Shingles

Topic Overview

What is shingles?

Shingles (herpes zoster) is a viral infection of the nerve roots. It causes pain and often causes a rash on one side of the body, the left or right. The rash appears in a band, a strip, or a small area. Shingles is most common in older adults and people who have weak immune systems because of stress, injury, certain medicines, or other reasons. Most people who get shingles will get better and will not get it again.

What causes shingles?

Shingles occurs when the virus that causes chickenpox starts up again in your body. After you get better from chickenpox, the virus ”sleeps” (is dormant) in your nerve roots. In some people, it stays dormant forever. In others, the virus “wakes up” when disease, stress, or aging weakens the immune system. It is not clear why this happens. But after the virus becomes active again, it can only cause shingles, not chickenpox.

You can't catch shingles from someone else who has shingles. But a person with a shingles rash can spread chickenpox to another person who hasn't had chickenpox and who hasn't gotten the chickenpox vaccine.

What are the symptoms?

Shingles symptoms happen in stages. At first you may have a headache or be sensitive to light. You may also feel like you have the flu but not have a fever.

Later, you may feel itching, tingling, or pain in a certain area. That’s where a band, strip, or small area of rash may occur a few days later. The rash turns into clusters of blisters. The blisters fill with fluid and then crust over. It takes 2 to 4 weeks for the blisters to heal, and they may leave scars. Some people only get a mild rash, and some do not get a rash at all.

It’s possible that you could also feel dizzy or weak, or you could have long-term pain or a rash on your face, changes in your vision, changes in how well you can think, or a rash that spreads. If you have any of these problems from shingles, call your doctor right away.

How is shingles treated?

There is no cure for shingles, but treatment may help you get well sooner and prevent other problems. Call your doctor as soon as you think you may have shingles. The sooner you start treatment, the better it works. Treatment may include:

  • Antiviral medicines to help you get well sooner and feel less pain.
  • Medicines to help long-term pain. These include antidepressants, pain medicines, and skin creams.

Good home care can help you feel better faster. Take care of any skin sores, and keep them clean. Take your medicines as directed. And use over-the-counter pain medicines to relieve pain.

Avoid contact with people until the rash heals. While you have shingles, you can spread chickenpox to people who have never had chickenpox and who haven't gotten the chickenpox vaccine. Be extra careful to avoid people with weak immune systems and pregnant women and babies who have never had chickenpox and have never gotten the vaccine.

Who gets shingles?

Anyone who has had chickenpox can get shingles. You have a greater chance of getting shingles if you:1

  • Are older than 50.
  • Have an autoimmune disease that causes your immune system to attack your body’s own tissues.
  • Have another health problem or stress that weakens the immune system.

If you have never had chickenpox and have not gotten the chickenpox vaccine, avoid touching someone who has shingles or chickenpox. If you are at least 60 years old, you can get a vaccine that may prevent shingles or make it less painful if you do get it.

Frequently Asked Que stions

Learning about shingles:

Being diagnosed:

Getting treatment:

Ongoing concerns:

Cause

Shingles is a reactivation of the varicella-zoster virus, a type of herpes virus that causes chickenpox. After 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 get 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 medicines slow down the immune system. For example, medicines that destroy cancer cells (chemotherapy) can interfere with the immune system.

Transmission

Exposure to shingles will not cause you to get shingles. But if you have not had chickenpox and have not gotten the chickenpox vaccine, you can get chickenpox if you are exposed to shingles. Someone with shingles can expose you to chickenpox if you come into contact with the fluid in the shingles blisters. If you cover the shingles sores with a type of dressing that absorbs fluid and protects the sores, you can help prevent the spread of the virus to other people.

Symptoms

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 pain where a band, strip, or small area of rash may appear several days or weeks later. A rash can appear anywhere on the body but will be on only one side of the body, the left or right. The rash will first form blisters, then scab over, and finally clear up over a few weeks. 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 area of skin supplied by those specific nerve roots. This is why the rash can wrap around either the left or right side of your body, usually from the middle of your back toward your chest. It can also appear on your face around one eye. It is possible to have more than one area of rash on your body.

Shingles develops in stages:

Prodromal stage (before the rash appears)

  • Pain, burning, tickling, tingling, and/or numbness occurs in the area around the affected nerves several days or weeks before a rash appears. The discomfort usually occurs on the chest or back, but it may occur on the belly, 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 band, strip, or small area of rash appears. It can appear anywhere on the body but will be on only one side of the body, the left or right. Blisters will form. Fluid inside the blister is clear at first but may become cloudy after 3 to 4 days. A few people won't get a rash, or the rash will be mild.
  • A rash may occur on the forehead, cheek, nose, and around one eye (herpes zoster ophthalmicus), which may threaten your sight unless you get prompt treatment.2
  • Pain, described as “piercing needles in the skin,” may occur along with the skin rash.
  • Blisters may break open, ooze, and crust over in about 5 days. The rash heals in about 2 to 4 weeks, although some scars may remain.3

Postherpetic neuralgia (chronic pain stage)

  • Postherpetic neuralgia is the most common complication of shingles. It lasts for at least 30 days and may continue for months to years. Symptoms are:4
    • Aching, burning, stabbing pain in the area of the earlier shingles rash.
    • Persistent pain that may linger for years.
    • Extreme sensitivity to touch.
  • The pain associated with postherpetic neuralgia most commonly affects the forehead or chest. This pain 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.

