Shingles

What is shingles?

Shingles (herpes zoster) is a viral infection of the nerve roots. It causes pain and a band of rash that spreads on one side of your body. Shingles is most common in older adults and people who have weakened immune systems because of stress, injury, certain medications, or other factors.

What causes shingles?

Shingles is caused by the reactivation of the virus (varicella-zoster virus) that causes chickenpox. After you recover from chickenpox, the virus lies dormant (inactive) in your nerve roots. In some people, it stays dormant for the rest of their lives. In others, the virus reactivates when disease, stress, or aging weakens the immune system.¹ The cause of reactivation of the virus is unclear; however, once it does reactivate, it causes shingles, not another case of chickenpox. Most people who get shingles will not get the disease again, although it does come back in a few people.

What are the symptoms of shingles?

Early symptoms of shingles include:

• Headache.
• Sensitivity to light.
• Flu-like symptoms without a fever.

You may then feel itching, tingling, or extreme pain in the area where a rash will develop several days later, commonly on your back or neck. The rash progresses into clusters of blisters along the path of the nerve. The blisters fill with fluid and eventually crust over. It takes 2 to 4 weeks for the blisters to heal, although some scars may remain.²

Complications of shingles can occur and include:

• Postherpetic neuralgia, persistent pain that lasts longer than 1 month after the rash heals.
• Disseminated zoster, a blistery rash that spreads over a large portion of the body and can affect the heart, lungs, liver, pancreas, joints, and intestinal tract. Infection may spread to nerves that control movement, which may cause temporary weakness.
• Cranial nerve complications, if shingles affects the nerves originating in the brain. Complications can include inflammation or blockage of blood vessels.
• Herpes zoster ophthalmicus , a shingles rash on the forehead, cheek, nose, and around one eye that could threaten your sight. This type of shingles needs immediate treatment.³

How is shingles treated?

There is no cure for shingles, but treatment may shorten the length of illness and prevent complications. Treatment may include:

• Antiviral medications, sometimes in combination with corticosteroids, to reduce the pain and duration of shingles.
• Pain medications, antidepressants, and topical creams to relieve long-term pain.

Who gets shingles?

You must have had chickenpox, even a mild case, to get shingles. You have an increased risk of developing shingles if you:¹

• Are older than 50.
• Have an autoimmune disease, meaning your immune system attacks its own tissues as though they were foreign substances.
• Have another medical condition or stress that weakens the immune system.

You cannot develop shingles if you have not had chickenpox.

Frequently Asked Questions

Shingles is a reactivation of the varicella-zoster virus, a type of herpes virus that causes chickenpox. Once you have had chickenpox, the virus lies inactive in your nerve roots and remains inactive until, in some people, it flares up again. When the virus becomes active again, you develop shingles instead of chickenpox.

Anyone who has had even a mild case of chickenpox can get shingles. People who have a weak immune system are vulnerable to reactivation of the virus that causes shingles. Many factors can weaken your immune system, including aging, injury, and illness. Some medications slow down the immune system; for example, medications that destroy cancer cells (chemotherapy) also interfere with the immune system.

Transmission

Exposure to shingles will not cause you to develop shingles; however, if you have not had chickenpox and you are exposed to shingles, you can develop chickenpox. Someone with shingles can potentially expose you to chickenpox if you come into contact with the fluid in the shingles rash blisters.

One study reports that the virus that causes shingles may be released into the air from shingles sores. Covering the shingles sores with a type of dressing that absorbs fluids and protects the sore (hydrocolloid dressing, such as DuoDerm) appears to effectively contain the virus.⁴

When the virus that causes chickenpox reactivates, it causes shingles. Early symptoms of shingles include headache, sensitivity to light, and flu-like symptoms without a fever. You may then feel itching, tingling, or extreme pain in the area where a rash is developing. Several days later, a belt-shaped or bandlike rash appears. This band of pain and rash is the clearest sign of shingles.

