What are shingles?

Shingles, also known as herpes zoster, is a viral infection caused by the varicella-zoster virus (VZV), the same virus that causes chickenpox.^1,5 The characteristic feature of shingles is a painful rash,^1,2 which usually appears as a band or patch of blisters¹¹ extending from the middle of the back to the breastbone (sternum),⁷ typically on one side of the face or body.⁴

Shingles is most commonly seen in older adults and individuals with weakened immune systems, which can be due to medications or chronic illnesses.⁴

What causes shingles?

Most people contract chickenpox in childhood, and the varicella-zoster virus (VZV) remains inactive in their bodies. As people age, their immune systems weaken,¹ allowing the virus to reactivate and cause shingles.¹¹ Among individuals with a history of chickenpox, one in three will develop shingles in later life.⁵

Shingles itself cannot spread to others. However, since shingles is caused by the same virus that causes chickenpox, individuals who have not had chickenpox or the chickenpox vaccine can contract chickenpox from someone with shingles.³ It is important to note that a person who has never had chickenpox cannot develop shingles.

Individuals typically experience shingles only once in their lifetime, however, it is possible to get shingles more than once.⁶

What are the symptoms of shingles?

The initial symptoms of shingles may develop up to a week before the appearance of the distinctive shingles rash.¹¹ These early symptoms include:^2,3,6,7

• General viral infection symptoms:¹¹ 
• Headache
• Tiredness
• Mild fever      
• Muscle pain
• Swollen glands
• Chills
• Upset stomach
• Malaise (feeling unwell)
• Itching in a particular area of the skin
• Tingling or numbness in a particular area of the skin
• Burning or shooting pain
• A red rash
• Photophobia (sensitivity to light)

After a few days, the patient may develop a rash, which looks like a cluster of blisters (fluid-filled spots). The rash usually appears on one side of the body,² but it can also occur on the neck or face, such as around the eye.⁷

Pain remains the main symptom of shingles. It may be constant or intermittent, dull or sharp, and vary in intensity from mild to severe. The affected area may also be painful to the touch.²

What are the complications of shingles?

Complications can sometimes occur with shingles, particularly in older adults and those with severely weakened immune systems. Some of the potential complications include:^2,3,7,11

• Post-herpetic neuralgia (patients continue to have burning or stinging pain in the affected area for several weeks after the blisters have healed)
• Eye problems which may cause vision loss
• Secondary bacterial infection of the rash
• Changes in skin colour or scarring after the rash heals
• Muscle weakness
• Ramsay Hunt syndrome
• Meningitis
• Encephalitis  
• Pneumonia
• Hepatitis

These complications show the importance of early diagnosis and treatment to reduce the risk of severe outcomes.

How is shingles diagnosed?

A physician will assess the symptoms and typically diagnose shingles based on the distinctive rash, which follows the path of the nerve where the virus has been dormant.⁷ The healthcare provider will also review the patient’s medical history, including any prior history of chickenpox.

Generally, tests are not required to confirm the diagnosis. However, when the presentation is atypical, a sample from a blister may be taken for viral culture.¹⁰ Other tests that may be used include the direct fluorescent antibody (DFA) test, polymerase chain reaction (PCR) test, blood tests and the Tzanck smear.¹⁵

What other conditions present with similar symptoms to shingles?

Some conditions that may present with similar symptoms to shingles include:^8,9

• Herpes simplex virus (HSV) infection
• Dermatitis herpetiformis
• Fungal skin infection
• Contact dermatitis
• Folliculitis
• Impetigo
• Drug eruptions
• Insect bites
• Scabies
• Urticaria (hives)

How do you treat shingles?

