Let’s Talk About Shingles Signs and Symptoms
This condition features a painful skin rash that can result in serious complications. But what if you could spot the virus coming, before the first red bump even appeared?by Stephanie Wood Health Writer
Most people think of shingles as a rash, but that’s only the tip of the proverbial iceberg. Sure, it’s painful and downright disturbing to look at, but that’s nothing compared to the number shingles can do on your nerve cells if you don’t deal with those oozing, angry blisters immediately. We’ve got the doctor-approved scoop on what to look for when it comes to shingles, plus how to avoid the uncomfortable scenario altogether—there’s a vaccine for that!—so you can return to your regularly scheduled program.
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
At first you might think you have poison ivy or provided dinner to a pack of ravenous mosquitoes. The difference is that these small, red bumps usually present in the shape of a thick stripe—like a shingle on a house—only on one side of the body, frequently the torso. After a few days, the bumps fill with fluid like blisters and begin to ooze or weep.
Yes, shingles can occur in childhood and in younger adults, but it’s uncommon. Usually when shingles occurs in an adult younger than 50, it’s because the person is immune-compromised. Pediatric shingles is rare, but more likely to occur in a child who had chickenpox before age 1, or if the child’s mother had chickenpox late in pregnancy.
Not in the usual ways. The virus isn’t airborne so you can’t get it just from being around someone. You’d have to actually touch the fluid in the blisters to contract the virus, but even then you’d get chickenpox. The first exposure always results in chickenpox, whereas the second activation always causes shingles. Add the fact in that most people today are already immune to chickenpox because they either had it themselves as a child or had the vaccine, and the chances of someone with shingles spreading the virus are very low.
There’s a vaccine for that! Shingrix has been found to be more than 90% effective for people 50 and older. It requires two doses given between two and six months apart. Although it’s possible you might still get shingles after having the vaccine, the case will be much less severe. An earlier vaccine, Zostavax, is no longer widely available but may be an option for people allergic to Shingrix. Ask your doc for details.
What Is Shingles, Again?
Think of shingles as that cousin you kinda sorta remember from childhood but haven’t seen in years. Then suddenly one day, she shows up on your doorstep and gets all territorial, hanging around and wreaking havoc on your very existence. She may have been annoying when you were younger, but now she’s downright mean. Shingles is that grown-up cousin—the adult version of chickenpox that you vaguely remember from your childhood.
Weird but true: You can’t get shingles unless you’ve first had chickenpox, as the virus that causes the former must be introduced into your system by the later. Here’s what happens. Chickenpox is caused by varicella zoster, a virus that takes up residence in the roots of your nerve cells. Once the pox outbreak is over, the virus doesn’t leave your body—instead it hibernates in those nerve cells. Then, decades later it can wake up and cause shingles (known as herpes zoster in this second phase). Since 98% of Americans over the age of about 40 have had chickenpox at some point, that means they are carrying the virus that causes shingles. Creepy, no?
If you’re young enough to have had the varicella vaccine that prevents chickenpox—its been available for about 25 years—you should never have to worry about contracting shingles either. It will take a few more decades to say for sure, however, because we have to see what happens when the vaccinated population reaches the age when they become vulnerable to a shingles outbreak.
Meanwhile, one million people in the United States who are too old to have been vaccinated for chickenpox develop shingles each year, usually after age 50. Close to one in three people will get shingles in their lifetime, and that increases to 50% of people who live to age 85. Shingles gets its name from the thick band of blistering rash that literally looks like a shingle on a house. Shingles usually occurs on your torso, often in a belt-like pattern around the midsection, but it can show up anywhere on the body.
For most people, shingles resolves in three to five weeks with treatment and no further complications. About 20% of the time, however, it progresses to serious nerve damage and chronic pain in the area where the rash was, 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. 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.
Causes and Risk Factors for Shingles
So we’ve established that you have to have the chickenpox first, but not everyone who had chickenpox is destined to get shingles. What makes the virus spring back to life in some people and not others? Scientists have been trying to figure that out forever and the only thing we know for sure is that the virus takes advantage of a weakened immune system to reassert its presence. For that reason, folks with a weaker or compromised immune system are at a higher risk. That includes:
Anyone over age 50. Our immune system gets sluggish and less effective at protecting us as we age.
People with certain medical conditions. People with cancer, HIV, autoimmune disorders, and organ transplant recipients are more vulnerable to shingles because the conditions themselves drag down immunity, and they often require treatment with medications that further suppress it.
