Shingles (Herpes Zoster) Symptoms, Causes & Treatment Options

Shingles is a painful rash that results from reactivation of the virus that causes the chickenpox. Symptoms include small, fluid-filled blisters that form over a few days that then dry up and heal over several weeks. Pain or strange skin sensations may persist for longer.

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Contents

  1. Overview
  2. Symptoms
  3. Potential Causes
  4. Treatment, Prevention and Relief
  5. When to Seek Further Consultation
  6. Questions Your Doctor May Ask
  7. References

What Is Shingles (Herpes Zoster)?

Summary

Shingles is a painful rash that results when the varicella zoster virus (VZV) — the same virus that causes the chickenpox — becomes reactivated. It results in a painful rash of small fluid-filled blisters (vesicles) over a single strip of skin on one side of the body.

The onset of the rash is often preceded by changes in skin sensation and flu-like symptoms. Blisters form over three to five days before beginning to dry up and scab and then heal over the following two to four weeks.

The diagnosis is largely by clinical examination, although blood tests can aid in diagnosis in unclear situations. People who are older or have compromised immune systems are most frequently affected and at a greater risk of complications.

Treatment involves antiviral medications and supportive treatments. Fortunately, shingles can be effectively prevented with a vaccine, which is recommended for all adults over age 50.

Recommended care

You should go to a retail clinic or your primary care physician to be treated for shingles. Most common treatments involve pain killers and prescription antiviral medicines.

Shingles (Herpes Zoster) Symptoms

Main symptoms

Shingles results in a painful, itchy rash, typically confined to a strip of skin on one side of the body.

  • Rash: Shingles causes a painful rash of small fluid-filled blisters that often occur over a single strip of skin (dermatome) on one side of the body, most commonly on the chest. For identification purposes, there are photos here, (WARNING: graphic images, viewer discretion advised) [1]. Blisters often form for three to five days and then begin to dry up and scab. They may continue forming for longer if you have a compromised immune system [2]. Blisters usually heal in two to four weeks, but sometimes leave behind scars or changes in skin color.
  • Itching: Itching, tingling sensations (paresthesia), and pain may occur for a few days before the rash appears.
  • Sensitive skin: Affected skin often becomes exquisitely sensitive, even to air or light touch.

Other symptoms

You may also experience non-specific flu-like symptoms for a few days before the rash appears [3], including:

  • Malaise
  • Headache
  • Low-grade fever

Complications

Although many people with shingles find their symptoms improve with time, shingles can sometimes result in serious complications. People who are older or have compromised immune systems are at higher risk of developing complications [4].

  • Postherpetic neuralgia: For about 10 percent of people with shingles, pain persists in the skin even after itching has resolved [2]. It is described as burning or electric shock-like and may correspond with changes in sensation in the skin. Pain may linger for weeks, months, or in rare cases, years, after the rash has improved. It is caused by damage to nerves that occurs as a result of inflammatory responses to the virus reactivating [3].
  • Herpes zoster ophthalmicus: When shingles occurs around the eye, it can lead to severe pain and result in vision loss.
  • Herpes zoster oticus (Ramsay Hunt syndrome): When shingles occurs in the cranial nerve to the ear, it can lead to vertigo, hearing loss, and ringing in the ears (tinnitus).
  • Bacterial superinfection: Shingles can predispose your skin to bacterial infections, often with Staphylococcus aureus or Streptococcus species.
  • Nerve palsies: Shingles can result in dysfunction of nerves, resulting in weakness.

Shingles (Herpes Zoster) Causes

Shingles is caused by reactivation of the varicella zoster virus (VZV), the virus that causes the chickenpox, which often lays dormant in the roots of nerves for many years. Reactivation is common over the lifespan, and particularly affects people with compromised immune systems, due to aging, or other medical conditions.

How VZV spreads

VZV can be spread by anyone with an active skin rash from the virus to anyone without immunity to the virus, including anyone who has never had the virus or the vaccination. Transmission occurs via direct skin contact. A VZV rash is infectious until it dries and crusts over. Shingles occurs when the VZV reactivates later in life [4].

Why VZV reactivates to cause shingles

After infection with VZV, the virus lies dormant in your nerves. The precise reason why the virus reactivates after many years of dormancy remains unknown. It is generally thought that cell-mediated immunity weakens, allowing the virus to reactivate.

Who is most likely to be affected

Shingles is common, and an estimated one in three people in the U.S. experience shingles in their lifetime. Although anyone can get shingles, some people are affected more often than others [4].

