Shingles (also called herpes zoster) is an illness caused by the varicella-zoster virus (VZV)—the same virus that causes chickenpox. After a person recovers from chickenpox, usually in childhood, the virus stays inactive in the body’s nerve cells. Many years later, it can become active again and cause shingles.
The condition is most common in older adults and people with weakened immune systems, such as those with certain illnesses or taking medicines that lower immunity. Shingles usually appears as a painful rash on one side of the body or face, following the path of a single nerve. It often starts with red patches that turn into small, fluid-filled blisters before scabbing over. Before the rash appears, some people feel pain, itching, burning, tingling, or increased sensitivity in the area.
A common complication is postherpetic neuralgia (PHN)—long-lasting nerve pain that can remain after the rash heals, especially in older adults. The chance of getting shingles increases with age; about 20–30% of people will develop it at some point, and the risk is higher after age 50. Although shingles is rarely life-threatening, it can cause significant pain and affect daily life.
Starting antiviral treatment quickly can help reduce symptoms, speed recovery, and lower the risk of complications. Vaccination, particularly with the recombinant zoster vaccine, is highly effective at preventing shingles and PHN.
Difference Between Shingles and Chickenpox
Shingles and chickenpox are both caused by the varicella-zoster virus (VZV) but represent different stages of infection. Chickenpox is the primary infection, most often occurring in childhood, and is marked by a widespread, itchy rash with small, fluid-filled blisters covering much of the body. Once a person recovers, the virus remains dormant in nerve cells.
Shingles (herpes zoster) occurs when this dormant virus becomes active again, usually years or decades later. Unlike chickenpox, shingles causes a localized rash that typically forms a stripe, band, or patch on one side of the body or face.
The rash is often painful and lasts about two to four weeks. While chickenpox generally resolves without lasting effects, shingles can lead to postherpetic neuralgia (PHN)—persistent nerve pain that may last months or even years after the rash heals.
Shingles is typically more severe in adults, particularly in older individuals, than chickenpox is in children.
Prevalence and At-Risk Populations
Shingles affects approximately one in three people during their lifetime, with incidence increasing significantly with age. The condition is most common in individuals over 50 years old, though younger people can develop it, especially if their immune system is weakened.
Populations at higher risk include:
- Individuals with weakened immunity due to illnesses such as HIV/AIDS
- People undergoing cancer treatments like chemotherapy or radiotherapy
- Organ transplant recipients taking immunosuppressive drugs
- Individuals experiencing chronic stress or certain autoimmune disorders
Vaccination is widely recommended for adults aged 50 years and older to lower both the incidence and severity of shingles and its complications. Shingles in children is rare, but it can occur if they have previously had chickenpox or received the varicella vaccine, particularly if their immune defenses later drop significantly.
Transmission and Contagion
Shingles itself cannot be directly transmitted from one person to another. However, the varicella-zoster virus can spread from someone with active shingles to a person who has never had chickenpox or received the chickenpox vaccine. In such cases, the newly infected person will develop chickenpox, not shingles.
Transmission occurs through direct contact with the fluid from shingles blisters. The risk of spreading the virus is highest when the rash is blistering and decreases significantly once the lesions have crusted over. The virus is not typically spread through coughing or sneezing, unlike many respiratory infections.
Symptoms of Shingles
Shingles presents with a combination of nerve pain, skin changes, and other secondary signs. These symptoms evolve progressively, starting with early warnings and advancing to distinct rash patterns and associated complications.
Early Warning Signs
Before the rash appears, individuals often experience localized pain or tingling sensations. This pain can be sharp, burning, or stabbing and typically occurs on one side of the body or face.
Other early symptoms include itching, numbness, or sensitivity in the affected area. Some patients report flu-like symptoms such as fever, headache, or fatigue, but these are less common.
These warning signs usually precede the rash by 1 to 5 days. Early recognition is important to initiate treatment promptly.
