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Shingles (Herpes zoster)

On this page: Symptoms | Cause | Complications | Diagnosis | Treatment | News | References

Overview The Rash of Shingles:

Shingles (herpes zoster) is a viral infection of the nerve root that causes:

  • Pain which usually starts a few days before the rash appears
  • The painful rash occurs on only one side of the body

The pain of shingles can be severe, and the cause might not be immediately evident. But once the classic rash and blisters start on one side of the body, it's more easily identified as shingles.

There is no cure for shingles but early treatment with medicines that fight the virus may help shorten the infection, prevent lingering pain or reduce the risk of complications. Contact your physician if you think you might have shingles.

People who have shingles that extend onto the nose or into the eye should contact their doctor immediately to prevent permanent damage to the eye.

Do not apply cortisone cream to the rash as it can make it worse. Cortisone cream is available over-the-counter as hydrocortisone cream and is also available by a number of names as a prescription.

Aspirin is not recommended because it might cause a liver problem called Reye's syndrome.

A person who has a rash from shingles should stay away from

  • babies younger than 12 months,
  • pregnant women, and
  • people with decreased immunity.

Symptoms

For one to three days before the onset of a rash there may be burning, itching, tingling, or extreme sensitivity in one area of the skin, usually limited to one side of the body. Fever, chills or headache may also be present.

In the same area as the pain, the rash begins with reddish bumps, but in a few days turns into groups of fluid-filled blisters on reddened skin. The blisters generally last for two to three weeks. The blisters start out clear but then develop a yellow or bloody appearance. The blisters crust over and fall off leaving temporary changes in the color of the skin. In severe cases of shingles, these color changes last forever.

The pain is often severe and frequently requires pain medicine.

The rash follows the distribution of the affected nerve and most commonly wraps around the back, chest, or buttocks. It can also appear on one side of the face, arms, or legs. People who have shingles that extend into the eye should see a health care provider immediately as it can lead to permanent damage, even blindness. Blisters on the tip of the nose are a sign of potential eye involvement.

The course of shingles most often clears up on its own within a few weeks, but this varies from person to person. In some cases, the pain can last longer but usually completely resolves in 1 to 3 months. Healthy patients with shingles rarely require hospitalization, however shingles is a serious threat in immunosuppressed individuals — for example, those with HIV infection or who are receiving cancer treatments that can weaken their immune systems. People who receive organ transplants are also vulnerable to shingles because they are given drugs that suppress the immune system.

In the same area as the pain, the rash begins with reddish bumps, but in a few days turns into groups of fluid-filled blisters on reddened skin. In the photo below, pus has formed in the fluid-filled vesicles. Photo courtesy of the CDC, Center for Disease Control Shingles in the early stage of the rash
 
As the rash from shingles progresses, the blisters will dry up and crust over.
Photo courtesy of the CDC/Dr. Dancewiez
A rash from shingles
 

Shingles on Dat 21Day 21 of shingles: A skin lesion on the forehead of an elderly woman is due to the herpes zoster virus (shingles) on the 21st day of the illness. The blister has crusted over and will eventually fall off leaving a temporary change in the color of the skin. Photo courtesy of the CDC/Dr. Heinz F. Eichenwald


Cause

Shingles is caused by the same virus that causes chickenpox (varicella-zoster virus). Viruses in this group also include the Herpes simplex virus (HSV) which causes blisters and sores around the mouth, nose, genitals, and buttocks, but they may occur almost anywhere on the skin. There are two types of HSV: Type I (most often occurs on the face) and Type II (most often occurs in genital area). The virus is spread through direct contact with secretions or herpes skin lesions.

Once the infection develops in the skin (primary), the virus travels down the nerve, where it remains latent until reactivation (recurrence). The virus can be reactivated by stress, ultraviolet light, fever, tissue damage, or immunosuppression.

After a person recovers from chickenpox, the virus remains in the nerve root in a dormant state. Later in life, the virus may reactivate as shingles, not chickenpox, which is estimated to affect 2 in every 10 people in their lifetime. You can only get shingles if you had chickenpox in the past or if you have had the chickenpox vaccine. Although there have been cases of recurrence, most people who get shingles will not get the disease again.

It is not possible to catch shingles from a person with shingles, but it is possible to catch chickenpox if the exposed person hasn't already had chickenpox or had the chickenpox vaccine. The chickenpox virus is found in the blisters formed from the shingles, and the virus can be spread as long as the blisters are still present. A person who has a rash from shingles should stay away from babies younger than 12 months, pregnant women, and people with decreased immunity.

