Signs of Shingles: Herpes Zoster

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] It is also known as herpes zoster, but it is not caused by the same virus that produces genital or oral herpes.

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.

The first signs of shingles are typically sensations of itching, numbness or a burning pain on the face, chest or back; in most cases this develops into the condition’s characteristic rash. This results in blisters on one side of the body, most commonly on the neck, torso or face. A shingles outbreak typically lasts for three to four weeks.[3] Many people experience only one outbreak of shingles in their lifetime, although the condition can reoccur.

Symptoms of shingles

The principal symptom of shingles is a painful skin rash which eventually features weeping blisters.

Sensations which may precede the appearance of the rash include:

  • Itching
  • Chills
  • Tingling
  • Fever
  • Headache
  • Burning pain
  • Upset stomach
  • Numbness

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. The varicella zoster virus which causes shingles lies dormant in the nervous system, so the rash will appear in a dermatomal pattern, in a band or area of skin on the body corresponding to a particular set of nerves.[4] The shingles rash usually appears on the face, neck or one side of the torso.

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 where no rash is present
  • 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)

It is possible for a person to develop shingles without being affected by the painful 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
  • Headache
  • Fatigue
  • An itchy, burning sensation
  • Generalized aches
  • Hypersensitivity to touch

When shingles is present, 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 can produce neurological and visceral diseases, such as inflammation of the brain (encephalitis), paralysis of the facial nerves and problems related to balancing or hearing.[5]

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.[6]

Internal shingles

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.

People, who have a weakened immune system and suspect they may have shingles, should make their healthcare professional aware of their medical history immediately in order to prevent shingles developing internally. Symptoms of internal shingles are related to the affected internal organ.

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.[7]

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 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 is affected. The cranial nerve VII (nervus facialis) is affected in around 90 % 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 (nervus vestibulocochlearis), which produces vestibular 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.


  1. Varicella Zoster Virus Infection: Clinical Features, Molecular Pathogenesis of Disease, and Latency.” Neurological Clinics. August 2008. Accessed: 24 October 2017.

  2. Facts about chickenpox.” Pediatric Child Health. September 2005. Accessed: 24 October 2017.

  3. How Long Does It Take to Recover from Shingles?.” New Health Guide. 24 October 2017. Accessed: 24 October 2017.

  4. Dermatomes Anatomy.” Medscape. 13 October 2017. Accessed: 24 October 2017.

  5. Varicella-Zoster Virus Reactivation without Rash.” Journal of Infectious Diseases. 01 August 1992. Accessed: 24 October 2017.

  6. Diagnosis & testing.” National Center for Immunization and Respiratory Diseases, Division of Viral Diseases. 19 August 2016. Accessed: 24 October 2017.

  7. Managing ophthalmic herpes zoster in primary care.” British Medical Journal. 16 July 2005. Accessed: 24 October 2017.