Let's Talk About Shingles
We've got the doctor-approved scoop on the causes, symptoms, treatments, and a jillion other facts and tips that can make life with shingles easier.
Whether you’ve just been diagnosed with shingles or worry you could have them, you’re probably nervous, confused, and maybe a little scared. That’s normal, and everyone featured on HealthCentral who is dealing with a painful illness has felt like you do now. But we—and they—are here for you. Read on to learn about the realities and challenges you’ll face with shingles, as well as the causes, treatments, and other crucial information to help you manage—or possibly prevent—this condition. We’re sure you’ve got a lot of questions—and we’ve got the answers you need.
Our Pro Panel
We went to some of the nation’s top experts on shingles to bring you the most up-to-date information possible.
Charles Crutchfield, M.D.
Clinical Professor of Dermatology, University of Minnesota Medical School; Medical Director, Crutchfield Dermatology
Peter O’Neill, M.D.
Chief of Dermatology and Clinical Assistant Professor
NYU Winthrop Hospital and NYU Long Island School of Medicine
William Schaffner, M.D.
Medical Director and Professor of Medicine
National Foundation for Infectious Diseases and Vanderbilt University School of Medicine
Any type of board-certified primary care physician or a dermatologist can diagnose and treat shingles. Since timing is critical, see whomever is available first. Depending on your specific symptoms or complications, you may also need to see a neurologist, ophthalmologist, or a pain management specialist.
Technically, it’s possible for shingles to return, but getting shingles a second time is not all that common and getting shingles three times is very rare. Overall, 1% to 6% of people will experience a recurrence of shingles; those who are immune-compromised are at a higher risk.
The first generation to receive the childhood varicella vaccine is about 25 years old now, so there are still several decades ahead before they’d be likely to get shingles. We’ll have to wait and see, but it’s expected that the varicella vaccine will be a twofer: People who had it should have a dramatically lower risk of chickenpox as well as shingles.
Wrong. Many people don’t recall having chickenpox and not everyone gets a rash with chickenpox. Some people only have a fever, runny nose, and body aches, so they may not realize they had it. It’s estimated that almost every adult (98%) born prior to 1980 carries the dormant virus, which can reactivate anytime, especially after age 50, so you really want to get that vaccine.
What Is Shingles, Actually?
When medical experts who literally see everything describe an illness as “really nasty,” “very unpleasant,” and even “so debilitating people have committed suicide,” you’re going to want to listen up. That’s because shingles—a super common viral illness that affects one million Americans every year—can do way more damage than most people think.
The really good news is that shingles is preventable, thanks to a vaccine for adults known as Shingrix. The chickenpox vaccine that’s been given to children for the last 25 years is also helping to reduce the odds of getting shingles later in life since the virus behind the two conditions is the same one: the varicella zoster virus. Anyone who has ever had the chickenpox (or roughly 95% of the adults in the U.S.) is vulnerable to developing shingles eventually, usually after age 50. (We’ll explain more in a minute.) About one in three people will get shingles at some point, and that increases to 50% in unvaccinated people who live to age 85.
For most people, shingles resolves in three to five weeks with no further complications. In about 20% of patients with herpes zoster, however, it progresses to serious nerve damage and intense pain in the area where the rash occurred. This pain may become chronic, a complication known as postherpetic neuralgia or PHN.
The older you are when you get shingles, the higher your risk of PHN, which can be so debilitating that it results in depression, anxiety, sleep deprivation, weight loss, and difficulty with daily activities. Also, if shingles occurs on the face or head, it can seriously impact your vision, and—rarely—cause hearing loss, facial paralysis, and swelling of the brain.
Clearly, these are complications you want to avoid—along with the virus itself. And unlike many conditions you read about here at HealthCentral, in the case of shingles, it is possible to reduce your odds of infection to almost nothing. Read on to learn more about the causes, treatments, and prevention of this virus.
What Causes Shingles?
It’s all about chickenpox, folks. You can’t get shingles unless you’ve first been exposed to the varicella zoster virus that causes the highly contagious chickenpox, which pretty much applies to anyone over the age of about 40. If you’re young enough to have had the varicella vaccine you may never have to worry about contracting shingles either. It will take a few more decades when the vaccinated population reaches shingles age for researchers to say for sure if the varicella vaccine protects against shingles.
