What is Shingles?

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Shingles, also called herpes zoster, is caused by reactivation of the varicella-zoster virus (VZV), the same virus that causes chickenpox.

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After a person has chickenpox, the virus remains inactive within certain nerves. Years or decades later, the virus can reactivate and travel along a nerve to the skin, producing shingles.

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Shingles can occur at any age, but the risk increases with older age and in people with a weakened immune system.

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Signs & Symptoms

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Pain or abnormal sensations may begin several days before the rash appears.

Symptoms may include:

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• Burning, tingling, itching, or stabbing pain

• Increased skin sensitivity

• Headache

• Fatigue or feeling unwell

• Sensitivity to light

 

A typical shingles rash:

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• Usually affects one or two neighboring dermatomes (areas of skin supplied by particular nerves)

• Usually occurs on one side of the body or face

• Usually does not cross the body's midline

• Develops into clusters of fluid-filled blisters

• Most commonly affects the trunk or face

• Usually heals within 2–4 weeks

 

New blisters may continue to develop for several days before the lesions begin drying and crusting.

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Zoster Sine Herpete — Shingles Without a Rash

 

Rarely, VZV can reactivate and cause symptoms without producing the characteristic shingles rash. This is known as zoster sine herpete.

Depending on the affected nerve, symptoms may include:

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• Burning, stabbing, or shooting nerve pain

• Tingling or abnormal sensations

• Pain following the distribution of a particular nerve

• Cranial nerve symptoms, such as facial weakness

• Other neurological symptoms

 

Because the characteristic rash is absent, zoster sine herpete can be difficult to diagnose, and other causes of nerve pain or neurological symptoms must be considered.

Specialized testing for evidence of VZV infection may sometimes be necessary.

 

Localized vs. Disseminated Shingles

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Localized Shingles

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Most shingles is localized. The typical rash involves one or two adjacent dermatomes and generally remains confined to that region of the body.

 

Disseminated Shingles

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Disseminated herpes zoster occurs when lesions appear outside the primary or immediately adjacent dermatomes. The rash may therefore appear in multiple, separated areas of the body and can sometimes resemble chickenpox. Disseminated shingles occurs most commonly in people with weakened immune systems. In severe cases, VZV can spread beyond the skin and involve internal organs, potentially causing complications.

 

Is Shingles Contagious?

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A person with active shingles can transmit the varicella-zoster virus to a susceptible person. Someone who has never had chickenpox or has not been vaccinated against chickenpox may develop chickenpox, not shingles, following infection. Active shingles lesions remain infectious until they have dried and crusted. VZV can spread through:

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• Direct contact with fluid from active blisters

• Inhalation of virus-containing particles originating from the lesions

 

*Covering shingles lesions reduces the risk of transmission.

 

Infection-Control Precautions

 

Localized Shingles 

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For a patient with localized shingles whose lesions can be completely covered:

Standard Precautions are recommended. The lesions should remain completely covered until they are dry and crusted.

 

Disseminated Shingles

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Airborne (n95 mask) + Contact + Standard Precautions are required in the hospital setting. These precautions are maintained until the lesions are dry and crusted.

Airborne Precautions generally require placement in an Airborne Infection Isolation Room (AIIR/negative-pressure room) in healthcare facilities equipped to provide one.

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Diagnosis

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Shingles can often be diagnosed based on the appearance, symptoms, and characteristic dermatomal distribution of the rash. When laboratory confirmation is necessary, PCR testing of material from a skin lesion is the preferred method for detecting VZV.

Diagnosis can be more difficult with zoster sine herpete because there are no skin lesions to sample. Depending on the clinical situation, specialized testing for VZV DNA or antibodies may be considered.

 

Treatment

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Antiviral Medications

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Antiviral medications used to treat shingles include:

• Valacyclovir

• Famciclovir

• Acyclovir

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Antiviral therapy provides the greatest benefit when initiated within approximately 72 hours after the rash begins.

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Treatment may still be appropriate after 72 hours, particularly when:

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• New lesions are continuing to develop

• The eye or other high-risk structures are involved

• The patient is immunocompromised

• Disseminated disease is present

• Neurological or other serious complications are suspected

 

Severe, disseminated, or complicated VZV infection may require hospitalization and intravenous antiviral therapy, such as IV acyclovir.

 

Pain & Itching

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Depending on the patient's medical history and severity of symptoms, treatment may include:

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• Acetaminophen

• NSAIDs such as ibuprofen or naproxen

• Cool, wet compresses

• Calamine lotion

• Oatmeal baths

• Gabapentin or pregabalin

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Postherpetic Neuralgia

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The most common complication of shingles is postherpetic neuralgia (PHN). The risk of PHN increases significantly with age. PHN is nerve pain that persists in the area previously affected by shingles. It is commonly defined as pain continuing more than 90 days after the shingles rash began.

Symptoms may include:

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• Burning pain

• Stabbing or shooting pain

• Tingling

• Extreme sensitivity to light touch

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Treatment may include:

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• Gabapentin

• Pregabalin

• Certain antidepressant medications

• Topical lidocaine

• Capsaicin

 

Shingles Involving the Eye

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Shingles affecting the ophthalmic division of the trigeminal nerve is called herpes zoster ophthalmicus. It can involve structures of the eye and potentially cause vision loss.

Seek urgent medical evaluation for a shingles rash involving the nose, forehead, or area around the eye. Urgent ophthalmology evaluation may be necessary.

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Other Possible Complications

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• Postherpetic neuralgia

• Bacterial infection of the skin lesions

• Facial or other nerve weakness

• Hearing or balance problems

• Ramsay Hunt syndrome

• Vision loss

• Meningitis or encephalitis

• Pneumonitis

• Disseminated infection

 

Serious complications occur more frequently in older adults and people with weakened immune systems.

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Shingles Vaccine — Shingrix

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The CDC recommends 2 doses of Shingrix for:

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• Adults age 50 years and older

• Adults age 19 years and older who are or will be immunodeficient or immunosuppressed because of disease or treatment

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For most adults, the second dose is given 2–6 months after the first dose.

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Shingrix is recommended even if you:

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• Previously had shingles

• Previously received the older Zostavax vaccine

 

Shingrix should not be given during an active episode of shingles. Vaccination should be delayed until the acute illness has resolved. Shingles can come back. For this reason, eligible patients should still receive Shingrix even if they have previously had shingles.

 

                                                                               References & Guidelines
 

• Centers for Disease Control and Prevention (CDC). About Shingles (Herpes Zoster).

• Centers for Disease Control and Prevention (CDC). Clinical Overview of Shingles (Herpes Zoster).

• Centers for Disease Control and Prevention (CDC). Preventing VZV Transmission in Healthcare Settings.

• Centers for Disease Control and Prevention (CDC). Shingles Vaccine Recommendations — Shingrix.

• Infectious Diseases Society of America (IDSA). Clinical guidance relevant to varicella-zoster virus infection in immunocompromised patients.