The rash caused by shingles is more painful than itchy. The nerve roots that supply sensation to your skin run in pathways on each side of your body. When the virus becomes reactivated, it travels up the nerve roots to the bandlike area of skin supplied by those specific nerve roots. This is why the rash appears on only one side of your body, usually the chest or back, and sometimes on your face around one eye. It is possible to develop more than one bandlike rash on your body with shingles.

Shingles develops in stages:

Prodromal stage (before the rash appears)

• Pain, burning, tickling, tingling, or numbness develops in the area around the affected nerves several days before a rash begins. The discomfort occurs on a single side of the body, commonly on the chest or back, but it may occur on the abdomen, head, face, neck, or one arm or leg.
• Flu-like symptoms (usually without a fever), such as chills, stomachache, or diarrhea, may develop just before or along with the start of the rash.
• Swelling and tenderness of the lymph nodes may occur.

Active stage (rash and blisters appear)

• A rash consisting of small fluid-filled blisters develops on reddened skin on one side of your body. Fluid inside the blister is initially clear but may become cloudy after 3 to 4 days.
• The rash may occur on the forehead, cheek, nose, and around one eye (herpes zoster ophthalmicus ), which may threaten your sight unless you receive prompt treatment.³
• Extreme pain, described as “piercing needles in the skin,” may accompany the skin rash.
• Blisters may break open, ooze, and crust over in about 5 days. Complete healing takes about 2 to 4 weeks, although some scars may remain.²

Postherpetic neuralgia (chronic pain stage)

• Postherpetic neuralgia is the most common complication of shingles. It lasts for at least 30 days and continues for months to years. Symptoms are:⁵
  • Aching, burning, stabbing pain in the area of the earlier shingles rash.
  • Persistent pain that may linger for years.
  • Extreme sensitivity to the touch.
• The pain associated with postherpetic neuralgia most commonly affects the forehead or chest, and it may make it difficult for the person to eat, sleep, and perform daily activities. It may also lead to depression.

Shingles may be confused with other conditions that cause similar symptoms of rash or pain, such as herpes simplex infection or appendicitis.

Shingles is caused by the same virus that causes chickenpox. After an attack of chickenpox, the virus remains in the tissues in your nerves. As you get older, or if you have an illness or stress that weakens your immune system, the virus may reappear in the form of shingles.

You may first experience a headache, flu-like symptoms (usually without a fever), and sensitivity to light, followed by itching, tingling, or even severe pain in the area where your rash will develop. The pain usually occurs 1 to 3 days before a bandlike rash appears on one side of your body.¹ Within 3 to 5 days, the rash turns into fluid-filled blisters that ooze and crust over. Complete healing takes about 2 to 4 weeks, although you may have permanent scars.²

Most people who get shingles will not get the disease again, although it does recur in a few people.

Complications of shingles

Complications of shingles can occur and include:

• Postherpetic neuralgia, which is pain that does not go away within 1 month and lasts for months or even years after shingles heals. Postherpetic neuralgia affects up to 10% to 15% of those who experience shingles.⁶ It is more common in people age 50 and older, and in people who have a weakened immune system due to another disease, such as diabetes or HIV infection. People who have severe pain and rash during shingles have an increased risk for postherpetic neuralgia.⁷
• Disseminated zoster, which is a blistery rash that spreads over a large portion of the body and can affect the heart, lungs, liver, pancreas, joints, and intestinal tract. Infection may spread to nerves that control movement, which may cause temporary weakness.
• Cranial nerve complications. If shingles affects the nerves originating in the brain (cranial nerves), complications may include:
  • Inflammation, pain, and loss of feeling in one or both eyes. The infection may threaten your vision. A rash may appear on the side and tip of the nose (Hutchinson's sign).
  • Intense ear pain, a rash around the ear, mouth, face, neck, and scalp, and loss of movement in facial nerves (Ramsay Hunt syndrome). Other symptoms may include hearing loss, dizziness, and ringing in the ears. Loss of taste and dry mouth and eyes may also occur.
  • Inflammation, and possibly blockage, of blood vessels, which may lead to stroke.
• Scarring and skin discoloration.
• Bacterial infection of the blisters.
• Muscle weakness in the area of the infected skin before, during, or after the episode of shingles.

