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Complications

Anticipating and identifying complications

Although herpes zoster (shingles) is usually self-limiting, patients can experience complications1,2
Some complications of shingles can be medical emergencies, requiring urgent treatment and referral to specialists1

Find out more

Multidisciplinary approach to patient care

A variety of medical specialists may need to be involved in the care of patients with shingles

Risk factors for complications of shingles include:1,3

  • Advanced age
  • Immunocompromised status
  • Severe predisposing skin diseases (e.g. atopic dermatitis/eczema)
  • Shingles in the head and/or neck area
  • Shingles with:
    • Moderate to severe prodromal or acute shingles‐associated pain
    • Severe rash and/or signs of cutaneous dissemination
    • Signs of involvement of the central nervous system
    • Signs of visceral involvement

The range of possible complications is wide

Long-term nerve pain known as post-herpetic neuralgia (PHN) is the most common complication of shingles, but there are other complications too1

Post-herpetic neuralgia (PHN)

An icon of a person’s face grimacing in pain

Definition:

  • Pain that persists for, or rash which appears for longer than, 90 days after initial rash onset1,4

Cause:

  • Shingles-induced peripheral nerve damage1

Incidence:

  • The most common complication of shingles1
  • Risk of developing PHN is 6–45% across immunocompromising conditions5

Demonstrable change in the rate of PHN in those over 50 years1

A column graph depicting the percentage of patients developing postherpetic neuralgia (PHN) by age. The y-axis represents the percentage of patients, while the x-axis displays age in years. The columns increase from age 50 to over 80, reaching the highest percentage at the latter age range

Chart created using data from National Institute for Health and Care Excellence. Clinical knowledge summary: Shingles. https://cks.nice.org.uk/topics/shingles/ (accessed February 2024).

Duration:
  • ~3–6 months, occasionally persisting for many years4,6
Features:
  • Severity varies from mild to excruciating4,6
  • Pain may last for any duration, from a few minutes to being constant on a daily or almost daily basis6
  • Pain may be triggered by trivial stimuli, for example by wind on the face4,6
    • More than 70% of patients with PHN experience this tactile allodynia, which is usually considered the most distressing and debilitating symptom7
Risk factors:
  • PNH is most common in older people; the risk for PHN among people with shingles increases with age, particularly for those aged >50 years4,6
  • Predictors include the occurrence and severity of pain both before and after onset of the rash, the extent of the rash, trigeminal or ophthalmic distribution, and the occurrence of viremia6
Impact:
  • The persistency of PHN means that patients may have few periods of respite from erratic, painful and prolonged attacks7
  • PHN can disrupt sleep, mood, work, and activities of daily living, adversely affecting quality of life and leading to social withdrawal and depression.6,7 Suicide has been reported in patients with PHN6,7

Examples of other complications of shingles

  • Complications of herpes zoster ophthalmicus (HZO)

    Possible complications:

    • HZO is associated with a high rate of complications, including loss of vision, pain, keratitis, uveitis, optic neuritis, retinitis, conjunctivitis, scleritis, corneal ulceration, secondary glaucoma, eyelid retraction, oculomotor palsies, paralytic ptosis and facial scarring1,3,6
    • Papulovesicular lesions on the side and top of the nose (Hutchinson’s sign) indicate an increased likelihood of eye inflammation and permanent corneal denervation1,3,6

    Cause:

    • Varicella zoster virus (VZV) reactivation in the ophthalmic division of the trigeminal nerve1,8

  • Complications of shingles oticus (also known as Ramsay Hunt syndrome)

    Possible complications:

    • Hearing loss, sensitivity to sound, tinnitus, ear pain, dysgeusia, loss of taste, peripheral facial weakness, vertigo and osteonecrosis, with recovery often incomplete3,6

    Cause:

    • VZV spreading from the facial nerve to the vestibulocochlear nerve, with involvement of the ear9

  • Complications of oral shingles

    Possible complications:

    • Osteonecrosis, tooth loss, periodontitis, pulp calcification, pulp necrosis, periapical lesions, and tooth development anomalies9

    Cause:

    • VZV spreading from the maxillary or mandibular division of the trigeminal nerve to blood vessels, compromising the blood supply9

  • Dermatological changes

    Possible complications:

    • Scarring, changes in pigmentation and keloid formation after the rash has healed1

    Cause:

    • Impact of the rash1

  • Bacterial skin infections

    Possible complications:

    • Cellulitis, osteomyelitis or other life-threatening complications (such as necrotising fasciitis and sepsis)1

    Cause:

    • Secondary bacterial infection of lesions1

  • Cardiovascular complications

    Possible complications:

    • Increased risk of cerebrovascular and cardiac events, including stroke, transient ischaemic attack and myocardial infarction1

    Cause:

    • Believed to be caused by movement of VZV from the trigeminal ganglion to the internal carotid artery or its branches, resulting in inflammation6

  • Peripheral motor neuropathy

    Possible complications:

    • Loss of movement in the affected area1

    Cause:

    • Involvement of a motor nerve1

    Risk factors:

    • Occurs in 5% of cases; more common in the elderly and people with an underlying malignancy or cranial nerve involvement1

  • Central nervous system (CNS) complications

    Possible complications:

    • Encephalitis, meningoencephalitis, myelitis, cerebellitis, cerebrovascular disease, radiculitis, cranial nerve palsies, muscular weakness, diaphragmatic paralysis, neurogenic bladder and Guillain–Barré syndrome, predominantly in patients who are immunocompromised1,3,6,9

    Cause:

    • VZV resides in the sensory root ganglia and can affect any part of the brain; CNS involvement is not uncommon9

  • Systemic dissemination: A rare but serious complication

    Possible complications:

    • Pneumonia, hepatitis, encephalitis or disseminated intravascular coagulopathy1,9
    • Can be lethal1,9

    Cause:

    • Dissemination of reactivated virus into the lungs, liver, gut or brain may occur, for example, in patients who are severely immunocompromised1
    • Cutaneous dissemination, which occurs in up to 37% of shingles cases among patients who are immunocompromised in the absence of antiviral treatment, is a marker for systemic dissemination6

The case fatality rate of disseminated disease is 5–15%, with most deaths being caused by pneumonia1,6

References

  1. National Institute for Health and Care Excellence. Clinical knowledge summary: Shingles. https://cks.nice.org.uk/topics/shingles/ (accessed February 2024).
  2. Centers for Disease Control and Prevention. Shingles (herpes zoster). https://www.cdc.gov/shingles/index.html (accessed February 2024).
  3. Werner RN et al. European consensus-based (S2k) guideline on the management of herpes zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 1: Diagnosis. J Eur Acad Dermatol Venereol 2017;31:9-19.
  4. UK Health Security Agency. Shingles: The Green Book, chapter 28a (July 2023). https://assets.publishing.service.gov.uk/media/64c1153cd4051a000d5a9409/Shingles_Green_Book_on_Immunisation_Chapter_28a_26_7_23.pdf (accessed February 2024).
  5. McKay SL et al. Herpes zoster risk in immunocompromised adults in the United States: A systematic review. Clin Infect Dis 2020;71:e125-e134.
  6. Harpaz R et al. Prevention of herpes zoster: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2008;57:1-30: quiz CE2-4.
  7. Johnson RW et al. The impact of herpes zoster and post-herpetic neuralgia on quality-of-life. BMC Med 2010;8:37.
  8. Shaikh S and Ta CN. Evaluation and management of herpes zoster ophthalmicus. Am Fam Physician 2002;66:1723-1730.
  9. Nair PA and Patel BC. Herpes zoster. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/pubmed/28722854 (accessed February 2024).

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July 2024 | NP-GB-HZU-WCNT-240025 (V1.0)