Here’s the connection: Once the varicella zoster virus enters your body and causes chickenpox, it never leaves, even after you’ve recovered. Instead it goes into hibernation in the roots of your nerve cells and can be reactivated many years later as shingles (known as herpes zoster in this second phase).
It is possible—though pretty uncommon—for there to be airborne transmission from individuals with localized herpes zoster. It's also possible (though unlikely) that if someone who has never had chickenpox (or the vaccine) came into direct contact with the fluid in someone’s shingles blisters, they could be infected with the virus, but in that case they would get chickenpox, not shingles. The body’s first exposure to the virus always causes chickenpox; shingles is the consequence of the virus reactivating later on.
The real mystery here is what causes the virus to suddenly wake up again. A peek at certain risk factors offers a big clue. In addition to having had chickenpox, risk factor for shingles include:
Anyone over age 50
Those with certain medical conditions like cancer, HIV, autoimmune disorders, and organ transplant recipients
Those under chronic daily stress or who have just experienced a highly stressful event, such as the death of a loved one, divorce, or job loss. (Some research associates stress with shingles and some does not.)
Do you see the common denominator here? It’s a weakened immune system. As we age, our immune system becomes less effective at fighting off invaders. If you have a chronic illness, and especially if you are on medication to treat it that suppresses the immune system (such as chemotherapy for cancer or immunosuppresive therapies used to treat autoimmune disorders) you’re also at increased risk of developing shingles. The stress connection is a little harder to pin down. Stress is a fact of life for most people, yet many people who experience significant life-changing events don’t come down with shingles. Still, we know that cortisol, the hormone that floods your body when you’re under stress, may also diminish the effectiveness of the immune system, so it makes sense that stress could contribute to a shingles outbreak on some level. Physical stress is worth noting as well: It’s not unheard of for shingles to develop while the body is fighting off another type of infection, or after an injury that could irritate a nerve in which the virus is hanging out.
Can Shingles Be Prevented?
If you take nothing else away from this article, remember this: There is a highly effective vaccine for adults that can prevent shingles. Known as Shingrix, it’s actually the second vaccine developed for the virus. The first, Zostavax, was approved by the FDA in 2006 and prevented shingles in about 50% of the people who received it. But the new vaccine has taken that prevention to a whole other level: It has been found to be more than 90% effective since its approval in 2017. (Zostavax is no longer available in the U.S.) Long-term data is not available for Shingrix, but experts believe it should remain highly effective for at least four years.
Another key difference between the old and new vaccine: The Zostavax vaccine used live viruses so people with compromised immune systems couldn’t be given the vaccine, even though they are the most at risk for shingles. Shingrix, however, does not use live viruses, making the vaccine safer for immune-compromised people. (Studies on this population are still ongoing.)
Shingrix is available for adults age 50 and up and requires two doses given between two and six months apart. Normally older adults don’t respond as well to vaccines because their immune systems are not as robust, but Shingrix is what’s known as an adjuvanted vaccine, meaning it has extra ingredients that help create a stronger immune response (translation: it works better). If you received the Zostavax vaccine, it is now recommended that you be revaccinated with Shingrix. As with the flu, there is a chance you could still develop shingles after being vaccinated, but the rash will be milder, the pain less severe, and the duration of the illness will be shorter. Plus, you will be less likely to develop PHN.
Do I Have Shingles Symptoms?
Although the telltale rash is what gives shingles its name, you can detect some symptoms before the rash appears. In fact, patients often feel the first sign before they see it: An itchy or burning sensation on the skin. Some people describe it as feeling like there’s a cut even though the skin still looks normal. The rash appears shortly thereafter. Check out the typical path of shingles:
Burning: You experience the sensation of burning, tingling, numbness, itching, or sensitivity in a patch of skin. Some people also have flu-like symptoms such as fatigue, headache, and fever.
Rash: Between one and five days later, an angry, painful rash made up of small red spots will appear at the same site.
Oozing blisters: After a few more days, the rash turns into fluid-filled blisters that weep or ooze.
Scabbing: About seven to 10 days later, the blisters dry up and crust over.
Resolution: In a few more weeks, the scabs clear up.
