Shingles – A Guide

Shingles is an infection of a nerve and the area of skin around it. It is caused by the herpes varicella-zoster virus, which also causes chickenpox.

Introduction
Symptoms
Causes
Diagnosing
Risks
Treating
Complications

Introduction

Shingles is an infection of a nerve and the area of skin around it. It is caused by the herpes varicella-zoster virus, which also causes chickenpox.

Most people have chickenpox in childhood, but after the illness has gone, the virus remains dormant (inactive) in the nervous system. The immune system (the body’s natural defence system) keeps the virus in check, but later in life it can be reactivated and cause shingles.

Shingles usually affects a specific area on either the left or right side of the body. The main symptoms are:

• pain
• a rash, which develops into itchy blisters and then scabs over

See Shingles – symptoms for more information.

How common is shingles?

It is estimated that about 3 people in every 1,000 have shingles in the UK every year.

Shingles can occur at any age, but is most common in people who are over 50 years of age. Among people who are over 80 years of age, about 11 people in every 1,000 have shingles each year. Shingles is much less common in children.

It is unknown exactly why the shingles virus is reactivated at a later stage in life, but it may be due to having lowered immunity (protection). This may be the result of:

• being older
• being stressed
• a condition that affects your immune system, such as HIV and AIDS

Outlook

In most cases, the painful rash of shingles lasts 7 to 10 days and takes 2 to 4 weeks to fully heal. A number of different medicines can be used to treat the pain.

Complications can occur after you have had shingles, such as postherpetic neuralgia (see Shingles – complications). This is where severe nerve pain lasts for more than three months after the rash has gone.

It is estimated that postherpetic neuralgia affects at least 1 in 10 people with shingles. It is more common in older people, and affects around one-third of people who are over 80 and who have shingles.

Symptoms of shingles

An episode of shingles usually lasts two to four weeks. The first sign of the condition is a tingling sensation in the affected area, followed by pain and then a rash.

Any part of your body can be affected by the rash and pain of shingles, although the chest and abdomen (tummy) are most commonly affected. You may also:

• experience pain in your arms and legs
• find that the nerves in the upper half of your face (including your eyes) are affected
• feel exhausted

Early symptoms

Shingles may cause some early (prodromal) symptoms that last for one to four days before the rash first appears. These early symptoms can include:

• a high temperature (fever) of 38C (100.4F) or over
• myalgia (muscle pain)
• burning, tingling, numbness or itchiness of the skin in the affected area
• a feeling of being generally unwell

Not everyone will experience these prodromal symptoms. In particular, a high temperature is uncommon.

Pain

Along with the early symptoms above, people with shingles experience a localised ‘band’ of pain in the affected area.

The pain caused by shingles can be a constant, dull or burning sensation and its intensity can vary from mild to severe. You may have sharp stabbing pains from time to time and the affected area of skin will usually be tender.

The pain is less common in young, healthy people and is rare in children. The pain can last for more than a week before the rash begins.

Rash

The shingles rash usually follows several days after the start of the pain. The rash appears on one side of your body and develops on the area of skin that is related to the affected nerve.

Initially, the shingles rash appears as red blotches on your skin, before quickly developing into itchy blisters that are similar in appearance to chickenpox. New blisters may appear for up to a week, but about three days after appearing they become yellowish in colour, flatten and dry out.

Finally, scabs form where the blisters were, which may leave some slight scarring. It usually takes two to four weeks for the rash to completely heal.

Seek medical attention

The symptoms of shingles are often mild. However, see your GP as soon as possible if you have the symptoms of shingles. Early treatment may help reduce the severity of your symptoms and your risk of developing complications.

Seek immediate medical treatment if you have any of the following symptoms:

• a high temperature (fever) of 38C (100.4F) or over
• confusion
• memory loss
• severe headache
• any symptoms that affect your eye area (see box, right, about ophthalmic shingles)

See your GP if you develop the symptoms of shingles and you are pregnant or you have a weakened immune system (the body’s natural defence system).

Causes of shingles

Shingles is caused by the reactivation of the varicella-zoster virus, which is the virus that causes chickenpox (a highly infectious condition that most people have during childhood).

Chickenpox causes an itchy rash that blisters and then crusts over.

After you have had chickenpox, the varicella-zoster virus lies dormant (inactive) inside your body. It can later be reactivated and cause shingles.

Reactivation

It is not known exactly how the varicella-zoster virus is reactivated, but it may be linked to having lowered immunity (protection).