Rash Characteristics
The rash usually begins as red patches on one side of the body or face, often following a nerve path known as a dermatome. It rarely crosses the body’s midline.
Vesicles or fluid-filled blisters then develop over the red patches. These blisters may cluster and eventually break open, crusting over in 7 to 10 days.
The rash progression includes stages of redness, blistering, and crust formation. Pain often intensifies as the rash develops.
Nerve Pain and Complications
The hallmark symptom of shingles is nerve pain, which can be severe and persistent. This pain often precedes and lasts beyond the rash.
Postherpetic neuralgia is a common complication where pain continues for months or years after the rash heals. It affects older adults more frequently.
Other nerve-related issues include muscle weakness and, in some cases, vision or hearing problems if facial nerves are involved.
Secondary Symptoms
In addition to skin and nerve symptoms, some patients experience systemic effects. These include fever, headache, chills, and general malaise.
Swollen lymph nodes near the affected area can also occur. Secondary bacterial infections may develop if blisters are not properly cared for.
Rarely, shingles can cause inflammation in organs, depending on the location of the infection.
Causes and Risk Factors
Shingles is caused by the reactivation of the varicella-zoster virus (VZV), the same virus responsible for chickenpox. After a person recovers from chickenpox, typically in childhood, VZV remains dormant in sensory nerve cells located near the spinal cord and brain, specifically in structures called dorsal root ganglia and cranial nerve ganglia.
Reactivation of Varicella-Zoster Virus
Reactivation occurs when the virus begins to multiply again and travels along nerve fibers toward the skin. This process produces the characteristic localized rash and nerve-related pain of shingles. While the exact trigger is not fully understood, reactivation is strongly associated with a decline in the body’s immune defenses, especially in the ability of cell-mediated immunity—the branch of the immune system that targets virus-infected cells—to control the latent virus.
Reactivation is more likely when immune surveillance is weakened, either due to natural aging, medical conditions, or treatments that suppress immune function. The rash almost always appears on one side of the body and follows the distribution of a specific nerve, known as a dermatome.
Age and Immune System Weakness
Risk of shingles increases substantially after the age of 50. This rise correlates with the natural decline in immune function known as immunosenescence.
Older adults have a diminished ability to keep the varicella-zoster virus in check. This weakened immune response allows the virus to reactivate.
Immune suppression from aging is a key factor, making elderly individuals particularly vulnerable. The severity of shingles also tends to increase with age.
Medical Conditions Increasing Risk
Certain diseases and medical treatments can impair the immune system and increase susceptibility to shingles, including:
- HIV/AIDS, which reduces immune function through depletion of CD4+ T cells
- Cancer, particularly hematological malignancies like leukemia and lymphoma
- Autoimmune diseases requiring immune-modifying therapy
- Organ transplantation, where immunosuppressive drugs are used to prevent rejection
Therapies such as chemotherapy, radiation therapy, and long-term corticosteroid use can also significantly lower immune defenses, enabling VZV reactivation. In these high-risk groups, shingles may present more severely and lead to a greater likelihood of complications, such as postherpetic neuralgia or widespread skin lesions.
Diagnosis of Shingles
Diagnosis relies on identifying characteristic symptoms and confirming the presence of the varicella-zoster virus. Accurate diagnosis helps guide treatment decisions and rule out other conditions with similar presentations.
Physical Examination
A diagnosis is often made through a detailed clinical evaluation of the rash and associated symptoms. The hallmark sign is a unilateral vesicular rash—small, fluid-filled blisters grouped on a red, inflamed base—distributed along the path of a dermatome (the area of skin supplied by a single spinal nerve). The rash rarely crosses the body’s midline, a pattern that helps differentiate shingles from other rashes.
Symptoms often begin with prodromal pain in the affected dermatome one to five days before the rash appears. This pain may be burning, stabbing, or tingling and is sometimes accompanied by tactile allodynia—a heightened sensitivity in which even light touch causes discomfort or pain.