Risks for developing shingles include:¹

• Having had chickenpox. You must have had chickenpox to get shingles.
• Being older than 50.
• Having a weakened immune system due to another disease, such as diabetes or HIV infection.
• Experiencing stress or trauma.
• Developing chickenpox prior to age 1.⁸
• Having cancer or receiving treatment for cancer.

If a pregnant woman gets chickenpox, her baby has a high risk of developing shingles within his or her first 2 years of life.¹

Postherpetic neuralgia is a common complication of shingles that lasts for at least 30 days and continues for months to years. If more than one of the following risk factors is present, your risk increases for postherpetic neuralgia.⁷

• Developing shingles after age 50
• Having severe pain and rash during shingles
• Being female

Call your health professional immediately if :

• Any sign of shingles develops (such as pain or changes in vision) that affects your forehead, nose, eye, or eyelid.
• Any symptoms of shingles develop (such as headache, stiff neck, dizziness, weakness, hearing loss, or changes in your thinking and reasoning abilities) that affect your central nervous system.
• Skin sores spread to parts of your body beyond the original area of the rash.
• You think you have a bacterial skin infection in the same area as the shingles rash, or your rash has not healed in 2 to 4 weeks.
• You develop pain in your face or are unable to move muscles in your face.

Call your health professional today if:

• You suspect you might have shingles. There are medications that can limit your pain and rash . The earlier you start treatment for shingles, the better the results.

Watchful Waiting

If you think you have shingles, see a health professional as soon as possible. Early treatment with antiviral medications may help decrease pain and prevent complications of shingles, such as disseminated zoster or postherpetic neuralgia.

If intense pain persists for more than 1 month after the skin heals, see your health professional to determine whether you have postherpetic neuralgia.

Who To See

• Family medicine physician
• Internist
• Dermatologist
• Physician assistant
• Nurse practitioner
• Neurologist, for central nervous system complications of shingles

To prepare for your appointment, see the topic Making the Most of Your Appointment

Shingles is usually diagnosed by the appearance of the bandlike rash that occurs on one side of your body. If a diagnosis of shingles is not clear, your health professional may order lab tests, most commonly herpes tests, on cells taken from a blister.

If there is reason to think that shingles is present, your health professional may not wait to perform tests before treating you with antiviral medications. Early treatment may help shorten the length of the illness and prevent complications such as postherpetic neuralgia.

There is no cure for shingles, but treatment may shorten the length of illness and prevent complications. Treatment options include:

• Antiviral medications, sometimes in combination with corticosteroids, to reduce the pain and duration of shingles.
• Pain medications, antidepressants, and topical creams to relieve long-term pain.

Initial treatment

As soon as you are diagnosed with shingles, your health professional probably will begin treatment with antiviral medications. If you begin medications within the first 2 to 3 days of the appearance of the shingles rash , your chances of developing complications, such as postherpetic neuralgia, decrease. Early treatment of shingles is important, because the possible complications can be serious and resistant to treatment. For example, 40% to 50% of people with postherpetic neuralgia do not respond to treatment.⁶

The most common treatments for shingles include:

• Antiviral medications, such as acyclovir, famciclovir, or valacyclovir, to reduce the pain and the duration of shingles.
• Nonprescription pain medications, such as acetaminophen, aspirin, or ibuprofen, which may help reduce pain during an attack of shingles.
• Corticosteroids, in combination with antiviral medication, to reduce pain and the duration of shingles.
• Topical antibiotics, applied directly to the skin, to stop infection of the blisters.

Ongoing treatment

If you have pain that persists longer than a month after your shingles rash heals, your health professional may diagnose postherpetic neuralgia, the most common complication of shingles. Postherpetic neuralgia can cause pain for months or years. It affects 10% to 15% of those who experience shingles.⁶ Treatment to reduce the pain of postherpetic neuralgia includes:⁶

• Antidepressant medications, such as a tricyclic antidepressant (for example, amitriptyline).
• Topical anesthetics, such as lidocaine patches, to numb the area.
• Anticonvulsant medication, such as gabapentin.
• Opioids, such as codeine.

