Shingles

What is shingles?

Shingles (also known as herpes zoster) is a painful, blistery rash which develops in one specific area of the body.

Shingles is a reactivation of the chickenpox virus but only in one nerve root. So instead of getting spots all over the body, as you do when you have chickenpox, they appear in just in one area.

It is almost always just on one side of your body, although it may go right around from front to back, following the skin of the affected nerve. The skin is usually painful, and this pain may start to hurt before the rash appears. The pain may continue for some time after the rash has gone. You may feel tired, run down and generally unwell. You may also have a high temperature or feel feverish for a few days.

Patient picks for Viral infections

Infections

How to protect yourself from shingles

There are hundreds of viruses out there. Lots of them cause rashes, especially in children. But shingles is easy to spot - it only affects a strip on one side of your body and stops precisely in the midline at the front and back. About 1 in 4 people will know all about the symptoms at some point in their lives, because they'll develop them - but how do you protect yourself if you've never had shingles?

by Dr Sarah Jarvis MBE, FRCGP

Infections

Slapped cheek disease

Slapped cheek disease is normally a mild, short illness. However, the rash may appear to be quite dramatic. No treatment is usually needed. However, it can cause harm to an unborn baby so women who are pregnant and come into contact with people who have this illness need to seek medical advice.

by Dr Toni Hazell

Shingles symptoms

The usual symptoms of shingles are:

• Pain.

• A rash.

Shingles symptoms occur in the area of skin that is supplied by the affected nerve fibres. Occasionally, two or three nerves next to each other are affected. Very rarely, shingles can cause more widespread infection, or can affect both sides of the body, but this usually only occurs in people with a weakened immune system.

The most commonly involved nerves are those supplying the skin of the chest or tummy (abdomen). The upper face (including the eye) is also a common site.

Pain

The pain usually appears in a band around the body, usually on one side only. It can be anywhere on the body, depending on which nerve is affected. The pain can range from mild to severe. The pain may be constant, dull, burning, or gnawing in nature. In addition, or instead, you may have sharp and stabbing pains that come and go. The affected area of skin is usually tender.

Rash

The shingles rash typically appears 2-3 days after the pain begins. Red blotches and quickly change into itchy fluid-filled blisters. The rash looks like chickenpox but only appears on the band of skin supplied by the affected nerve. New blisters may appear for up to a week.

The soft tissues under and around the rash may become swollen for a while due to inflammation caused by the virus. The blisters then dry up, form scabs and gradually fade away. Slight scarring may occur where the blisters have been.

What does shingles look like?

Shingles appears as red blotches, usually on the chest or stomach. These rashes develop into blisters filled with fluid and usually only appear on one side of the body. If they appear on both sides of your body, it's unlikely to be shingles.

Shingles Day 2

Shingles Day 6 (Wikimedia Commons)

Images above by Mariegriffiths via Wikimedia Commons

How long does shingles last?

An episode of shingles usually lasts 2-4 weeks. In some cases there is a rash but no pain. Rarely, there is no rash but just a band of pain.

Causes of shingles

Shingles is caused by the varicella-zoster virus, it is the same virus that causes chickenpox. Most people have chickenpox at some stage (usually as a child). The virus does not completely go after you have chickenpox. Some virus particles remain inactive in the nerve roots next to the spinal cord. They do no harm there and cause no symptoms.

For reasons that are not clear, the virus may begin to multiply again (reactivate), usually many years later. The reactivated virus travels along the nerve to the skin to cause shingles.

In most cases, an episode of shingles occurs for no apparent reason. Sometimes a period of stress or illness can trigger it. Ageing of the immune system may increase the risk of developing shingles; it is more common in older people.

Risk Factors

The risk of getting shingles increases in people with a poor immune system (immunosuppression). For example, shingles commonly occurs:

• People who have HIV/AIDS.

• In those who are taking steroids.

• In those who are receiving chemotherapy.

How common is shingles?

About 1 in 4 people have shingles at some time in their lives. It can occur at any age but it is most common in older adults (over the age of 50 years).

After the age of 50, it becomes increasingly more common with age. It is uncommon to have shingles more than once but some people do have it more than once.

Is shingles contagious?

You cannot get shingles from someone who has shingles. You can catch chickenpox from someone with shingles if you have not had chickenpox before, as the fluid-filled blisters arising in shingles shed the reactivated chickenpox virus as the blisters burst. But most adults and older children have already had chickenpox and so are immune from catching chickenpox again.

The shingles rash is contagious (for someone else to catch chickenpox) until all the blisters (vesicles) have scabbed and are dry. If the blisters are covered with a dressing, it is unlikely that the virus will pass on to others. This is because the virus is passed on by direct contact with the blisters.

Can I go to work with shingles?

