Signs of Shingles: Herpes Zoster

Shingles is an infection that usually produces a painful skin rash, but the painful tingling sensations which characterize the condition can also occur when no rash is present. Shingles is caused by the varicella zoster virus (VZV). 1

VZV is the same virus that causes chickenpox, a very common childhood infection. 2 After a person has had chickenpox, VZV remains dormant in their body for the rest of their lifetime. If the virus reactivates, which can happen decades later, most often due to a weakened immune system, the resulting condition is called shingles. Although anybody who has already had chickenpox can develop shingles, the condition most commonly affects adults, typically those over 50 years of age. 3

The early signs of shingles are typically sensations of itching, numbness, or burning pain on the skin of the face, chest, or back; in most cases, this develops into the condition’s characteristic rash.

The rash develops into blisters on one side of the body, most commonly in one of the following areas:

• Neck
• Torso
• Face

A shingles outbreak typically lasts for three to four weeks. 4 Many people experience only one outbreak of shingles in their lifetime, although the condition can recur.

Read more about Genital Herpes »
Read more about Herpes Labialis »

The principal symptom of shingles is a painful skin rash. This looks like red or discolored skin at first and eventually features weeping blisters.

Before the rash appears, early warning signs of shingles, which may be present, include:

• Itching, burning pain, numbness, tingling in the place where the rash will develop
• Flu-like symptoms such as chills, fever, headache, feeling fatigued or overly tired
• Upset stomach

After the initial skin complaints develop into a shingles rash, the condition typically lasts for two to four weeks. The pain typically worsens as the rash develops and alleviates as it heals.

The varicella-zoster virus which causes shingles lies dormant in the nervous system, so the rash will appear in a dermatomal pattern; a band or area of skin on the body corresponding to a particular set of nerves. 5 The shingles rash usually appears on the face, neck or one side of the torso.

As the condition progresses, the rash site develops blisters that fill with clear fluid. Because shingles interact with a person’s nervous system, the rash is often accompanied by an intense, stabbing pain that worsens as it develops. The area affected by the rash may be hypersensitive to touch, which can render it difficult to dress or to sleep in certain positions.

A person with shingles is contagious to others during the period when their rash is blistering. During this period, a person should avoid physical contact with others, in particular, certain population groups, including:

• Elderly people
• Pregnant people
• People with a weakened immune system
• People who have not had chickenpox in the past

The blistering phase of the rash usually lasts for seven to ten days, and the lesions should then reduce in size as they heal, eventually disappearing.

Although the painful shingles rash on one side of the face, neck or torso is present in most cases of shingles, the condition can take various other forms.

Less common forms of shingles include:

• Zoster sine herpete; shingles with pronounced pain, but without the rash
• Internal shingles; shingles affecting the internal organs
• Herpes zoster ophthalmicus; shingles affecting the nerve in the eye
• Herpes zoster oticus; shingles which invade the facial nerve

It is possible for a person to develop shingles without being affected by the rash, although this is rare. When shingles occur without the rash being present, this is called zoster sine herpete (ZSH).

When shingles occur without a rash, the first symptoms of the condition may involve:

• A feeling of numbness in a certain area
• An itchy, burning sensation
• A painful sensation
• Headache
• Fatigue
• Generalized aches
• Hypersensitivity to touch

When shingles is present, even without the rash, sensations will be concentrated in a specific area of the body – commonly the face, neck, one side of the torso or the eyes. However, in the absence of the shingles rash, zoster sine herpete may still rarely lead to neurological and visceral diseases, such as inflammation of the brain (encephalitis), Varizella pneumonia, paralysis of the facial nerves and problems related to keeping one’s balance or problems with hearing. 6

Because shingles shares characteristics with many other conditions, including herpes simplex, impetigo, dermatitis herpetiformis, and contact dermatitis, it can easily be confused with these conditions. In cases where a rash is not present, a laboratory test will usually be necessary to establish the presence of the varicella-zoster virus in the body.

In rare cases, shingles can invade the lungs, nervous system, and brain instead of – or as well as – the external areas of the body. This is more likely to happen in cases where a person has a weakened immune system, for example as caused by human immunodeficiency virus (HIV) or by undergoing a course of chemotherapy.

It is rarely possible to have internal shingles without a rash if it only affects internal parts of the body. People, who have a weakened immune system and suspect they may have shingles even though the typical rash is not present, should make their healthcare professional aware of their medical history immediately in order to prevent shingles from developing internally.