Topical creams containing capsaicin may provide some relief from pain. Capsaicin may irritate or burn the skin of some people, and it should be used with caution.

Treatment if the condition gets worse

In some cases, shingles causes long-term complications. Treatment depends upon the specific complication.

• Postherpetic neuralgia is persistent pain that lasts months or even years after the shingles rash heals. Certain medications, such as anticonvulsants, antidepressants, and opioids, can relieve pain. Most cases of postherpetic neuralgia resolve within a year. On very rare occasions, surgical treatment may be used to treat postherpetic neuralgia by cutting nerves to help block pain signals.
• Disseminated zoster is a blistery rash over a large portion of your body. It may affect your heart, lungs, liver, pancreas, joints, and intestinal tract. Treatment may include antiviral medications to prevent the virus from multiplying and antibiotics to stop infection.
• Herpes zoster ophthalmicus is a rash on the forehead, cheek, nose, and around one eye, which could threaten your sight. You should seek prompt treatment from an ophthalmologist for this condition.³ Treatment may include rest, cool compresses, and antiviral medications.
• If the shingles virus affects the nerves originating in the brain (cranial nerves), serious complications involving the face, eyes, nose, and brain can develop. Treatment depends on the nature and location of the complication.

Anyone who has had chickenpox may get shingles later in life. However, the U.S. Food and Drug Administration (FDA) has approved a vaccine that may help prevent shingles. It is known as Zostavax (shingles vaccine (What is a PDF document?)). One dose is recommended for adults 60 years of age and older. Ask your doctor about the availability of this vaccine.

Also, if you have never had chickenpox, you may avoid getting the virus that causes both chickenpox and later shingles by receiving the varicella vaccine currently recommended for preventing chickenpox.

If you have never had chickenpox, avoid contact with people who have shingles or chickenpox. Fluid from shingles blisters is contagious, and exposure to it can cause chickenpox (but not shingles) in people who have never had chickenpox.

If you develop shingles, avoid close contact with people until after the rash blisters heal. It is especially important to avoid contact with people who are at special risk from chickenpox or shingles, such as:

• Pregnant women, infants, children, or anyone who has never had chickenpox.
• Anyone who is currently ill.
• Anyone with a weak immune system who is unable to fight infection (such as someone with HIV infection or diabetes).

One study reports that the virus that causes shingles may be released into the air from shingles sores. If you have active shingles, you may be able to prevent spreading the disease by covering the shingles sores with a type of dressing that absorbs fluids and protects the sore (hydrocolloid dressing, such as DuoDerm).⁴

You may reduce the duration and pain of shingles by:

• Taking good care of skin sores, such as not scratching blisters and keeping your skin clean.
• Using medications as prescribed to treat shingles or postherpetic neuralgia, which is pain that lasts for at least 30 days after the shingles rash heals.
• Using nonprescription pain medications, such as acetaminophen, aspirin, or ibuprofen, to help reduce pain during an attack of shingles or ongoing pain caused by postherpetic neuralgia.

If home treatment does not reduce postherpetic neuralgia pain, talk with your health professional about what you can do to control the pain.

Medications can help limit the pain and discomfort caused by shingles, shorten the time you have symptoms, and prevent the spread of the disease. Medications also may reduce your chances of developing shingles complications, such as postherpetic neuralgia or disseminated zoster. Early treatment of shingles is important, because the possible complications can be serious and resistant to treatment. For example, 40% to 50% of people with postherpetic neuralgia do not respond to treatment.⁶

Medication Choices

Medications to treat shingles when the one-sided, bandlike rash is present (active stage) may include:

• Nonprescription pain medications, such as acetaminophen, aspirin, or ibuprofen, which may help reduce pain.
• Antiviral medications, to reduce the pain and duration of shingles.
• Corticosteroids, in combination with antiviral medication, to reduce the pain and duration of shingles.
• Topical antibiotics, which are applied directly to the skin to stop infection of the blisters.

