Let's Talk About Shingles Diagnosis and Treatment
Recovery is easier if you start your meds before the telltale rash appears. Here's how to know if you have it.
OK, it’s not deadly like cancer, or chronic like diabetes, or debilitating like multiple sclerosis. But trust us: Shingles is still an intensely painful illness you want to avoid. Fortunately, a breakthrough vaccine is making that possible. If you do get shingles though, early diagnosis is everything: The sooner you begin treatment, the less likely you are to experience a severe case with complications that can last long after the blistering rash has cleared up. We asked the experts how to spot—and treat—this challenging condition.
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.
Daniel Allan, M.D.
Section Head of Family Medicine
Cleveland Clinic Avon Lake Family Health Center
Avon Lake, OH
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
There is no cure, but there are effective treatments that can lessen the severity of the illness, especially if you’re diagnosed early. Antiviral medications are the first-line treatment, and doctors may also prescribe the steroid prednisone and the anticonvulsant gabapentin in an effort to prevent PHN (postherpetic neuralgia), a painful, potentially chronic complication that results from nerve damage and occurs in about one in five people with shingles.
Believe it or not, many people can feel shingles before the rash even appears. This symptom is known as paresthesia, an itching, burning, or tingling sensation that you experience on one side of the body before the rash is even present. It happens because the virus hangs out in the nerves of your skin, becoming active there before triggering the telltale rash a few days later. If you are experiencing a painful sensation on one side of your body, even if you don’t see a rash, get things checked out.
There’s a good chance you’re not going to feel great for one to three days after, but the side effects are nothing compared to the unpleasantness of shingles. You might experience pain, redness, and swelling at the injection site; muscle pain; fatigue; headache; fever; or upset stomach. Sounds like a drag, but it will rev up your immune system so it’s primed to beat back shingles, which is exactly what you want.
Yes, although rare. If shingles occur in or near your eyes, forehead, or nose it can lead to eye pain, glaucoma, or even permanent loss of vision. Shingles on or around your ears can cause Ramsay Hunt Syndrome, which leads to dizziness and balance problems, ringing in your ear (tinnitus), earaches, facial paralysis, and hearing loss. And shingles can spread into the brain or spinal cord, resulting in a stroke or meningitis.
What Is Shingles, Again?
Shingles is a painful rash that is caused by the same virus as chickenpox. If you were born before 1980, it’s highly likely that you had chickenpox when you were younger. The red, itchy rash is caused by the varicella zoster virus, and once it enters your body, it never leaves, even after you’ve recovered. Instead it takes up residence in the roots of your nerves and goes into hibernation. Decades later, the virus can “wake up” and cause shingles—medically known as herpes zoster when it makes this second appearance.
Given how common chickenpox was before a vaccine was developed for it 25 years ago, it’s easy to see why shingles is equally prevalent among the older population. In fact, one million adults develop shingles every year in the United States. Close to one in three people will get shingles in their lifetime, and that increases to 50% of people who live to age 85.
One of the biggest mysteries with shingles is what causes the virus to reactivate suddenly, after years of snoozing. While doctors are still exploring the reasons, a weakened immune system appears to be the primary culprit. To that end, along with exposure to chickenpox, risk factors for shingles include:
Age: Anyone over age 50 is vulnerable because the immune system becomes less effective with age.
Certain medical conditions: Having cancer, HIV, autoimmune disorders, or being an organ transplant recipient all weaken the immune system.
Undergoing cancer treatment: Radiation and chemotherapy can lower your resistance to diseases and may trigger shingles.
Stress: Chronic daily stress or a single, highly stressful event such as the death of a loved one, divorce, or job loss, causes the body to produce the stress hormone cortisol, which diminishes the effectiveness of the immune system. Physical stress may contribute, too: Shingles has been known to develop while the body is fighting another type of infection or after an injury that could irritate a nerve the virus calls home.
Immunocompromising drugs: Taking long-term steroids (such as prednisone) or other medicines that can weaken the immune system and drugs designed to prevent rejection of transplanted organs can increase the risk of shingles.
Serious physical injury: Physical trauma (which could be anything from a wound to a fracture) may be a risk factor, especially for shingles.
Usually shingles resolves in three to five weeks with treatment and no further complications. But about 20% of the time, it progresses to serious nerve damage and chronic pain in the area where the rash was that can last for months or even years. Nerve fibers that have been damaged by shingles can’t send messages from your skin to your brain as effectively, so they become exaggerated, causing chronic and even excruciating pain known as postherpetic neuralgia (PHN). A bit about PHN:
The condition is defined as pain in the same area lasting more than three months after the acute shingles rash has healed.