Symptoms of internal shingles are related to the affected internal organ. If a person has internal shingles affecting the lungs, for example, developing pneumonia is a possible symptom. 7

Also called ophthalmic herpes zoster, this form of the condition involves shingles invading the nerve in the eye. The first indicator that shingles has spread to the eye is the development of the shingles rash and/or associated sensations in the tip of the nose. 8

If shingles is suspected in the nasal area, it is advisable to consult an ophthalmologist, a doctor specializing in conditions which affect the eyes, without delay, as this form of shingles can cause visual distortions and even blindness.

Read more about Herpes Zoster Ophthalmicus »

This type of shingles occurs when shingles affects the facial nerves. Symptoms may vary, depending on which of the cranial nerves in the head is affected. The cranial nerve VII (nervus facialis) is affected in around 90 percent of cases of herpes zoster oticus, resulting in shingles on the face, neck, ear and/or mouth.

The other, less common, forms of herpes zoster oticus are:

• Ramsay Hunt Syndrome; a peripheral facial palsy, characterized by acute pain in one ear and the face. Vesicles may be present in the external ear canal, as well as additional auditory symptoms in some cases.
• HZO affecting cranial nerve VIII; or nervus vestibulocochlearis, which produces vestibular (balance system) symptoms such as dizziness and vertigo in addition to the shingles rash.

If a person suspects they may be affected by herpes zoster oticus, they should consult a healthcare professional immediately, as shingles which affects the facial nerves, indicates a likelihood of developing internal shingles.

All people who have been affected by chickenpox and, rarely, people who have been vaccinated against chickenpox and thereby carry VZV ‒ the virus which causes herpes zoster/shingles ‒ in their body, are at risk of developing shingles.

Shingles will affect around one in three people in the U.S. during their lifetime. After a person has recovered from chickenpox, VZV remains dormant in their body. It is stored in the nervous system and can reactivate as shingles when a person’s immune system is compromised by aging, illness, or stress.

Shingles is only contagious at the point when the rash is blistering. At this time, VZV can be passed from a person with shingles to others via direct bodily contact, passing on traces of infected blister fluids and the sharing of towels, bedding, and utensils.

It is only possible to catch the varicella zoster virus, rather than shingles itself: If a person who has never had chickenpox before is infected with VZV by somebody with shingles, they will develop chickenpox ‒ the first infection which VZV causes when it enters the body ‒ as opposed to shingles. 9

Shingles is most common in adults over 50 years of age. The Center for Disease Control and Prevention recommends that all people over 50 be vaccinated against shingles. The vaccine reduces the overall risk of contracting the condition by around 50 percent, and lessens the duration and severity of shingles if it occurs. 10

Since 2018, there is a dead vaccine against shingles. Getting the vaccine is recommended for everyone aged 50 or older and has an effectivity of over 90%. 11

Shingles can also affect people whose immune systems have been weakened by injury or illnesses, such as human immunodeficiency virus (HIV), cancer or the use of certain medicines or treatments which place a lot of stress on the immune system – such as organ transplants and chemotherapy. People of any age, who have previously had chickenpox and are experiencing a prolonged period of severe stress, are also at risk of shingles.

If a person develops shingles while pregnant, it is usually mild and poses no further risk to the individual or their unborn baby. 12 However, pregnant people who have never had chickenpox, should avoid contact with those affected by chickenpox and those affected by shingles as a precautionary measure.

People with shingles or chickenpox both have the capacity to infect others with VZV and developing chickenpox whilst pregnant can result in potentially severe health complications for both the pregnant person and the developing fetus.

Because the shingles rash is instantly identifiable due to its dermatomal pattern, the rash, and accompanying pain, usually on one side of the body, are generally the only symptoms which need to be present for a shingles diagnosis to be made. The doctor will usually perform a physical examination and may take a swab from a blister, sending a sample of cells from the aggravated area of skin for a laboratory test in order to confirm the diagnosis.

It is recommended that anyone who thinks that they may be developing shingles seek medical attention as soon as possible to get supportive treatment and decrease the chance of infecting others. Although it is not possible to cure shingles, various pharmaceutical products can be prescribed on diagnosis which can help ease the pain and lessen the duration of the condition. These work most effectively when taken as soon as possible after the onset of shingles. If you suspect that you could be experiencing the first signs of shingles, or are unsure, consult the Ada app for a free symptom assessment.

There is no cure for shingles, but by diagnosing the condition early, it is possible to:

• Prevent the spread and severity of shingles
• Reduce associated health complications
• Ease the pain
• Lessen the duration of the outbreak

Following a diagnosis of shingles, a physician will generally advise on a recovery plan designed to alleviate the discomfort associated with the shingles rash.