In addition to inspecting the skin, physicians assess for:
- Secondary bacterial infection of blisters
- Ophthalmic involvement (rash near the eye, which may threaten vision if untreated)
- Neurological complications such as facial paralysis in cases of Ramsay Hunt syndrome
The combination of unilateral, dermatomal vesicles with acute nerve pain is considered a strong clinical indicator of shingles.
Laboratory Testing
While diagnosis is usually clinical, laboratory tests are used when the presentation is atypical, when lesions resemble other blistering skin disorders, or in immunocompromised patients, where symptoms may be less distinctive.
Polymerase chain reaction (PCR) testing detects varicella-zoster virus DNA from lesion samples with high sensitivity and specificity.
Direct fluorescent antibody (DFA) testing can also identify viral antigens from vesicular fluid. Serologic testing for varicella antibodies is generally less helpful due to previous exposure in most adults.
In rare situations, a viral culture may be performed, but it is less sensitive and slower than PCR. Laboratory confirmation is particularly valuable when ruling out conditions such as herpes simplex virus (HSV) infections, contact dermatitis, impetigo, or other vesicular rashes.
Treatment Options
Treatment of shingles (herpes zoster) aims to limit viral replication, reduce symptom severity, relieve pain, and prevent complications such as postherpetic neuralgia (PHN). Management typically involves a combination of antiviral therapy, pain control, and skin care measures. Early initiation of treatment, ideally within 72 hours of rash onset, is associated with the best outcomes.
Antiviral Medications
The mainstay of shingles treatment is the use of prescription antiviral agents such as:
- Acyclovir
- Valacyclovir
- Famciclovir
These drugs inhibit replication of the varicella-zoster virus, reducing the severity and duration of the outbreak. They also help minimize nerve damage and lower the risk of PHN. For maximum effectiveness, antiviral therapy should begin within 72 hours after the appearance of the rash.
Typical courses last 7 days, but the duration may be extended in immunocompromised patients or in cases of severe or disseminated shingles. Dosing schedules vary depending on the specific medication, patient age, kidney function, and immune status.
Intravenous antivirals (e.g., acyclovir) may be required for severe cases, such as:
- Disseminated shingles affecting multiple dermatomes
- Ophthalmic involvement
- Shingles in immunocompromised individuals
Pain Management Strategies
Pain is often the most distressing symptom of shingles, ranging from mild discomfort to severe, debilitating nerve pain. The approach to pain management depends on both the intensity and the type of pain experienced by the patient.
For mild pain, over-the-counter medications such as acetaminophen (paracetamol) or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are commonly recommended. These agents help reduce pain and inflammation during the acute phase of the illness.
Moderate to severe pain may require stronger interventions. Short-term use of opioid analgesics can be prescribed for acute, intense pain that does not respond to standard painkillers. Medications that target nerve-related pain, such as the anticonvulsants gabapentin or pregabalin, are often effective in controlling shingles-related neuropathic pain. Tricyclic antidepressants, including amitriptyline or nortriptyline, are also used for neuropathic pain relief, particularly in patients at risk of developing postherpetic neuralgia (PHN).
In select cases, physicians may prescribe corticosteroids, usually in combination with antiviral drugs, to help reduce inflammation and swelling in affected nerves. However, the routine use of corticosteroids in shingles remains debated because of potential side effects. For persistent or severe pain unresponsive to medication, nerve blocks may be considered as an additional treatment option. Early intervention with pain treatment can reduce the likelihood of chronic pain development.
Topical Treatments
Topical therapies can help reduce localized pain, itching, and inflammation:
- Cool compresses to soothe skin and reduce discomfort
- Calamine lotion to relieve itching
- Lidocaine patches or gels for targeted numbing of painful areas
- Capsaicin cream for PHN, used cautiously due to potential skin irritation
Proper skin hygiene is essential during recovery. The affected area should be kept clean, dry, and loosely covered to prevent secondary bacterial infection. Patients are advised to avoid scratching or picking at lesions to reduce the risk of scarring and infection.