Another important sign you have shingles: The rash is only on one side of your body. Shingles occurs in the same area as the nerve that’s serving as an Airbnb to the virus. These patches of skin are known as dermatomes—an area that is controlled by a single nerve coming out of the spine. The job of this nerve is to detect surface sensations like pain or itching and send signals to the brain. The body has 31 spinal nerves between the neck and the tailbone. Each nerve runs from one side of the spine and travels across the body horizontally, never crossing the midline. For that reason, the rash only occurs on one side of the body, and usually in the midsection where these nerves live (although it’s possible for shingles to appear on your extremities as well). In rare cases, shingles can develop on the face, if the virus has hitchhiked to the cranial nerves which emanate from the top of the spine.
How Is Shingles Diagnosed?
If you’re concerned you might have shingles, this is no time to take a wait-and-see approach. Contact your primary care doctor or dermatologist (if you have one) at the first sensation of discomfort or rash. These pros see a lot of shingles and will not think you’re wacko when you describe an unpleasant sensation without anything to show for it. The shingles presentation is so textbook predictable that they know exactly what’s coming next.
Since shingles symptoms occur in such a specific pattern, doctors are almost always able to diagnose the illness by appearance. In some cases, a blister sample might be taken for examination in a lab test to confirm the diagnosis if there’s any question, but it’s usually not necessary. This scenario is more likely if you’re at high risk due to a weakened immune system, are pregnant, or if the lesions are recurring or it is not a classic rash.
Even if a test is done, your doctor will likely start you on an antiviral medication while waiting for any results. You need to start taking them within 72 hours of the rash appearing in order for them to really work. The takeaway here: Don’t wait to seek help.
There are several medications that can help you get through the illness as it runs its course. The primary treatment is usually a prescription antiviral, which will help the rash to heal faster and reduce the severity and duration of pain. Antivirals are typically taken orally for a week. There are three possible options in this category:
Zovirax (acyclovir): This was one of the first antivirals approved to treat shingles and is the least expensive option. It works by inhibiting the ability of the virus to multiply, thereby reducing your symptoms. The downside: It needs to be taken five times a day, which can be a challenge to keep up with.
Valtrex (valacyclovir): Although very similar to acyclovir in composition, valacyclovir is better absorbed by your G.I. tract so it only needs to be taken a more manageable three times a day. In addition, studies have found that valacyclovir was better at reducing the duration of pain than acyclovir. For these reasons, it is now more commonly used shingles treatment.
Famvir (Famciclovir): This medication is equivalent to valacyclovir in effectiveness and also only needs to be taken three times a day.
All three antiviral drugs are considered very safe and are usually well-tolerated by most people. Side effects that may occur include headache, nausea, vomiting, and malaise, although none of these are considered common.
There are two other prescription medications that may be included in your treatment, particularly if your rash is what a doc might refer to as “impressive.” Normally that might be considered a compliment, but not this time. An impressive shingles rash means it appears worse or more aggressive than other cases, which could be a sign you may be more likely to develop the painful aftermath of shingles known as PHN.
As a reminder, about 20% of people who get shingles go on to develop PHN and others don’t. The meds you could be given in addition to your antiviral prescription are:
Deltasone (prednisone): This corticosteroid, or steroid for short, is an oral prescription drug that can help ease the discomfort, pain, redness, and itching of the rash and blisters by lowering inflammation level in your body. Steroids can be miracle workers, but also have significant side effects such as high blood pressure and weakened bones, so they should never be taken long-term.
Neurontin (gabapentin): This is an oral prescription nerve pain medication that’s typically used to prevent and control seizures, but can also be effective for the pain of shingles. The most common side effects of gabapentin are drowsiness and dizziness.
While you’re waiting for these meds to do their job, you can try other remedies to ease your discomfort, including:
Baths: Add colloidal oatmeal or baking soda to cool bath water and soak about 10 minutes each day to relieve itching.
Bandages: When you’re not bathing or applying compresses, doctors recommend a sterile, occlusive, nonadherent dressing to protect the lesions and prevent healing.
Clothing: Dress in loose fitting clothing made of soft, natural fibers that won’t put any pressure on your skin
Cold water compresses: While the rash is still in the weeping stage, soak a soft cloth in ice water and then apply it directly to your skin. This helps put out the “fire” from the rash and may speed drying of the blisters.