Activities which are usually recommended for a swift recovery from shingles may include:

• Resting and relaxing
• Wearing loose-fitting clothes
• Keeping the rash clean and dry in order to dry out the blisters
• Keeping the rash uncovered so that the blisters can progress into the scabbing stage as quickly as possible
• Using cool compresses to alleviate the burning sensation on the skin
• Avoiding sharing bedding, clothing, or towels, as this can facilitate the spread of infection to others

Medications which may be prescribed for alleviating the physical discomfort of shingles and combating the flare-up of the varicella-zoster virus may include: 12

• Painkilling medications such as non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol, or opioids in cases of severe pain. In some cases, antidepressants or anticonvulsants may be prescribed for their pain-relieving properties, which can work effectively in combination with other painkillers.
• Antiviral medications

Q: Are there further health risks associated with shingles?
A: If left untreated, shingles is more likely to result in post-herpetic neuralgia (PHN), a condition in which a burning pain continues to be felt in the areas affected by shingles for more than three months after the rash and blisters themselves have disappeared. Approximately one-fifth of people who are affected by shingles will go on to develop PHN. 13 The likelihood of shingles spreading to internal regions of the body likewise increases in the absence of a promptly initiated treatment and recovery plan.

Q: Are the signs of shingles different in adults to those in children?
A: The signs of shingles in children are largely the same as the signs of shingles in adults. However, shingles in children is generally less severe and lasts for a shorter duration than in adults, and most children recover well with no associated health complications. Shingles rarely affects children under three years of age and can only affect children who have already had chickenpox. 14 Shingles are not common in children. 15 However, having a weakened immune system as a result of an autoimmune disease, other chronic or serious disease, or because of being overly stressed, however, can increase the likelihood of a child developing shingles. 16

Does stress cause shingles?
A: Stress itself does not cause shingles. However, it can, in some cases, make an attack on shingles more likely. 16 This is because stress may weaken the immune system, potentially leaving a person more vulnerable to all types of infection, including the varicella-zoster virus. 17

Good to know: People who have a weakened immune system, and who have never been infected by VZV before, will develop chickenpox the first time they catch the virus, rather than its subsequent form, shingles.

Q: Can herpes zoster cause encephalitis?
A: This rare condition occurs when the brain becomes inflamed, which is usually caused by the spread of an infection in the body to the brain. Viral infections, including the herpes simplex virus causing oral and genital herpes, and VZV, which causes shingles, are more associated with developing encephalitis than bacterial infections. The possibility of developing encephalitis due to the spread of VZV or another virus is greater in people with a weakened immune system; for example, if a person’s immune system is compromised due to another underlying health condition, such as human immunodeficiency virus (HIV). 18

Early signs of encephalitis include flu-like symptoms such as headaches, fever, aching muscles, and nausea, 18. More serious symptoms include drowsiness, seizures, and difficulty speaking. 19 Immediate medical attention should be sought if encephalitis is suspected, as it can be life-threatening and should be treated as soon as possible. Diagnostic tests for encephalitis will involve an MRI or CT scan to visualize the extent of the inflammation and a lumbar puncture to determine its cause. This will allow doctors to decide on the best course of treatment. If encephalitis is caused by the herpes simplex of VZV virus, treatment will involve a course of antiviral medication. 20

Q: What are the signs of shingles healing?
A: Normally, the blisters that feature in the shingles rash will burst around five days after they first develop. At this point, the stages of shingles healing are as follows: they will weep, turn into crusty scabs, and begin to heal thereafter. From the time they burst, the scabbing and healing process takes approximately two weeks. Signs that shingles is healing as normal during this time include the size of the scabs diminishing, and, correspondingly, the severity of the pain associated with the rash reducing. 21

Q: Should I get the shingles vaccine?
A: The Centres for Disease Control and Prevention recommend the shingles vaccine for all people over 50 years of age, whether they have had chickenpox or not. The vaccine reduces the overall risk of contracting the condition by around 50 percent and lessens the duration and severity of shingles if it occurs. 22

Since 2018, there has been a dead vaccine against shingles. Getting the vaccine is recommended for everyone aged 50 or older and has an effectivity of over 90%. 11

The shingles vaccine is not recommended for certain population groups, including people who are: 22

• Pregnant. A person who has had the shingles vaccine should wait a minimum of four weeks before trying to become pregnant
• Affected by a condition which weakens the immune system, such as HIV
• Affected by any type of cancer affecting bone marrow or the lymphatic system
• Using immunosuppressive medications such as steroids
• Undergoing radiation therapy or chemotherapy
• Receiving an organ or bone marrow transplant in less than 4 weeks time, just having received it, or while being on immunosuppressive medication after receiving one 23