It is more likely to occur the older you are.
People with weakened immune systems are more susceptible.
It is more like to affect those who experienced a severe shingles 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.
It 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 about a year, but it can persist much longer or come and go intermittently and can have serious repercussions: It can be so debilitating that it causes depression, anxiety, sleep deprivation, weight loss, and difficulty with daily activities.
Treatment will depend on the type of pain as well as the patient’s physical, neurological, and mental health. Treatment can be painkillers, anticonvulsants, steroids, or antidepressants. In some cases, electrodes may be placed over the pain area and a device called “transcutaneous electrical nerve stimulation” (TENS) is used to relieve symptoms. Similar to TENS, sometimes spinal cord or peripheral nerve stimulation might be required to relieve the pain.
You Can Prevent Shingles
The good news is that you can avoid this misery entirely by getting a fairly new vaccine that’s proving to be highly effective. There has actually been a shingles vaccine since 2006, but the first incarnation, Zostavax, only prevented shingles in about 50% of people. Plus, Zostavax was made from live viruses so people with compromised immune systems couldn’t get it even though they are the ones most at risk for shingles.
The new vaccine, Shingrix, available since 2017, does not use live viruses in its formulation so it’s safer and has been found to be more than 90% effective. Shingrix is what’s known as an adjuvanted vaccine, meaning it has extra ingredients that help create a stronger immune response. A booster shot may be needed eventually, but experts currently estimate the vaccine provides protection for at least seven years. It’s available for adults age 50 and up and requires two doses given between two and six months apart.
On the slim chance you do get shingles after being vaccinated, the illness will be much milder and you will be less likely to develop PHN.
How Is Shingles Diagnosed?
So let’s say you read all that and you still haven’t gotten the shingles vaccine. And let’s say you wake up one morning feeling weird pain in parts of your back, and then before you know it, you see a rash forming. How will your doctor know if it’s shingles?
You needn’t worry about undergoing a lot of poking and prodding—tests are seldom needed to diagnose this illness. Most doctors can do it by sight since there are some obvious clues and a very specific pattern of symptoms. (In some cases, a blister sample might be taken for examination under a microscope to confirm the diagnosis if there’s any question, but it’s usually not necessary.) You can also do a preliminary telehealth appointment if you do not want to visit your healthcare provider during the continuing COVID-19 crisis.
One reason it’s easy to recognize is that shingles is aptly named: The wide stripe-shaped rash that occurs literally resembles a shingle on a house. Another red flag is the location. Shingles will only develop on one side of the body—most likely the torso—in the same area as the nerve that’s playing host to the virus. Here’s how that works:
The patch of skin where the rash appears is known as a dermatome—an area that is supplied by a single spinal nerve whose job is to send sensations like pain or itching to the brain.
The body has 31 such spinal nerves between the neck and the tailbone, each of which originates at one side of the spine and runs horizontally around your torso to the front of the body, where it stops.
These spinal nerves never cross the midsection of your body, so neither does the rash. (You would never get a shingles rash that starts on the left of your waist and spreads across to the right side—it is always going to stop by the mid-point of your abdomen or back.)
The next big clue is the very specific pattern that a shingles outbreak follows. Here’s the highly predictable course of events, which lasts from three to five weeks:
Day 1: You experience the sensation of burning, tingling, numbness, itching, or sensitivity in a patch of skin. Some people also have flulike symptoms such as fatigue, headache, fever, or upset stomach.
Day 2 to 5: You develop an angry, painful rash made up of small red spots will appear at the same site. The rash will not cross the mid-line of your body.
Day 5 to 7: After a few more days, the rash turns into fluid-filled blisters that weep or ooze.
Day 14 to 20: The blisters dry up and crust over.
About a month after infection: The scabs clear up.
What’s the Best Treatment for Shingles?
You’re going to want to get yourself to your doctor at the first sensation of discomfort, and certainly the first sign of the rash. That’s because treatment is most effective if it’s started as soon as possible. You can expect to take at least one and possibly several prescription medications. There are also over-the-counter therapies you can try to help ease the discomfort of shingles while the illness runs its course.
Antiviral drugs are the first line treatment for shingles to treat and shorten the length and severity of the illness, but timing is of the essence: They need to be started within 72 hours of the rash appearing to do their job well. After that point, an antiviral may still help if new blisters are continuing to appear. And although there is no cure for shingles, these drugs can help the blisters dry up faster, limit your pain during the illness, and lessen the chances that you will develop PHN.
Antivirals are usually taken orally for a week and there are three possible options in this category:
Zovirax (acyclovir): This was the first antiviral approved to treat shingles and is the least expensive option. It works by lowering the ability of the virus to multiply, thereby reducing your symptoms. Unfortunately, acyclovir needs to be taken five times a day, which can be a challenging schedule for many people.