Pain relievers: Over-the counter acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen can help with mild pain; prescription pain medications may be given in more severe cases.
Does Shingles Cause Complications?
Most of the time, shingles goes away on its own. But when it doesn’t, we’ve got to tell you, it’s not pretty. Let’s take a look at some of the complications that can occur.
Postherpetic Neuralgia (PHN)
As mentioned before, the most common complication is a painful condition affecting the nerve fibers and skin. Tissue damage from shingles causes changes in certain neurons or nerve cells, sensitizing them to further input and resulting in pain, even though there is no longer active tissue damage.
PHN is defined as pain in the same area of your body lasting more than three months after the acute rash has healed. It is more likely to occur the older you are, in those with weakened immune systems, and in those who had a severe rash and intense pain.
PHN pain has been described as burning, stinging, jabbing, shooting, and sharp. You may also experience deep, throbbing, and aching pain. PHN can make you extremely sensitive to touch, so activities like getting dressed or trying to sleep can be difficult. Often PHN pain will gradually go away within months to years, but it can persist much longer.
Treatments for PHN include:
Gabapentin: The anti-seizure medication is also used for active shingles cases.
Antidepressants: Low doses of certain meds affect how your body interprets pain.
Skin Patches: Applied to the skin surface, patches that contain either pain-relieving lidocaine or capsaicin (an extract of chili peppers) can relieve topical pain.
Opioids: In severe cases, treatment may require opioid pain relievers, but these are usually only given as a last resort because of their addictive potential.
Complications with shingles are also more common if the rash occurs on your head or face. An outbreak in or near your eyes, forehead, or nose can lead to several difficulties, ranging from eye pain to conjunctivitis to permanent loss of vision.
While rare, shingles on or around your ears can lead to a complication called Ramsay Hunt Syndrome, which can cause balance problems, ringing in your ear (tinnitus), earaches, facial paralysis, and hearing loss. And finally, though also rare, shingles can spread into the brain and central nervous system, resulting in a stroke or meningitis.
Living With Shingles
If none of this sounds like a walk in the park, well, it certainly isn’t. That’s why the most important thing you can do if you are 50 or older is to talk with your doctor about getting the shingles vaccine. Why risk such a painful outcome if you don’t have to? Curiously, only about one in three people who are eligible to get the new vaccine have actually done so, possibly because of the cost or lack of insurance.
If you do get shingles, don’t panic but act fast to see your doctor. You may be lucky and your case will be mild. But even severe cases can be greatly helped by starting antivirals immediately. In either case, remind yourself that no matter how bad you itch or hurt right now, shingles is a temporary condition and you should feel better in a matter of weeks. (Small consolation when it feels like your skin is on fire, we know). See it as an excuse to soak in the bathtub, then slip into a soft cotton robe that will pamper your sensitive spots until the rash passes.
- Shingles Statistics: National Foundation for Infectious Diseases. (n.d.). “Shingles (Herpes Zoster).” nfid.org/infectious-diseases/shingles/
- Stress and Shingles: Innovations in Clinical Neuroscience. (2014). “Herpes Zoster and Postherpetic Neuralgia: An Examination of Psychological Antecedents.” ncbi.nlm.nih.gov/pmc/articles/PMC4140624/
- Shingles Diagnosis: Medline Plus. (2020). “Chickenpox and Shingles Tests.” medlineplus.gov/lab-tests/chickenpox-and-shingles-tests/
- Antiviral Efficacy: Drugs. (2000). “Valaciclovir: A Review of Its Use in the Management of Herpes Zoster.” pubmed.ncbi.nlm.nih.gov/10882165/
- Antidepressants and PHN: Mental Health Clinician. (2015). “Review of Antidepressants in the Treatment of Neuropathic Pain.” meridian.allenpress.com/mhc/article/5/3/123/127941/Review-of-antidepressants-in-the-treatment-of
- Chickenpox Vaccine and Shingles: Pediatrics. (2019). “Incidence of Herpes Zoster Among Children: 2003-2014.” pediatrics.aappublications.org/content/144/1/e20182917
- Shingles Vaccine Rates: Centers for Disease Control and Prevention. (2020). “Shingles Vaccination Among Adults Aged 60 and Over: United States, 2018.” cdc.gov/nchs/products/databriefs/db370.htm