Potential Complications
Shingles can lead to persistent pain, eye problems, and secondary skin infections that may require specific treatments. These complications vary in severity and may significantly impact quality of life if not managed properly.
Postherpetic Neuralgia
Postherpetic neuralgia (PHN) is the most frequent complication of shingles, occurring in approximately 10–18% of patients, with the risk increasing sharply with age. PHN is defined as nerve pain that persists for three months or longer after the shingles rash has healed. The pain is often localized to the same dermatome affected by the initial outbreak and is described as burning, stabbing, throbbing, or electric shock–like sensations.
Risk factors include older age (particularly over 60), a severe rash, intense acute pain during the shingles episode, and delayed initiation of antiviral therapy. PHN can significantly affect daily activities, sleep, and emotional well-being.
Treatment options include:
- Anticonvulsants such as gabapentin or pregabalin
- Tricyclic antidepressants like amitriptyline or nortriptyline
- Topical agents including lidocaine patches or capsaicin cream
- Opioid analgesics in severe, refractory cases
Early initiation of antiviral therapy during the acute shingles phase may lower the likelihood of developing PHN, though it does not eliminate the risk entirely.
Ocular Involvement
When shingles affects the ophthalmic branch of the trigeminal nerve, it results in herpes zoster ophthalmicus (HZO), which can involve one or more structures of the eye and surrounding skin. Symptoms include redness, swelling, eye pain, blurred vision, light sensitivity, and sometimes a vesicular rash on the forehead, eyelids, or tip of the nose (Hutchinson’s sign, which indicates a higher risk of eye involvement).
Potential complications of HZO include:
- Keratitis (inflammation of the cornea)
- Uveitis (inflammation of the middle layer of the eye)
- Secondary glaucoma (increased intraocular pressure)
- Permanent scarring and vision loss if untreated
Immediate antiviral therapy, ideally within 72 hours of rash onset, is critical in preventing damage to ocular structures. Patients with suspected or confirmed eye involvement should be urgently referred to an ophthalmologist for specialized assessment and ongoing monitoring.
Skin Infections
The blisters and open sores caused by shingles can become secondarily infected with bacteria, most commonly Staphylococcus aureus or Streptococcus pyogenes. Signs of secondary infection include increased redness, swelling, localized warmth, pus or yellow crusting, and worsening pain.
If left untreated, bacterial infections can lead to more serious skin conditions such as cellulitis (a deep skin infection) or abscess formation. In rare cases, infection can spread to the bloodstream, causing sepsis.
Treatment of secondary skin infections typically involves:
- Systemic antibiotics for moderate to severe infections
- Topical antibiotic ointments for mild, localized infections
- Proper wound care, including gentle cleansing, keeping the rash clean and dry, and avoiding scratching to reduce bacterial entry
Maintaining good skin hygiene during the active phase of shingles significantly reduces the risk of bacterial superinfection.
Prevention and Vaccination
Preventing shingles primarily involves vaccination and changes in lifestyle that reduce the risk of reactivation of the varicella-zoster virus. Vaccines have been developed to lower both the chance of getting shingles and the severity if it occurs.
Shingles Vaccines
Two vaccines are approved for shingles prevention: Shingrix and Zostavax. Shingrix is the preferred option due to its higher efficacy, providing over 90% protection against shingles and postherpetic neuralgia (PHN) in adults aged 50 and older. It is a non-live, recombinant subunit vaccine combined with an adjuvant to boost immune response. Shingrix is administered in two doses, 2 to 6 months apart, and has been shown to maintain strong immunity for at least a decade in most recipients.
Zostavax is a live attenuated vaccine given as a single dose. Its efficacy is lower—about 51% against shingles and 67% against PHN—and it declines more rapidly with age. Because it contains live virus, Zostavax is contraindicated in immunocompromised individuals.
