Shingles

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  • Also Known As:
  • Herpes Zoster
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What is shingles?

Shingles, also called herpes zoster, is an infection caused by the varicella zoster virus (VZV), the same virus that causes chickenpox. It can cause nerve inflammation and intense pain, a reddened rash, and blisters (vesicles) that break open and crust over before slowly resolving. In most cases, the rash and pain subside within a few weeks, but some of those affected may have severe pain that lingers for months or even years.

When someone is first exposed to VZV, usually in childhood, the person develops chickenpox, a common, highly contagious, primary systemic infection that causes multiple “crops” of vesicles in multiple locations on the body. Chickenpox is passed from person to person through direct contact with fluid from the blisters or coughing or sneezing. Once the chickenpox has resolved, the virus becomes dormant, persisting in a latent form at the base of sensory nerve cells near the spinal cord and brain. Normally, the body’s immune system maintains this latency and produces sufficient VZV antibodies to protect against future exposures.

The virus can re-activate and cause shingles in people with:

  • Medical conditions such as certain cancers or HIV/AIDS that compromise the immune system
  • Immunosuppressive drug treatments given after an organ transplant
  • A decline in immunity due to aging

The virus begins to reproduce again and moves outward along the length of one or more sensory nerves to the surface of the skin. This can cause symptoms associated with shingles, including a ribbon or band of lesions on one side of the trunk, face, or arm corresponding to the section of skin (dermatome) that the affected nerve serves.

The virus that causes shingles may be passed to other people through contact with an open vesicle. The people who are exposed will only become infected if they have not been previously exposed to a VZV infection or have not been vaccinated – and will develop chickenpox, not shingles.

Almost one out of three people in the United States will develop shingles during their lifetime. Nearly 1 million Americans are affected each year. About half of those cases occur in people who are over the age of 60.

Although most people will only have shingles once, the virus can potentially re-activate and cause shingles again. Those with weakened immune systems may have difficulty regaining and maintaining virus latency. A baby who is born with chickenpox is at an increased risk for developing pediatric shingles. This is a rare event that sometimes occurs when a woman has chickenpox, or – even more rarely – develops shingles, during her pregnancy.

 

About Shingles

Signs, Symptoms, and Complications

Itching, tingling or burning pain in a specific location, such as one side of the waist or face, may start several days before other signs of shingles emerge. The pain may be moderate or severe and the skin may be hypersensitive. A person may also have nonspecific symptoms such as fever, fatigue, muscle aches, headache, nausea, or chest pain.

A reddened rash then appears and eruptions of blisters develop over several days within one or two characteristic bands of skin (dermatomes) on one side of the body at the waist, face, or other location. There may be few or many vesicles and, in some cases, they may merge together. The vesicles typically have a clear fluid in them that turns cloudy over time.

At some point, the vesicles burst, become crusty, and then begin to resolve over the next few weeks. In most cases, the skin does not scar unless it is damaged by scratching or unless a secondary bacterial infection or complication develops. Rarely, a person may have shingles without vesicle formation.

A variety of other symptoms and complications may be seen, depending upon which nerves are affected. Symptoms can be atypical and/or more severe and persistent in those who have weakened immune systems. Complications may include:

  • Postherpetic neuralgia (PHN) – this is severe pain from damaged nerves that persists long after other signs of shingles have resolved, for weeks to months or even years in some people. PHN can occur in up to half of untreated people 60 years of age or older.
  • Herpes zoster opthalmicus (HZO) – when shingles occurs next to the eye, it can cause a variety of eye-related symptoms, facial scarring, and it can threaten a person’s vision. Eye involvement may appear weeks after other symptoms have resolved.
  • Ramsay Hunt syndrome – when shingles involves the facial nerve and ear, it can cause facial palsy, persistent abnormal sounds in the ear (tinnitus), hearing loss, a loss of taste, and vertigo. Those affected may not fully recover.
  • Herpes zoster encephalomyelitis (meningoencephalitis or encephalitis) – central nervous system involvement may occur in some immunocompromised or severely ill people. This form of shingles can be life-threatening.
  • Disseminated herpes zoster – shingles that affects many areas and clinically appears to be chickenpox. It may sometimes occur in those with weakened immune systems.

Diagnosis and Tests

The diagnosis of shingles is primarily clinical, based upon the characteristic pain and band of rash and blisters. Laboratory testing for varicella zoster virus (VZV) may sometimes be performed to confirm or rule out VZV when a person has atypical symptoms and/or complications that may be due to another cause. It may also be performed for organ transplant recipients or pregnant women to help diagnose a current infection and to determine whether the person has been previously exposed to VZV – to help evaluate their immune status. Read more about chicken pox and shingles (VZV) tests.

Prevention and Treatment

A varicella vaccine is now routinely given as part of childhood immunizations. It is intended to prevent chickenpox as well as latent VZV and so decrease the number of people who get shingles later in life.

There are Herpes zoster vaccines approved by the Food and Drug Administration (FDA) for use in people age 50 and older,which are intended to decrease the risk of developing shingles and the risk of postherpetic neuralgia.The Centers for Disease Control and Prevention (CDC) recommends that healthy adults age 50 years and older get two doses of the shingles vaccine called Shingrix®, 2 to 6 months apart, to prevent shingles and PHN. Shingrix®, which was approved by the FDA in 2017, is the preferred vaccine, over Zostavax®, a shingles vaccine that was first approved in 2006.

While there is no guarantee that someone who receives these vaccines will not get chickenpox or shingles, they reduce the severity of the disease and the likelihood of complications for someone who does get either of these infections.

People who do get shingles are treated with antiviral medications to decrease symptom severity and shorten the duration of the illness. Treatment may also reduce the risk of developing postherpetic neuralgia and reduce its duration. Antivirals are most effective when started within three days of rash development.

Topical therapies and pain medications may be used to relieve the symptoms associated with shingles. People who have shingles with eye, ear, or central nervous system complications may need to consult with specialists.

Individuals with severely weakened immune systems may sometimes be given zoster immune globulin to lessen the severity of the condition.

Related Images

  • Shingles is a painful rash that develops on one side of the face or body. The rash forms blisters that typically scab over in 7 to 10 days and clears up within 2 to 4 weeks. Image credit: NIAID

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