Valtrex (valacyclovir): This med is very similar to acyclovir, but with two big improvements. First, valacyclovir is better absorbed by the body so it only needs to be taken a more manageable three times a day. Studies have also found that valacyclovir works faster than acyclovir in reducing pain. As a result, it has become the most commonly prescribed antiviral for shingles treatment.
Famvir (famciclovir): This medication is equivalent to valacyclovir in effectiveness and also only needs to be taken three times a day.
Side effects you may experience with these antivirals include headache, nausea, vomiting, and stomach pain, although none of these are all that common. All three are considered very safe and are generally well-tolerated.
Two other prescription medications may be included in your treatment, particularly if your rash appears worse or more aggressive than average, which could mean you’re at greater risk of developing PHN. No one really knows why some shingles patients develop PHN and others don’t, but doctors often try to reduce those odds with more aggressive treatment. The meds you could be given in addition to your antiviral prescription are:
Deltasone (prednisone): This corticosteroid is an oral prescription drug that can help ease the discomfort, inflammation, pain, redness, and itching of the rash and blisters. Because steroids can have significant side effects, such as high blood pressure and weakened bones, they should never be taken long-term (more than three months) despite their effectiveness.
Neurontin (gabapentin): Gabapentin is known as an anticonvulsant, a medication that’s typically used to prevent and control seizures. It’s very effective for the pain of shingles because both seizures and shingles pain involve the abnormally increased firing of nerve cells. Gabapentin is taken orally; the most common side effects are drowsiness and dizziness.
While you’re waiting for the prescription meds to do their job, other remedies may help to ease your discomfort. Here are a few things you can try:
Aluminum acetate solution. This OTC remedy (sold as Domeboro or Burow’s) is a natural astringent that speeds the drying of blisters from the rash.
Calamine lotion can be used to relieve itching once your blisters have scabbed over.
Cold water compresses. During the initial rash and while your blisters are still in the weeping stage, soak a soft cloth in ice water and then apply it directly onto the rash to help ease pain and speed drying of the blisters.
Cool baths. Soak in the tub with colloidal oatmeal or baking soda to help relieve itching.
Loose-fitting clothing. Tight jeans are not your friend during shingles. Soft, natural fibers that don’t put pressure on your skin will be most comfortable.
Over-the-counter pain relievers. Options such as acetaminophen and nonsteroidal anti-inflammatories (NSAIDS) such as ibuprofen can reduce pain. (Prescription pain medications may be given in more severe cases.)
Petroleum jelly or Aquaphor ointment. Cover the rash with a thin layer of either lube, then apply a non-stick bandage so you avoid touching (and spreading) it.
Silvadene cream or Mupirocin ointment. These prescription topical antibiotics can be applied after the blisters stop weeping to prevent infection.
Treatment for PHN
If you are one of the 20% of people who develop this serious complication from shingles, your doc may prescribe you the anti-seizure medication gabapentin (if you aren’t already taking it). Low doses of certain antidepressants, including Effexor XR (venlafaxine) and Cymbalta (duloxetine) have also been shown to help because they affect how your body interprets pain.
Skin patches that contain either pain-relieving lidocaine or capsaicin, an extract of chili peppers, can also be applied to ease skin pain. Severe cases may require prescription pain relievers, but these are usually only given as a last resort because of their addictive potential.
There is no easy solution for PHN, which can last months or years, although these treatments may lessen the severity of it. That’s why the most important thing you can do to keep yourself healthy and pain-free is to get the shingles vaccine. Think about it: If you are over 50, you have a one in three chance of getting shingles. That’s like saying between your partner, sibling, and yourself, one of you will get the virus. With the vaccine, there less than a 3% chance that any of you will get sick. So what are you waiting for?
- Shingles Overview: National Institute of Neurological Disorders and Stroke. (2020). “Shingles: Hope Through Research.” ninds.nih.gov/disorders/patient-caregiver-education/hope-through-research/shingles-hope-through-research#3223_10
- 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/
- Shingrix Effectiveness: The Journal of Infectious Diseases. (2018). “Immune Responses to a Recombinant Glycoprotein E Herpes Zoster Vaccine in Adults Aged 50 Years or Older.” academic.oup.com/jid/article/217/11/1750/4911103
- Shingles Diagnosis: Medline Plus. (2020). “Chickenpox and Shingles Tests.” medlineplus.gov/lab-tests/chickenpox-and-shingles-tests/
- Antiviral Efficacy: PubMed.gov. (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