What Happens

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 have a headache, flu-like symptoms (usually without a fever), and sensitivity to light, followed by itching, tingling, or pain in the area where a rash may develop. The pain usually occurs several days or weeks before a rash appears on the left or right side of your body. The rash will be in a band, a strip, or a small area. In 3 to 5 days, the rash turns into fluid-filled blisters that ooze and crust over. The rash heals in about 2 to 4 weeks, although you may have long-lasting scars.3 A few people won't get a rash, or the rash will be mild.

Most people who get shingles will not get the disease again.

Complications of shingles

Complications of shingles include:

  • Postherpetic neuralgia , which is pain that does not go away within 1 month. It may last for months or even years after shingles heals. Postherpetic neuralgia affects up to 10% to 15% of those who experience shingles.5 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.6
  • 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.

What Increases Your Risk

Risks for developing shingles include:1

If a pregnant woman gets chickenpox, her baby has a high risk of developing shingles during 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 may continue for months to years. If more than one of the following risk factors is present, your risk increases for postherpetic neuralgia.6

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

When To Call a Doctor

Call your doctor immediately if:

  • Any sign of shingles develops (such as pain or changes in vision) on or in the area of 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 doctor today if:

  • You suspect you might have shingles. There are medicines 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 doctor as soon as possible. Early treatment with antiviral medicines may help reduce 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 doctor to find out whether you have postherpetic neuralgia.

Who To See

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

Exams and Tests

Doctors can usually identify shingles when they see an area of rash around the left or right side of your body. If a diagnosis of shingles is not clear, your doctor 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 doctor may not wait to perform tests before treating you with antiviral medicines. Early treatment may help shorten the length of the illness and prevent complications such as postherpetic neuralgia.

Treatment Overview

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

  • Antiviral medicines to reduce the pain and duration of shingles.
  • Pain medicines, antidepressants, and topical creams to relieve long-term pain.

Initial treatment

As soon as you are diagnosed with shingles, your doctor probably will start treatment with antiviral medicines. If you begin medicines within the first 2 days of seeing the shingles rash, you have a lower chance of having later problems, such as postherpetic neuralgia. Early treatment of shingles is important, because the problems that can arise can be serious and resistant to treatment. For example, 40% to 50% of people with postherpetic neuralgia do not respond to treatment.5

The most common treatments for shingles include:

  • Antiviral medicines, such as acyclovir, famciclovir, or valacyclovir, to reduce the pain and the duration of shingles.
  • Over-the-counter pain medicines, such as acetaminophen, aspirin, or ibuprofen, to help reduce pain during an attack of shingles.
  • Topical antibiotics, applied directly to the skin, to stop infection of the blisters.

Corticosteroids also may be used to reduce pain in people younger than 50 who have had a recent outbreak of shingles.

Ongoing treatment

If you have pain that persists longer than a month after your shingles rash heals, your doctor 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.5 Treatment to reduce the pain of postherpetic neuralgia includes:5

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 on the specific complication.

  • Postherpetic neuralgia is persistent pain that lasts months or even years after the shingles rash heals. Certain medicines, such as anticonvulsants, antidepressants, and opioids, can relieve pain. Most cases of postherpetic neuralgia resolve within a year. In very rare cases, 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 both antiviral medicines 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.2 Treatment may include rest, cool compresses, and antiviral medicines.
  • 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.

Prevention

Anyone who has had chickenpox may get shingles later in life. But there's a vaccine that may help prevent shingles or make it less painful if you do get it. The shingles vaccine(What is a PDF document?) is known as Zostavax. One dose is recommended for adults age 60 and older, whether or not they've had shingles before.7

If you have never had chickenpox, you may avoid getting the virus that causes both chickenpox and later shingles by receiving the varicella vaccine.

If you have never had chickenpox and have never gotten the chickenpox vaccine, avoid contact with people who have shingles or chickenpox. Fluid from shingles blisters is contagious. Exposure to this fluid can cause chickenpox (but not shingles) in people who have never had chickenpox and who have never gotten the chickenpox vaccine.

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).

If you cover the shingles sores with a type of dressing that absorbs fluid and protects the sores, you can help prevent the spread of the virus to other people.

Home Treatment

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 medicines 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 medicines, such as acetaminophen, aspirin, or ibuprofen, to help reduce pain during an attack of shingles or pain caused by postherpetic neuralgia.

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

Medications

Medicines can help limit the pain and discomfort caused by shingles, shorten the time you have symptoms, and prevent the spread of the disease. Medicines 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.5

Medication Choices

Medicines to treat shingles when the rash is present (active stage) may include:

  • Over-the-counter pain medicines, such as acetaminophen, aspirin, or ibuprofen, to help reduce pain.
  • Antiviral medicines, to reduce the pain and duration of shingles.
  • Topical antibiotics, which are applied directly to the skin, to stop infection of the blisters.