If you have a job, you can return to work once the blisters have dried up, or earlier if you keep the rash covered and feel well enough. Similarly children with shingles can go to school if the rash is covered by clothes and the child does not feel unwell.

Which groups of people to avoid if you have shingles

Pregnant women who have not had chickenpox should avoid people with shingles. See the separate leaflet called Chickenpox Contact in Pregnancy for more details. Also, if you have a poor immune system (immunosuppression), you should avoid people with shingles.

These general rules are suggested to be on the safe side, as it is direct contact with the rash that usually passes on the virus.

Can other people catch shingles?

No, you don't 'catch' shingles. You can catch chickenpox from other people, but you can't catch shingles from other people. You only get shingles from a reactivation of your own chickenpox infection in the past.

So if you have shingles, and you come into contact with somebody else, they cannot 'catch' your shingles. But if they have never had chickenpox, it is possible that they could catch chickenpox from you.

Only people who have never had chickenpox are likely to be at risk of catching chickenpox from your shingles. People who have had chickenpox should be immune from catching it again. If the rash is covered, the risk of anyone with whom you are not in close contact catching chickenpox is very low.

How to treat shingles

Two main aims of treating shingles are:

• To ease any pain and discomfort during the episode of shingles.

• To prevent shingles, as much as possible, complications from developing.

General measures to alleviate shingles symptoms

Loose-fitting cotton clothes are best to reduce irritating the affected area of skin. Pain may be eased by cooling the affected area with ice cubes (wrapped in a plastic bag), wet dressings, or a cool bath.

A non-stick dressing that covers the rash when it is blistered and raw may help to reduce pain caused by contact with clothing. Simple creams (emollients) may be helpful if the rash is itchy. Calamine lotion can help to cool the skin and reduce mild itchiness. Suitable creams, dressings and Calamine lotion can be obtained over the counter from a pharmacy without a prescription.

Painkillers for shingles

Painkillers - for example, paracetamol, or paracetamol combined with codeine (such as co-codamol), or anti-inflammatory painkillers (such as ibuprofen) - may give some relief for shingles. Strong painkillers (such as oxycodone and tramadol) may be needed, very rarely, in some cases.

Some painkillers are particularly useful for nerve pain. If the pain during an episode of shingles is severe, or if you develop postherpetic neuralgia (PHN), you may be advised to take:

• An antidepressant medicine in the tricyclic group. An antidepressant is not used here to treat depression or anxiety. Tricyclic antidepressants, such as amitriptyline, imipramine and nortriptyline, ease nerve pain (neuralgia) separate to their action on depression; or

• An anticonvulsant medicine such as gabapentin or pregabalin. They also ease neuralgic pain separate to their action to control convulsions.

If an antidepressant or anticonvulsant is advised, it should be taken regularly as prescribed. It may take up to two or more weeks for it to become fully effective to ease pain. In addition to easing pain during an episode of shingles, they may also help to prevent Postherpectic Neuralgia (PHN). See the separate leaflet called Postherpetic Neuralgia for more information.

Antiviral medicines for shingles

Antiviral medicines used to treat shingles include aciclovir, famciclovir and valaciclovir. An antiviral medicine is not a cure for shingles, it does not kill the virus but works by stopping the virus from multiplying. So, it may limit the severity of symptoms of the shingles episode.

An antiviral medicine is most useful when started in the early stages of shingles (within 72 hours of the rash appearing). However, in some cases your doctor may still advise you have an antiviral medicine even if the rash is more than 72 hours old - particularly elderly people with severe shingles, or if shingles affects an eye.

Antiviral medicines are not advised routinely for everybody with shingles. As a general rule, the following groups of people who develop shingles will normally be advised to take an antiviral medicine:

• If you are over the age of 50. The older you are, the more risk there is of severe shingles or complications developing and the more likely you are to benefit from treatment.

• If you are of any age and have any of the following:
  

  • Shingles that affects the eye or ear.

  • A poorly functioning immune system (immunosuppression - see later for who is included).

  • Shingles that affects any parts of the body apart from the trunk (that is, shingles affecting an arm, leg, neck, or genital area).

  • Moderate or severe pain.

  • Moderate or severe rash.

If prescribed, a course of an antiviral medicine normally lasts seven days.

Steroid medication for shingles

Steroids help to reduce swelling (inflammation). A short course of steroid tablets (prednisolone) may be considered in addition to antiviral medication. This may help to reduce pain and speed healing of the rash. However, the use of steroids in most cases of shingles is controversial. Your doctor will advise you. Steroids do not prevent PHN. If shingles occurs with facial weakness, a course of oral steroids is usually given (see section on 'Complications of shingles' below).

Are there any tests for shingles?

No, there is no specific test to diagnose shingles. The rash can be recognised by its typical pattern and symptoms.

