Signs of Shingles: Herpes Zoster
Written by Ada’s Medical Knowledge Team
What is shingles?
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 a 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 the following areas:
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.
Good to know: Shingles is also known as herpes zoster, but it is important to note that this condition is not caused by the same virus, called herpes simplex, that results in genital or oral herpes.
Symptoms of shingles
The principal symptom of shingles is a painful skin rash. This looks like red or discolored skin at first and eventually features weeping blisters.
Signs of shingles before the rash appears
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 the shingles rash, the condition typically lasts for two to four weeks. The pain typically worsens as the rash develops and alleviates as it heals.
What does the shingles rash look like?
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.
Good to know: If the relevant nerves are affected, it is also possible to experience shingles on the leg. It is relatively unusual, but also possible, to develop the shingles rash in more than one area of the body, i.e. in relation to more than one set of nerves. Even more rarely and especially in people with a compromised immune system, three or more dermatomes may be affected. This is a form of the condition known as disseminated zoster.
As the condition progresses, the rash site develops blisters which fill with clear fluid. Because shingles interacts with a person’s nervous system, the rash is often accompanied by an intense, stabbing pain which 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 in 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.
Subtypes of shingles
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 invades the facial nerve
Zoster sine herpete (ZSH): shingles without the rash
It is possible for a person to develop shingles without being affected by the rash, although this is rare. When shingles occurs without the rash being present, this is called zoster sine herpete (ZSH).
When shingles occurs 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
- 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. 7
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 developing internally.
Herpes zoster ophthalmicus
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. 9
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.
Good to know: In some cases of herpes zoster ophthalmicus, Hutchinson’s sign may be present. This involves vesicles (fluid-filled sacs) developing on the tip or side of the nose, due to shingles affecting the nasociliary branch of the trigeminal nerve, which is connected to parts of the nose as well as the cornea in the eye.
Herpes zoster oticus (HZO)
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.
Causes of 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.
Good to know: If a person who has been vaccinated against chickenpox develops shingles, the infection tends to be significantly less severe than the condition can be when it affects people who do not carry any form of VZV in their body. It is therefore, in general, worthwhile for a person, who has not experienced chickenpox, to be vaccinated against it, even though this is an attenuated vaccine (containing a weakened version of the virus that does not cause the illness), and therefore does not offer total protection against related conditions such as 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.
Is shingles (herpes zoster) contagious?
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. 10
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. 11
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%. 12
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. 13 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 to aid recovery
Medications which may be prescribed for alleviating the physical discomfort of shingles and combating the flare-up of the varicella zoster virus may include: 14
- 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
Signs of shingles FAQs
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. 15 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. 16 Shingles are not common in children. 17 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. 18
Does stress cause shingles?
A: Stress itself does not cause shingles. However, it can, in some cases, make an attack of shingles more likely. 18 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. 19
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). 20
Early signs of encephalitis include flu-like symptoms such as headaches, fever, aching muscles and nausea, 20. More serious symptoms include drowsiness, seizures and difficulty speaking. 21 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. 22
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. 23
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. 24
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%. 12
The shingles vaccine is not recommended for certain population groups, including people who are: 24
- 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 25