Medications to treat postherpetic neuralgia pain may include:

• Nonprescription pain medications, such as acetaminophen, aspirin, or ibuprofen.
• Tricyclic antidepressants, such as amitriptyline.
• Topical medications, such as a lidocaine patch.
• Anticonvulsants, such as gabapentin.
• Corticosteroids, such as prednisone.
• Nerve block injections.
• Opioids, such as codeine, oxycodone, and morphine.⁶

What To Think About

For some people, nonprescription pain relievers (analgesics) are enough to help control pain caused by shingles or postherpetic neuralgia.

A prescription medication called pregabalin (Lyrica) has been approved for the treatment of pain caused by postherpetic neuralgia. In tests, it provided rapid and long-lasting pain relief.

Surgery for shingles is quite rare and limited to only the most severe and prolonged cases of postherpetic neuralgia, the most common complication of shingles. Postherpetic neuralgia can be an ongoing and debilitating problem, especially for older people, but it usually decreases over time. When all other medical treatments fail to reduce or control pain, you and your health professional may consider surgical options.

Surgery to relieve postherpetic neuralgia interrupts the path of pain signals to the brain by cutting nerves in the skull or spinal column. There are significant risks to this surgery. If surgery is recommended, it is a good idea to get a second opinion before proceeding.

Postherpetic neuralgia, the most common complication of shingles, is difficult to treat. Your health professional may recommend other treatments, along with medications, to control the pain of postherpetic neuralgia.

Other Treatment Choices

Other treatments for postherpetic neuralgia include:

• Acupuncture, a Chinese therapy that has been used for centuries to reduce pain.
• Biofeedback, a method of consciously controlling a body function that is normally regulated automatically by the body.
• Transcutaneous electrical nerve stimulation (TENS), a therapy that uses mild electrical current to treat pain.
• Diathermy, a therapy that uses heat to increase blood flow for pain relief.

Psychological therapies that help you tolerate long-term pain may be helpful. These therapies teach you to shift your focus of attention away from the pain by using treatments such as relaxation techniques and counseling. You may want to consider going to a pain management specialist if you have not found relief from pain that interferes with your daily living.

What To Think About

It is difficult to assess the effectiveness of these treatments. While the pain may last many months or years, postherpetic neuralgia is usually a self-limiting condition and with time may heal on its own.

• Chickenpox (Varicella)
• Immunizations

Citations

1. Whitley RJ (2005). Varicella-zoster virus. In GL Mandell et al., eds., Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 6th ed., vol. 2, pp. 1780–1786. Philadelphia: Elsevier/Churchill Livingstone.

2. Gnann JW, Whitley RJ (2002). Herpes zoster. New England Journal of Medicine, 347(5): 340–346.

3. Barnes SD, et al. (2005). Microbial keratitis. In GL Mandell et al., eds., Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 6th ed., vol. 1, pp.1395–1406. Philadelphia: Elsevier/Churchill Livingstone.

4. Suzuki K, et al. (2004). Detection of aerosolized varicella-zoster virus DNA in patients with localized herpes zoster. Journal of Infectious Diseases, 189(6): 1009–1012.

5. Ashkenazi A, Levin M (2004). Three common neuralgias: How to manage trigeminal, occipital, and postherpetic pain. Postgraduate Medicine, 116(3): 16–48.

6. Dubinsky RM, et al. (2004). Practice parameter: Treatment of postherpetic neuralgia. An evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 63(6): 959–965.

7. Jung BF, et al. (2004). Risk factors for postherpetic neuralgia in patients with herpes zoster. Neurology, 62(9): 1545–1551.

8. Gilden DH, et al. (2000). Neurologic complications of the reactivation of varicella-zoster virus. New England Journal of Medicine, 342(9): 635–645.

Author:	Kerry V. Cooke	Last Updated April 19, 2005
Medical Review:	Patrice Burgess, MD - Family Medicine Adam Husney, MD - Family Medicine Alexander H. Murray, MD, FRCPC - Dermatology
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