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Shingles

Definition

Shingles (herpes zoster) is a painful, blistering skin rash due to the varicella-zoster virus, the virus that causes chickenpox.

See also: Ramsay Hunt syndrome

Alternative Names

Herpes zoster

Causes, incidence, and risk factors

After you get chickenpox, the virus remains inactive (becomes dormant) in certain nerves in the body. Shingles occurs after the virus becomes active again in these nerves years later.

The reason the virus suddenly become active again is not clear. Often only one attack occurs.

Shingles may develop in any age group, but you are more likely to develop the condition if:

• You are older than 60
• You had chickenpox before age 1
• Your immune system is weakened by medications or disease

If an adult or child has direct contact with the shingles rash on someone and has not had chickenpox as a child or a chickenpox vaccine, they can develop chickenpox, rather than shingles.

Symptoms

The first symptom is usually one-sided pain, tingling, or burning. The pain and burning may be severe and is usually present before any rash appears.

Red patches on the skin, followed by small blisters, form in most people.

• The blisters break, forming small ulcers that begin to dry and form crusts. The crusts fall off in 2 to 3 weeks. Scarring is rare.
• The rash usually involves a narrow area from the spine around to the front of the belly area or chest.
• The rash may involve face, eyes, mouth, and ears.

Additional symptoms may include:

• Abdominal pain
• Chills
• Difficulty moving some of the muscles in the face
• Drooping eyelid (ptosis)
• Fever and chills
• General ill-feeling
• Genital lesions
• Headache
• Hearing loss
• Joint pain
• Loss of eye motion
• Swollen glands (lymph nodes)
• Taste problems
• Vision problems

You may also have pain, muscle weakness, and a rash involving different parts of your face if shingles affects a nerve in your face. See: Ramsay Hunt syndrome

Signs and tests

Your doctor can make the diagnosis by looking at your skin and asking questions about your medical history.

Tests are rarely needed, but may include taking a skin sample to see if the skin is infected with the virus that causes shingles.

Blood tests may show an increase in white blood cells and antibodies to the chickenpox virus but cannot confirm that the rash is due to shingles.

Treatment

Your doctor may prescribe a medicine that fights the virus, called an antiviral. The drug helps reduce pain and complications and shorten the course of the disease. Acyclovir, famciclovir, and valacyclovir may be used.

The medications should be started within 24 hours of feeling pain or burning, and preferably before the blisters appear. The drugs are usually given in pill form, in doses many times greater than those recommended for herpes simplex or genital herpes. Some people may need to receive the medicine through a vein (by IV).

Strong anti-inflammatory medicines called corticosteroids, such as prednisone, may be used to reduce swelling and the risk of continued pain. These drugs do not work in all patients.

Other medicines may include:

• Antihistamines to reduce itching (taken by mouth or applied to the skin)
• Pain medicines
• Zostrix, a cream containing capsaicin (an extract of pepper) that may reduce the risk of postherpetic neuralgia

Cool wet compresses can be used to reduce pain. Soothing baths and lotions, such as colloidal oatmeal bath, starch baths, or calamine lotion, may help to relieve itching and discomfort.

Resting in bed until the fever goes down is recommended.

The skin should be kept clean, and contaminated items should not be reused. Nondisposable items should be washed in boiling water or otherwise disinfected before reuse. The person may need to be isolated while lesions are oozing to prevent infecting other people who have never had chickenpox -- especially pregnant women.

Expectations (prognosis)

Herpes zoster usually clears in 2 to 3 weeks and rarely recurs. If the virus affects the nerves that control movement (the motor nerves), you may have temporary or permanent weakness or paralysis.

Sometimes, the pain in the area where the shingles occurred may last from months to years. See: Postherpetic neuralgia

Complications

Sometimes, the pain in the area where the shingles occurred may last for months or years. This pain is called postherpetic neuralgia. It occurs when the nerves have been damaged after an outbreak of shingles. Pain ranges from mild to very severe pain. It is more likely to occur in people over 60 years.

Other complications may include:

• Another attack of shingles
• Blindness (if shingles occurs in the eye)
• Deafness
• Infection, including encephalitis or sepsis (blood infection) in persons with weakened immune systems
• Bacterial skin infections
• Ramsay Hunt syndrome if shingles affected the nerves in the face

Calling your health care provider

Call your health care provider if you have symptoms of shingles, particularly if you have a weakened immune system or if your symptoms persist or worsen. Shingles that affects the eye may lead to permanent blindness if you do not receive emergency medical care.

Prevention

Avoid touching the rash and blisters of persons with shingles or chickenpox if you have never had chickenpox or the chickenpox vaccine.

A herpes zoster vaccine is available. It is different than the chickenpox vaccine. Older adults who receive the herpes zoster vaccine are less likely to have complications from shingles. Adults older than 60 should receive the herpes zoster vaccine as part of routine medical care.

See: Chickenpox vaccine

References

Sampathkumar P, Drage LA, Martin DP. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009 Mar;84(3):274-80.

Whitley RJ. Varicella-Zoster virus. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap 137.

Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2010. Ann Intern Med. 2010;152:36-39.