Should I see a doctor for shingles?

It is worth seeing a doctor to be certain about the diagnosis and to see if you need treatment or not. Ideally you should see a doctor as soon as possible after the rash appears.

The rash of shingles can be very painful. So even if the doctor doesn't think you need an anti-shingles medicine, they may be able to give you stronger painkillers than those you can buy over the counter from the chemist.

Shingles and pregnancy

There's no danger to you or your baby if you develop shingles while pregnant. However, you may need antiviral treatment so you should be referred to a specialist.

What if I have shingles and a poor immune system?

If you have a poor immune system (immunosuppression) and develop shingles then see your doctor straightaway. You will normally be given antiviral medication whatever your age and will be monitored for complications. People with a poor immune system include:

• People taking high-dose steroids. (This means adults taking 40 mg prednisolone (steroid tablets) per day for more than one week in the previous three months. Or, children who have taken steroids within the previous three months, equivalent to prednisolone 2 mg/kg per day for at least one week, or 1 mg/kg per day for one month.)

• People on lower doses of steroids in combination with other immunosuppressant medicines.

• People taking anti-arthritis medications which can affect the bone marrow.

• People being treated with chemotherapy or generalised radiotherapy, or who have had these treatments within the previous six months.

• People who have had an organ transplant and are on immunosuppressive treatment.

• People who have had a bone marrow transplant and who are still immunosuppressed.

• People with an impaired immune system.

• People who are immunosuppressed due to HIV infection.

Complications of shingles

Most people who get shingles do not have any complications. Those that sometimes occur include the following:

Postherpetic neuralgia (PHN)

This is the most common complication of shingles. It is where the nerve pain (neuralgia) of shingles persists after the rash has gone. See the separate leaflet called Postherpetic Neuralgia for more details.

Skin infection

Sometimes the rash becomes infected with germs (bacteria). The surrounding skin then becomes red, hot and tender. If this occurs you may need a course of medicines called antibiotics.

Eye problems

Shingles of the eye can cause inflammation in front of the eye. In severe cases it can lead to inflammation of the whole of the eye which may cause loss of vision.

Weakness (Palsy)

Sometimes the nerve affected is a motor nerve (ones which control muscles) and not a usual sensory nerve (ones for touch). This may result in a weakness (palsy) of the muscles that are supplied by the nerve.

For example, if the affected nerve is the motor nerve in the face, the facial nerve, this results in weakness on one side of the face. This is known as Bell's palsy. Bell's palsy may be caused by reactivation of the chickenpox virus but there are other possible viral causes too - the exact cause of Bell's palsy is often unknown. Treatment with a course of steroid tablets is given for around 10 days to improve the chances of the facial weakness resolving. You should seek medical attention to start steroids if Bell's palsy is suspected, ideally within three days of the facial weakness starting. See the separate leaflet Bell's Palsy for more details.

Hearing loss

When reactivation of the chickenpox virus occurs in another location within the facial nerve, known as the geniculate ganglion, this can result in facial weakness, hearing loss, vertigo, tinnitus and pain or a rash within the ear canal or on the ear itself. Other nerves which supply the head and neck may also be affected. Similar to Bell's palsy, steroids and usually also antiviral treatment are given, ideally within three days of the onset of the symptoms to try to prevent permanent facial weakness and hearing loss.

Various other rare complications

Examples are infection of the brain by the varicella-zoster virus, or spread of the virus throughout the body. These are very serious but rare.

It is important to note that if you develop any symptom in addition to the pain and rash of shingles, such as a change in vision, hearing loss, weakness or numbness in other parts of the body, you should tell your doctor. Such symptoms may be caused by complications of shingles, which may require treatment, or there could be an another cause that may require investigation and management.

Is there a shingles vaccination?

In the UK there is a shingles vaccine immunisation programme for people aged 70 years to protect against herpes zoster. Changes to the vaccination programme have been made recently and if you are 65 on or after 1 September 2023 you are also eligible for your shingles vaccine, and if you have a severely weakened immune system you will be eligible for shingles vaccine from 50 years of age.

The vaccine is licensed for people aged over 50, and if you are not eligible for the vaccine on the NHS, your pharmacist may be able to provide the vaccine as a private (paid for) service.

The chickenpox vaccine is not routinely given to children in the UK but is offered to people who are in close contact with someone who is particularly vulnerable to chickenpox or its complications - eg, people with a weakened immune system.

There are two versions of the shingles vaccination; Zostavax® and Shingrix®. Zostavax® is a live vaccine which contains a weak form of the chickenpox virus. Because of this, it is not suitable for people with a weakened immune system. An inactivated vaccine called Shingrix®, which does not contain the live virus, is provided to those with a weakened immune system.