Speak to your healthcare provider as soon as symptoms develop to determine if antivirals are needed. Early treatment with antivirals such as acyclovir can reduce the severity and duration of the infection and minimise the risk of complications such as post-herpetic neuralgia.⁷ Acyclovir works best if treatment is started at the earliest possible time, ideally within 3 days of the rash appearing.^3,11

Following are some simple tips to manage shingles at home:²

• Wear loose-fitting clothes
• Use calamine lotion for itch relief
• Keep the rash clean and dry to reduce the risk of a secondary infection
• Use a cool, damp cloth or cool compress to soothe the skin

The symptoms generally improve in 2 to 4 weeks. The blisters crust over as they heal,¹¹ and the rash clears up over time.⁴

Pain management 

Since pain is the principal symptom of shingles, patients can control it using various medications:^10,12

• Over-the-counter painkillers such as paracetamol 
• Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
• Numbing agents such as lidocaine gel
• Capsaicin cream

For severe pain, stronger pain relief options include:^10,12

• Opioids (e.g., oxycodone)¹⁶
• Tricyclic antidepressants (e.g., amitriptyline)
• Anticonvulsants (e.g., gabapentin)
• Steroid injections

The healthcare provider can help the patient determine the most appropriate pain management strategy based on individual needs.

What is the prognosis for shingles in older adults?

The prognosis for shingles largely depends on the patient’s age and overall health. The severity of symptoms and the risk of complications increase with age. Complications such as  post-herpetic neuralgia, a secondary bacterial infection of the rash, and scarring are more common in elderly patients.¹⁵

The prognosis is also observed to be poor in immunocompromised patients. In rare cases, severely immunocompromised individuals may experience widespread infection throughout the body (disseminated zoster), which has a mortality rate of 5-10%, with most deaths being attributed to pneumonia.¹⁵

How do you prevent shingles?

To prevent shingles in older adults, it is essential to strengthen the immune system by maintaining a healthy lifestyle. This includes:^2,17

• Eating a balanced and nutritious diet 
• Getting at least seven hours of sleep every night
• Engaging in daily exercise
• Reducing stress levels
• Limiting alcohol intake
• Avoiding smoking

The most effective method for protecting against shingles is by getting the Zostavax or Shingrix vaccine. They help build up immunity to the virus and reduce the chances of developing shingles by more than 50% and 90%, respectively.^13,14 

If an individual does develop shingles despite being vaccinated, the shingles vaccine reduces the severity of the infection, the risk of post-herpetic neuralgia, and the likelihood of hospitalisation from complications.^12,13

FAQs

How long do shingles last?

The shingles rash can take up to 4 weeks to heal,³ and the patient remains contagious until every blister dries out and scabs over.^2,7 However, the pain can persist for several weeks after the rash has healed, but it tends to improve over time.

Who should you avoid contact with if you have shingles?

Individuals with shingles should avoid contact with certain groups of people who are at risk of complications from chickenpox. Therefore, until they are no longer contagious, shingles patients should stay away from the following individuals:^3,7

• Pregnant women
• Newborn babies
• Individuals with weakened immune systems, such as those receiving chemotherapy or individuals with chronic illnesses like acquired immune deficiency syndrome (AIDS)

Summary

Shingles is a viral infection caused by the varicella-zoster virus (VZV). It is predominantly seen in older adults and individuals with weakened immune systems. The initial symptoms include headaches, muscle pain, tingling, burning, or itching, followed by the development of a characteristic rash forming a band typically on only one side of the face or body.

Conditions presenting similarly to shingles include herpes simplex virus (HSV) infection, impetigo, drug eruptions, and insect bites. Patients with shingles should avoid contact with pregnant women, newborn babies, and immunocompromised individuals at risk of complications from chickenpox.

Treatment for shingles includes antivirals, steroids, and painkillers, depending on the individual patient and the symptom severity. Initiating treatment with antivirals as early as possible is crucial for minimising the duration of the infection and preventing complications such as eye infections and post-herpetic neuralgia.

Following a healthy lifestyle can help strengthen the immune system and reduce the likelihood of developing shingles. Additionally, shingles vaccine can be taken to build up immunity, reduce the severity of the infection, minimise the risk of post-herpetic neuralgia, and lower the likelihood of hospitalisation from complications.