Your immunity to illness and infection can become lowered if there is a problem with your immune system (the body’s natural defence system). This can happen as a result of:

• Being older. As you age, your immunity may also decrease. Shingles most commonly occurs in people who are over 80 years old.
• Physical and emotional stress. The chemicals that are released by your body when you are stressed can prevent your immune system from working properly (see the Health A-Z topic about Stress for more information).
• Having HIV and AIDS. People with HIV may be up to 25 times more likely to get shingles than the rest of the population.
• Recently having a bone marrow transplant (bone marrow is the spongy material in the centre of some bones). The conditioning that you receive before the transplant will weaken your immune system.
• Recently having an organ transplant. You may need to take medication to suppress your immune system so that your body accepts the donated organ. After a transplant, 25-45% of people may develop shingles.

Diagnosing shingles

Your GP can diagnose shingles from your symptoms and the appearance of your rash. Testing is not usually necessary.

Referral

If your GP feels that you are at risk of developing complications or if they are unsure about your diagnosis, they may refer you to a specialist. Who you are referred to will depend on your circumstances, but it could be:

• a paediatrician, who specialises in the care of babies and children (if your child has shingles, although this is not always necessary)
• an ophthalmologist (see below), if shingles is affecting your eyes
• your own consultant (a specialist in a particular area of medicine) if you have one for an existing medical condition, for example a consultant in infectious conditions if you have HIV or AIDS

If you have a weakened immune system (the body’s natural defence system), you may need to be referred to a specialist so that your condition can be closely monitored. This is because you are at greater risk of developing complications. A referral is not always necessary, but will depend on your circumstances.

You may have a weakened immune system if you:

• have had chemotherapy or radiotherapy (treatments for cancer) in the last six months
• have HIV or AIDS
• have received a bone marrow transplant (bone marrow is the spongy material that is found in the hollow centre of some bones)
• have received an organ transplant and are taking immunosuppressant medication (medication that prevents your immune system from working properly)
• are taking certain medication, particularly some corticosteroids (medication that contains steroids) or disease-modifying anti-rheumatic drugs (DMARDs, which are often used to treat rheumatoid arthritis)

You will also be referred to a specialist if:

• your pain or rash is not responding to medication
• the nerves involved are affecting your ability to move or to control your bowel or bladder
• you have any signs of complications (see Shingles – complications)

Children may be referred if their rash is extensive (covers most of their body) or if they are particularly unwell.

Ophthalmologist

If your GP suspects that your eyes are being affected by shingles (ophthalmic shingles, see Shingles – symptoms), you may be referred to an ophthalmologist (a doctor who specialises in treating eye conditions).

Signs that your eyes may be affected include:

• vision problems
• unexplained redness of your eye

If you have eye problems that are caused by shingles, it is very important to see an ophthalmologist. This is because you are at risk of losing some of your vision if ophthalmic shingles is not treated.

Risks of shingles

It is not possible to catch shingles from someone else with the condition. The shingles virus is reactivated from a previous infection with the varicella-zoster virus (the virus that causes chickenpox) and is not transmitted by person-to-person contact.

However, it is possible for someone who has never had chickenpox to catch chickenpox from someone with shingles. In the UK, chickenpox is so common during childhood that 9 out of 10 adults have had it, so will not be affected.

Catching chickenpox

The blisters (vesicles) that develop as a result of shingles contain virus particles. The virus can be spread through direct contact with the open blisters. If you have not had chickenpox before (usually as a young child), you can catch it from direct contact with:

• the fluid from the blisters of someone who has shingles
• something that has the fluid on it, such as bed sheets or a towel

If you have shingles, you are contagious until the last blister has scabbed over. This will usually occur five to seven days after your symptoms started.

Spreading the virus

If you have the shingles rash:

• Do not share towels or flannels.
• Do not go swimming.
• Do not play contact sports.

This will help prevent the virus being passed on to someone who has not had chickenpox.

People to avoid

If you have shingles, avoid:

• women who are pregnant and have not had chickenpox before as they could catch chickenpox from you, which may harm their unborn baby
• people who have a weak immune system (the body’s natural defence system), such as someone with HIV or AIDS
• babies who are less than one month old, unless it is your own baby, in which case your baby should have antibodies (proteins that fight infection) to protect them from the virus

Once your blisters have dried out and scabbed over, you are no longer contagious and you will not need to avoid anyone.

Treating shingles

There is no cure for shingles, but treatment can help ease your symptoms.