People under chronic daily stress. The death of a loved one, divorce, or job loss are highly stressful events—and can raise your risk of getting shingles. Why? Because stress causes the body to produce copious amounts of the hormone cortisol, which lowers the effectiveness of your immune system. Physical stress can also be a factor, and your odds of developing shingles is higher when your body is fighting another type of infection, or if you have an injury that irritates a nerve in which the virus is hanging out.
Shingles is also not contagious in the traditional sense: It’s not airborne so you can’t cough or sneeze it onto someone, or transmit it via saliva by sharing food or drink. It is possible to transmit it if someone who never had the chickenpox (or the vaccine) makes direct contact with the fluid in the blisters.
That’s going to be pretty rare though because the vast majority of the population has had either the virus or the chickenpox vaccine. And even if it happened, the unprotected person who touched the blisters would get chickenpox, not shingles. The body’s first exposure to the virus always causes chickenpox, and shingles is the consequence of the virus reactivating later on.
Do I Have Shingles Symptoms?
Given that this virus is painful, and that the complications from it can be significant, it’s natural to want to keep an eye out for any early indications that you could have shingles. That may prove trickier than you’d think, since the signs and symptoms of shingles can vary: The pain may be mild or severe, and some people have mostly itching while others have intense sensitivity to even the gentlest touch, such as the weight of sheets on a bed.
Shingles does, however, follow a fairly predictable pattern if you know what you are looking for. In fact, doctors usually diagnosis it simply by sight. Common symptoms of shingles include:
A burning sensation
Tingling or numbness
Sensitivity to touch
A red rash
Fever and chills
The key to recognizing shingles is not just the list of symptoms, but the very specific pattern they follow. In fact, you can usually feel some shingles symptoms before you see them—and your chances of a full recovery are better if you do. Here’s how the illness unfolds, usually over a period of three to five weeks.
First, you experience the sensation of burning, tingling, numbness, itching, or sensitivity in a patch of skin. It may feel like there’s a cut or burn on the skin even though it still looks normal. Some people also have flulike symptoms such as fatigue, headache, fever, or upset stomach.
Between one and five days later, an angry, painful rash made up of small red spots will appear at the same site.
After a few more days, the rash turns into fluid-filled blisters that weep or ooze.
About 7 to 10 days later, the blisters dry up and crust over.
In a few more weeks, the scabs disappear.
The other big hint that you’re dealing with shingles is that everything happens in one patch of skin on one side of the body. Docs call these patches dermatomes: An area of skin that is supplied by a single nerve coming out of the spine. Your body has 31 such spinal nerves between your neck and the tailbone, each of which run horizontally from one side of your spine around to the front of your body, without ever crossing the midline. For that reason, you wouldn’t get a shingles rash that starts on, say, the left of your waist and spreads across to the right side of the waist. The rash is always going to stop by the mid-point of your abdomen or back (where the nerve terminates or begins).
The primary job of these nerves is to send sensations like pain or itching to the brain, but when the virus become active and disrupts the signal, the nerves overreact and cause all the discomfort that accompanies the rash. Usually all this happens on the torso, but shingles can occur anywhere. The face is the second most common area for shingles to appear.
When to Call the Doctor
The short answer? As soon as possible. Any type of board-certified primary care physician (family physician, internal medicine, geriatrician) or a dermatologist can diagnose and treat shingles. The really important thing is that you want to get an early diagnosis, ideally before you even see the rash. That’s because the antiviral medications used to treat shingles are significantly more effective if taken within 72 hours of the rash appearing.
So focus on getting an appointment quickly (and if you're uneasy about an in-office visit, many doctors also offer telehealth services). Don’t worry about not being able to see a rash yet—these pros typically treat several cases of shingles every week and will not think you’re a hypochondriac 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.
If you miss that 72-hour window, don’t panic. After that point, an antiviral may still help if new blisters are continuing to appear. Also, antivirals can help the blisters dry up faster, limit your pain during the illness, and lessen the chances that you will develop PHN.
The bottom line: It’s entirely possible that 20 years from now, the chickenpox vaccine will make shingles obsolete. But for right now, the best thing you can do if you’re 50 or older is the get the shingles vaccine. There are plenty of unpleasant conditions out there that you’ll be faced with as you get older. If you can eliminate one painful illness from the mix, why wouldn’t you?
Shingles Statistics: National Foundation for Infectious Diseases. (n.d.) “Shingles (Herpes Zoster).” nfid.org/infectious-diseases/shingles/
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
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 Symptoms: Centers for Disease Control and Prevention. (2019). “Shingles (Herpes Zoster): Signs & Symptoms.” cdc.gov/shingles/about/symptoms.html
Postherpetic Neuralgia: Centers for Disease Control and Prevention. (2019). ““Shingles (Herpes Zoster): Complications of Shingles.” cdc.gov/shingles/about/complications.html
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