  • People with suppressed immune systems: If you are immunosuppressed, as a result of other medical conditions, you are at greater risk of shingles and its complications. This includes people with cancer, especially leukemia and lymphoma, HIV, organ transplants, and people with conditions that require taking immunosuppressive medications, such as steroids or chemotherapy.
  • Age greater than 50: Shingles is more common after age 50 and the chances of developing it continue to increase with aging.
  • Women: Women are more affected by men, for unclear reasons.

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Treatment Options and Prevention

Several types of medications can be used to control the virus and its resulting symptoms. Shingles can be treated with the following.

Antiviral medications

Antiviral medications disrupt the replication of viruses. These medications are most effective when started within three days of developing the rash, and are typically given for a total of seven days of treatment. They have been found to decrease the total time of new rash appearing, accelerate crusting over of the rash, and decrease pain [3]. Antivirals used for shingles include:

  • Acyclovir
  • Famciclovir
  • Valacyclovir (Valtrex)

Steroids

Steroids can be used in addition to antivirals to help reduce pain and accelerate healing such as the following.

  • Prednisone
  • Prednisolone

Pain medications

The pain caused by shingles can be extremely uncomfortable. Over-the-counter medications, such as acetaminophen (Tylenol) and non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen) are effective for most people. A physician will sometimes also prescribe medications for nerve pain, such as gabapentin, tricyclic antidepressants, or nerve blocks for severe pain [3].

Topical treatments

If you develop post-herpetic neuralgia, topical treatments can help relieve pain, in addition to the nerve pain control methods listed above.

  • Lidocaine patches: This prevents pain by numbing the skin.
  • Capsaicin cream: Made with an enzyme from chili peppers, this is considered a key treatment modality for postherpetic neuralgia-related pain [5].

Prevention

Fortunately, shingles is preventable with a vaccination. The vaccine is more than 90 percent effective at preventing shingles and post-herpetic neuralgia [4]. VZV vaccine (Shingrix) is recommended by the CDC for adults who fit the following description:

  • Are over 50 years old
  • Immunocompromised adults over 50: You should receive two doses of the vaccine, two to six months apart.
  • If you have had an older vaccine: Adults over 50 should get Shingrix regardless of whether or not the previously received Zostavax, an older Shingles vaccine.
  • If you are allergic to Shingrix: Although Shingrix is preferred to Zostavax, Zostavax remains an option for individuals who are allergic to Shingrix or when the Shingrix vaccine is unavailable [4].

When to Seek Further Consultation

If you are at least 50 years old and have not had the shingles vaccine

Shingles is common, but largely preventable through vaccination. If you are over 50 and have not received the shingles vaccine (Shingrix), discuss vaccination options with your physician.

If you have a painful rash over your eye

When shingles affects the skin surrounding your eye (zoster opthalmicus), it is an emergency that can lead to vision loss. Call 911 or go to the nearest emergency room for urgent evaluation and treatment.

If you have had shingles and continue to experience pain

If you have had shingles and continue to experience pain that interferes with your daily activities, speak with your physician. A number of treatments are available to treat post-herpetic pain.

Questions Your Doctor May Ask to Diagnose

To diagnose this condition, your doctor would likely ask about the following symptoms and risk factors.

  • Have you been feeling more tired than usual, lethargic or fatigued despite sleeping a normal amount?
  • Have you experienced any nausea?
  • Are you sick enough to consider going to the emergency room right now?
  • Any fever today or during the last week?
  • How long has your current headache been going on?

If you've answered yes to one or more of these questions

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References

  1. Shingles (herpes zoster). Centers for Disease Control and Prevention. Updated August 19, 2016. CDC Link
  2. Kaye KM. Shingles (herpes zoster). Merck Manual Consumer Version. Updated May 2018. Merck Manual Consumer Version Link
  3. Saguil A, Kane S, Mercado M, Lauters R. Herpes zoster and postherpetic neuralgia: Prevention and management. Am Fam Physician. 2017;96(10):656-663. AAFP Link
  4. Shingles (herpes zoster). Centers for Disease Control and Prevention. Updated October 17, 2017. CDC Link
  5. Yong YL, Tan LT, Ming LC, et al. The Effectiveness and Safety of Topical Capsaicin in Postherpetic Neuralgia: A Systematic Review and Meta-analysis. Front Pharmacol. 2017;7:538. Published 2017 Jan 10. NCBI Link