About 20 percent of those people who have had chicken pox will get zoster (shingles). Most people get zoster only once.

The exact cause of the reactivation is unclear, however it is associated with a weakened immune system due to aging, illness, medications, psychological stress, or physical trauma. A predisposition to getting shingles appears to run in families, according to a study in December 2008. Although children can get zoster, it is more common in people over the age 50.

Complications

Early treatment can help shorten a shingles infection and reduce the risk of complications:

  • Postherpetic neuralgia (PHN) is a potential complication that occurs when the pain of shingles persists for 3 months after the onset of the rash. Ten to twenty percent of people with shingles will get PHN which is a complication that is more common with advancing age. In fact, 50% of patients with shingles who are over 65 will develop PHN.(2) The immediate use of antiviral medication in the early stages of zoster may help prevent this complication. Like shingles, postherpetic neuralgia causes a stinging or burning pain. The skin can become very sensitive to temperature changes or a light touch, such as from a bedsheet or moving air. Most people with postherpetic neuralgia get better with time. Almost all of them are free of pain within 1 year. A few people have chronic pain that never fully resolves.

  • Shingles that extend into the eye if not treated early, can lead to permanent eye damage such as glaucoma, scarring, or blindness. Immediate treatment with antiviral medicines and oral steroids is necessary.

  • A bacterial infection of the blisters can occur as a complication of the rash. Pain and redness that increases or reappears should be seen by a physician. Treatment with an antibiotic may be necessary. An infection in association with shingles can lead to scarring if not promptly treated.

Diagnosis  
Usually the diagnosis is based on the appearance and location of the rash, as well as a history of pain before the rash. Sometimes skin cells from a blister are scraped onto a glass slide for examination under a microscope. Also, the blister fluid containing the virus can be sent to the laboratory for special testing.

Treatment  

Shingles is often treated with oral antiviral drugs: acyclovir (Zovirax), famciclovir (Famvir) or valacyclovir (Valtrex). These medicines should be started within the first 3 days of the onset of the rash. In fact, the sooner the medication is started the better. These medications are generally safe and well tolerated. Infrequent side effects of these medications include headache, stomach upset, and lightheadedness.

Oral corticosteroids are used for severe infections, those with eye involvement, and in patients with decreased immunity.

Over-the-counter pain medicine such as acetaminophen (Tylenol) or ibuprofen (Advil) can be helpful in relieving discomfort. Aspirin is not recommended because using it might cause a liver problem called Reye's syndrome. Frequently the pain is severe enough to require prescription pain medicine.

Medicated lotion (Caladryl) applied to the blisters might reduce the pain and itching.

Do not apply cortisone cream to the rash as it can make it worse. (Cortisone cream is available over-the-counter as hydrocortisone cream and is also available in stronger strengths by prescription.)

Cool compresses soaked in an astringent liquid (Bluboro, Domeboro), applied to the rash helps dry the blisters and relieve the pain and itching.

Postherpetic neuralgia is often treated with over-the-counter pain medicines and capsaicin cream (Capsin, Zostrix). If these medicines are not completely effective, a patch that contains lidocaine (Lidoderm) might be of benefit. A number of medications that are used to treat depression and seizures can also help the nerve pain. Nerve blocks are sometimes used to help control pain.

Shingles Vaccine  

In May of 2006, the FDA licensed a new vaccine to reduce the risk of shingles in older Americans. Zostavax, a live virus vaccine, is given as a single injection is recommended for use in people 60 years of age and older. Zostavax was studied in 38,000 individuals living in the United States who were 60 years of age and older. Researchers found that, overall, in those ages 60 and above the vaccine reduced the occurrence of shingles by about 50%, but for individuals aged 60-69 it reduced occurrence by 64%. Most importatly, for those that get shingles, despite the vaccination, it is reported to be less severe. FDA

References

(1) Video of disease animation from Merck. This is an excellent animation of the reactivation of the zoster virus that was dormant in sensory nerves from an earlier infection of chicken pox.
(2) Management of Varicella-Zoster Infection and Postherpetic Neuralgia; Audio-Digest, Vol 9, Issue 2, December 2005
(3) Shingles from the National Institute of Neurological Disorders and Stroke
(4) Shingles from the National Library of Medicine

Written by N Thompson, RN, MSN, ARNP and M Thompson, MD, Internal Medicine, last updated January 2009

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