Treating the rash

If you develop the shingles rash:

• Keep the rash as clean and dry as possible. This will reduce the risk of the rash becoming infected with bacteria
• Wear loose-fitting clothing. This may help you feel more comfortable.
• Do not use topical (rub-on) antibiotics or plasters (adhesive dressings) as this can slow down the healing process.
• Use a non-adherent dressing (a dressing that will not stick to the rash) if you need to cover the blisters, for example to prevent passing the virus to anyone else.

Calamine lotion has a soothing, cooling effect on the skin and can be used to relieve the itching. An antihistamine (a medicine that is often used to treat allergies) may also be useful for preventing itching at night. Before you use an antihistamine, read the manufacturer’s instructions or ask your pharmacist for advice.

Painkilling medication

To ease the pain caused by shingles, your GP may prescribe a painkilling medicine (analgesic). Several different painkilling medicines may be used, including:

• paracetamol
• non-steroidal anti-inflammatory drugs (NSAIDs)
• opioids
• antidepressants
• anticonvulsants

These are described in more detail below. For children, your GP will seek further advice, for example from a paediatrician (a specialist in the care of children and babies) if paracetamol and NSAIDs are not effective at relieving the pain.

Paracetamol

The most commonly used painkiller is paracetamol, which is available over-the-counter (OTC) without a prescription. Always read the manufacturer’s instructions to make sure that the medicine is suitable for you and that you are taking the correct dose.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are an alternative type of painkilling medicine, which are also available OTC. However, NSAIDs may not be suitable for you if you:

• have stomach or kidney problems, such as a peptic ulcer (an open sore on the inside lining of your stomach)
• have had stomach or kidney problems in the past
• have liver problems
• have asthma, a condition that causes the airways of the lungs to become inflamed (swollen)
• are pregnant or breastfeeding

Ask your GP or pharmacist if you are unsure about whether you should take NSAIDs.

Opioids

For more severe pain in adults, your GP may prescribe a weak opioid, such as codeine. This is a stronger type of painkiller which is likely to be prescribed with paracetamol. An even stronger opioid, such as morphine, is unlikely to be prescribed by your GP unless they seek specialist advice first.

Antidepressants

If you have severe pain as a result of shingles, you may be prescribed an antidepressant medicine.

Antidepressants are commonly used to treat depression, but they can also be useful in managing the pain caused by shingles. Antidepressants may be particularly useful if you have experienced severe or prolonged pain.

The antidepressants that are used to treat shingles pain are known as tricyclic antidepressants. Tricyclic antidepressants affect the levels of certain chemicals in your body. The most commonly prescribed tricyclic antidepressants are:

• amitriptyline
• imipramine
• nortriptyline

Side effects of tricyclic antidepressants may include:

• constipation (an inability to empty your bowels)
• difficulty urinating
• blurred vision
• dry mouth
• weight gain
• drowsiness

If you have shingles, you will usually be prescribed a much lower dose of tricyclic antidepressants than if you were being treated for depression. This will usually be as a tablet to take at night. Your dose may be increased until your pain settles down. It may take several weeks before you start to feel the antidepressants working, although this is not always the case.

Anticonvulsants

As with antidepressants, anticonvulsants are most commonly associated with treating another condition. Anticonvulsants are often used to control seizures (fits) caused by epilepsy.

However, anticonvulsants can also help manage nerve pain. They work by stabilising electrical nerve activity within your brain. Gabapentin is the most commonly prescribed anticonvulsant for shingles pain.

Side effects of gabapentin may include:

• headache
• dizziness
• diarrhoea (loose, runny stools)
• dry mouth
• swollen ankles

As with antidepressants, you will have to take gabapentin for several weeks before you notice it working. If your pain does not improve, your dose may be gradually increased until your symptoms are effectively managed.

Antiviral medication

As well as painkilling medication, some people with shingles may also be prescribed an antiviral medicine.

This type of medicine cannot kill the shingles virus, but it can help stop it multiplying. Antiviral medicine may:

• reduce the severity of your shingles, particularly if you take it in the early stages of the condition
• reduce how long your shingles lasts
• prevent complications from developing, such as postherpetic neuralgia (see Shingles – complications), although the evidence for this is uncertain

Antiviral medicines are most effective when they are taken within 72 hours (three days) of your rash appearing. However, they may be started up to a week after your rash appears if you are at risk of severe shingles or developing complications.

Commonly prescribed antiviral medicines include:

• aciclovir
• valaciclovir
• famciclovir

You will usually have to take this type of medicine for seven days.

Who is prescribed antiviral medication?