Corticosteroids also may be used to reduce pain in people younger than 50 who have had a recent outbreak of shingles.

Medicines to treat postherpetic neuralgia pain may include:

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 medicine 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

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 doctor 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.

Other Treatment

Postherpetic neuralgia , the most common complication of shingles, is difficult to treat. Your doctor may recommend other treatments, along with medicines, 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 can include counseling and/or relaxation techniques that teach you to shift your focus of attention away from the pain. 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. Although the pain may last many months or years, postherpetic neuralgia is usually a self-limiting condition and with time may heal on its own.

Other Places To Get Help

Organizations

National Institute of Neurological Disorders and Stroke
P.O. Box 5801
Bethesda, MD  20824
Phone: 1-800-352-9424
(301) 496-5751
TDD: (301) 468-5981
Web Address: www.ninds.nih.gov
 

The National Institute of Neurological Disorders and Stroke (NINDS), a part of the National Institutes of Health, is the leading U.S. federal government agency supporting research on brain and nervous system disorders. It provides the public with educational materials and information about these disorders.


American Academy of Dermatology
P.O. Box 4014
Schaumburg, IL  60618-4014
Phone: 1-866-503-SKIN (1-866-503-7546) toll-free
(847) 240-1280
Fax: (847) 240-1859
Web Address: www.aad.org
 

The American Academy of Dermatology provides information about the care of skin, hair, and nails. You can find a dermatologist in your area by calling 1-888-462-DERM (1-888-462-3376).


American Academy of Family Physicians
P.O. Box 11210
Shawnee Mission, KS  66207-1210
Web Address: www.familydoctor.org
 

The American Academy of Family Physicians produces a variety of health-related educational materials. Its Web site offers a health library and bulletin board, news, and comments sections.


Centers for Disease Control and Prevention (CDC): National Center for Immunization and Respiratory Diseases
1600 Clifton Road
Atlanta, GA  30333
Phone: 1-800-CDC-INFO (1-800-232-4636)
TDD: 1-888-232-6348
E-mail: cdcinfo@cdc.gov
Web Address: www.cdc.gov/vaccines
 

The CDC's National Center for Immunization and Respiratory Diseases has information about vaccines and the diseases that can be prevented by immunization. The Web site includes the recommended immunization schedules for children, teens, and adults. There is also information about vaccine side effects and safety, school and state requirements, and immunization records. Interactive schedules are also available.


National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health
NIAID Office of Communications and Public Liaison
6610 Rockledge Drive, MSC 6612
Bethesda, MD  20892-6612
Phone: 1-866-284-4107 toll-free
(301) 496-5717
Fax: (301) 402-3573
TDD: 1-800-877-8339
Web Address: www3.niaid.nih.gov
 

The National Institute of Allergy and Infectious Diseases conducts research and provides consumer information on infectious and immune-system-related diseases.


References

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. 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.
  3. Gnann JW, Whitley RJ (2002). Herpes zoster. New England Journal of Medicine, 347(5): 340–346.
  4. Ashkenazi A, Levin M (2004). Three common neuralgias: How to manage trigeminal, occipital, and postherpetic pain. Postgraduate Medicine, 116(3): 16–48.
  5. 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.
  6. Jung BF, et al. (2004). Risk factors for postherpetic neuralgia in patients with herpes zoster. Neurology, 62(9): 1545–1551.
  7. Advisory Committee on Immunization Practices (2008). Prevention of herpes zoster: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Advisory Committee on Immunization Practices. MMWR, 57(Early Release): 1–30. Also available online: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e0515a1.htm?s_cid=rr57e0515_e.

Other Works Consulted

  • Gilden DH (2008). Acute viral central nervous system diseases. In DC Dale, DD Federman, eds., ACP Medicine, section 11, chap. 16. Hamilton, ON: BC Decker.
  • Herpes zoster vaccine (Zostavax) (2006). Medical Letter on Drugs and Therapeutics, 48(1243): 73–74.
  • Johnson RW, Dworkin RH (2003). Treatment of herpes zoster and postherpetic neuralgia. BMJ, 326(7392): 748–750.
  • Katz J, et al. (2004). Acute pain in herpes zoster and its impact on health-related quality of life. Clinical Infectious Diseases, 39(3): 342–348.
  • Pregabalin (Lyrica) for neuropathic pain and epilepsy (2005). Medical Letter on Drugs and Therapeutics, 47(1217): 75–76.

Credits

Author Maria G. Essig, MS, ELS
Editor Susan Van Houten, RN, BSN, MBA
Associate Editor Pat Truman, MATC
Primary Medical Reviewer E. Gregory Thompson, MD - Internal Medicine
Specialist Medical Reviewer Alexander H. Murray, MD, FRCPC - Dermatology
Last Updated March 9, 2009

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