Shingrix is recommended even for those who:
- Have had shingles before (to prevent recurrence)
- Previously received Zostavax
- Have a history of chickenpox (which is the vast majority of adults)
Possible side effects include pain, redness, or swelling at the injection site, muscle aches, fever, chills, and fatigue. These are usually mild and resolve within 2–3 days. Severe allergic reactions are rare.
Vaccination Recommendations
The Centers for Disease Control and Prevention (CDC) recommends Shingrix for all adults aged 50 and older. This applies even if individuals had shingles before or received Zostavax previously. Immunocompromised individuals may also receive Shingrix but should consult their healthcare provider.
Two doses of Shingrix should be administered 2 to 6 months apart. Those unable to complete the series within 6 months should receive the second dose as soon as possible. Neither vaccine is recommended for pregnant or breastfeeding women.
Healthcare providers assess patient history and immune status to guide vaccination and ensure no contraindications exist, such as severe allergic reactions to vaccine components or acute illness.
Lifestyle Modifications to Lower Risk
- Stress management – Chronic stress suppresses immune function, increasing the chance of viral reactivation. Techniques such as mindfulness meditation, yoga, deep breathing, and relaxation exercises can be beneficial.
- Adequate sleep – Adults should aim for 7–9 hours per night, as poor sleep has been linked to weakened immunity.
- Balanced diet – Consuming nutrient-rich foods high in vitamins C, D, E, and zinc supports immune resilience. Probiotic-rich foods may also enhance immune health.
- Regular physical activity – Moderate-intensity exercise (e.g., brisk walking, cycling) for at least 150 minutes per week improves immune response and reduces inflammation.
- Avoiding exposure – Limiting contact with people who have active chickenpox or shingles lesions reduces the chance of new infection or reinfection.
- Management of chronic illnesses – Conditions such as diabetes, heart disease, or autoimmune disorders can increase susceptibility. Good disease control lowers shingles risk.
- Smoking cessation – Smoking weakens immunity and may promote viral reactivation.
- Moderate alcohol consumption – Excess alcohol can suppress immune function; moderation is key.
Living With Shingles
Managing shingles involves careful attention to skin care, pain control, and emotional support. Effective strategies focus on reducing discomfort, preventing complications, and accessing helpful resources.
Home Care Tips
- Keep the affected skin clean and dry to reduce the risk of bacterial infection.
- Apply cool, wet compresses several times a day to soothe burning and itching.
- Wear loose, breathable clothing to prevent further irritation of the rash.
- Take over-the-counter pain relievers such as acetaminophen or ibuprofen for mild pain and fever.
- Avoid scratching or picking at blisters to prevent scarring and secondary infection.
- Gently wash the rash with mild soap and lukewarm water to maintain hygiene.
- Get adequate rest to help the immune system fight the infection
- Stay well-hydrated and maintain a balanced diet rich in immune-boosting nutrients.
Coping With Pain
Shingles pain may be sharp, burning, or throbbing and can persist even after the rash resolves. For moderate to severe pain, doctors often prescribe antiviral medications in combination with pain relievers such as gabapentin, pregabalin, or, in severe cases, opioids.
Topical treatments like lidocaine patches or capsaicin cream can provide localized relief, but patients should follow dosing instructions to avoid side effects. If nerve pain persists beyond healing, as in PHN, long-term management may include nerve blocks or specialized neuropathic pain medications.
Psychological support, including counseling or stress-reduction techniques, can help patients cope with chronic pain, anxiety, or depression.
Support Resources
Patients can benefit from working closely with healthcare providers, including primary care physicians, dermatologists, and pain specialists, to tailor a treatment plan and monitor for complications.
Community or online support groups provide emotional encouragement and practical advice from individuals who have experienced shingles. Reliable educational materials from organizations such as the CDC and WHO help patients understand the condition and its management.
Additionally, many insurance plans cover antiviral drugs, topical treatments, and pain management therapies. Social workers or case managers can assist in navigating healthcare costs and connecting patients to local resources for additional support.