If you are over 50 years of age and you have the symptoms of shingles, it is likely that you will be prescribed an antiviral medication. You may also be prescribed antiviral medication if you have:

• symptoms that affect your eyes (ophthalmic shingles, see Shingles – symptoms)
• a weakened immune system (the body’s natural defence system)
• a rash on parts of your body other than your torso (the upper part of your body, excluding your head), such as your neck, arms or legs
• moderate to severe pain
• a moderate to severe rash

Pregnancy and antiviral medication

If you are pregnant and you have shingles, it is likely that your GP will discuss your case with a specialist to decide whether the benefits of antiviral medication significantly outweigh any possible risks.

Shingles will not harm your unborn baby. If you are under 50 years of age, you are at less risk of developing complications from shingles. If this is the case, you may not need antiviral medication.

Children and antiviral medication

Antiviral medication is not usually necessary for children because children:

• usually only experience mild symptoms of shingles
• only have a small risk of developing complications

If your child is otherwise healthy, antiviral medicines are not likely to be of significant benefit, so they may not be prescribed.

Complications of shingles

A number of possible complications can occur as a result of shingles. They are more likely to occur if you have a weakened immune system (the body’s natural defence system) or if you are elderly.

Possible complications include:

• an infected rash that becomes red and tender, which may need to be treated with a course of antibiotics (medicine to treat infections that are caused by bacteria)
• white patches (a loss of pigment) in the area of the rash
• scarring, although this is unusual
• encephalitis (inflammation of the brain), which only occurs in rare cases and causes a high temperature (fever) and confusion
• transverse myelitis (inflammation of the spinal cord), which is also rare and may cause pain in your neck and back

Ophthalmic shingles complications

Ophthalmic shingles is where shingles affects part of the trigeminal nerve (the nerve that controls sensation and movement in your face). This can cause complications that affect your eye, including:

• ulceration (sores) and permanent scarring of the surface of your eye (cornea)
• uveitis, which is inflammation (redness and swelling) of some parts of the inner eye, such as the iris (the coloured part) and ciliary body (the ring of muscle behind the iris)

Ophthalmic shingles may cause vision loss if it is not treated.

Ramsay Hunt syndrome

Ramsay Hunt syndrome is a complication that can occur if shingles affects certain nerves in your head. In America, Ramsay Hunt syndrome is estimated to affect 5 people in every 100,000 every year and it may affect a similar number of people in the UK.

Ramsay Hunt syndrome can cause:

• earache
• hearing loss
• dizziness
• vertigo (the sensation that you or the environment around you is moving or spinning)
• tinnitus (the perception of noise in one ear, both ears or inside your head, where the noise comes from inside your body rather than from an outside source)
• a rash around the ear
• loss of taste
• paralysis (weakness) of your face, known as Bell’s palsy

Ramsay Hunt syndrome is usually treated with following medications:

• antiviral medication (medication to treat viruses)
• corticosteroids (medication that contains steroids)

The earlier treatment is started, the better the outcome. Around three-quarters of people who are given antiviral medication within 72 hours (three days) of the start of their symptoms usually make a complete recovery. If treatment is delayed, half of those treated will recover completely.

You may be more likely to have some permanent facial palsy (paralysis) if:

• your face was completely paralysed before you started treatment
• you are over 50 years of age

Around 1 in 20 people with Ramsay Hunt syndrome may experience some degree of permanent hearing loss.

Postherpetic neuralgia

Postherpetic neuralgia is the most common complication of shingles. Estimates vary, but postherpetic neuralgia is thought to affect one or two people in every 10 who have shingles. The condition becomes more common with age, and affects one-third of people over 80.

Postherpetic neuralgia can cause severe nerve pain (neuralgia) that persists after the rash and any other symptoms of shingles have gone. If you have pain for more than three months after your shingles rash has gone, you may have postherpetic neuralgia.

Types of pain that can be experienced by people with postherpetic neuralgia include:

• burning, aching or throbbing pain
• stabbing or shooting pain
• allodynia, where you feel pain from something that should not be painful, such as a very light touch
• hyperalgesia, where you are very sensitive to pain

Postherpetic neuralgia may be treated with a number of different painkilling medicines.

Peripheral motor neuropathy

Peripheral motor neuropathy is a complication that affects one or two people in every 20 who have shingles. It is more common in elderly people.

Neuropathy means nerve damage. In this case, it is damage to a peripheral motor nerve (a nerve that controls movement). Peripheral motor neuropathy usually affects a single limb, such as an arm or leg, causing paralysis in that limb. It is usually possible to make a full recovery.