M, Payne E. Herpes Zoster Ophthalmicus. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557779/ :

• Antiviral drugs that specifically target herpes zoster virus, such as:
  • Acyclovir
  • Valacyclovir (Valtrex)
  • Famciclovir
• Topical antibiotics to prevent secondary bacterial infections of the skin, such as:
  • Mupirocin
  • Soframycin
• Eye drops to prevent secondary infections in the eye and/or alleviate symptoms, such as:
  • Erythromycin eye ointment
  • Prednisolone eye drops
  • Artificial tears
• Prescription pain-relievers that treat symptoms of nerve pain, such as:
  • Gabapentin (Neurontin)
  • Pregabalin (Lyrica)
  • Amitriptyline (Elavil)
• Topical pain-relieving agents to reduce pain and discomfort caused by blisters, such as:
  • Lidocaine
  • Capsaicin 
  • Aloe vera
• Over-the-counter pain-relievers for mild to moderate pain, such as:
  • Acetaminophen (Tylenol)
  • Ibuprofen (Motrin and Advil)

These medications play a crucial role in reducing the intensity and duration of shingles. 

See Pain Medications for Arthritis Pain Relief

If shingles is suspected, it's essential to promptly consult your doctor for treatment of the virus, addressing symptoms, and managing any potential secondary conditions.