Image of a virus

Signs and symptoms

The shingles rash

Shingles causes a distinctive rash, usually on one side of the body.1 It can appear differently on black or brown skin.1 It is important to note, however, that individuals with shingles may present with other, less typical symptoms.

The following photos show how the shingles rash may appear. This selection of photos is provided for educational purposes only and it is not exhaustive. The information presented here does not replace clinical judgment and a clinical examination of patients is always needed.

Examples of a shingles rash

  • A photo of the shingles rash on a person’s abdomen A photo of the shingles rash on a person’s abdomen
  • A photo of the shingles rash on a person’s back A photo of the shingles rash on a person’s back
  • A photo of the shingles rash on a person’s trunk A photo of the shingles rash on a person’s trunk
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Patient presentation

An icon of a lightning bolt

Pain is usually the first manifestation of shingles. It may be severe and accompanied by fever, headache and malaise.2,3 Neuroinflammation is, in part, responsible for this pain4

An icon of a clock

The average time between pain and skin symptoms developing is 1.4 days for shingles affecting the face and 3.2 days when affecting the trunk2

How patients might describe their pain

An icon of 10 people. 9 of them are highlighted in red

Up to 90% of patients with shingles report experiencing pain5

  • In the acute phase of shingles, pain is usually described as moderate or severe, with patients ranking it as being more intense than post-surgical or labour pains5
  • Patients may report burning, sharp, stabbing or pulsating sensations, itching, tingling or numbness, angina-like aching or squeezing sensations, and a deep aching or 'pulled muscle' sensation5,6
  • Many patients experience disabling pain from stimuli that are not normally painful, such as the touch of clothing or a light breeze across the skin5

Pain intensity may be assessed using a validated pain assessment scale, such as the Visual Analogue Scale or Numeric Rating Scale3,4

Typical clinical features

A diagnosis of shingles is usually made clinically.7 Typically, shingles is a unilateral, dermatomal eruption with skin lesions that evolve from macules to papules, vesicles and pustules. Clinical features include:3,8,9

An illustrated diagram of a person. The different dermatomes are shown in different colours and a shingles rash across one dermatome on the trunk is shown. Aspects of the symptoms of shingles are described on the illustration.
  • Thoracic dermatomes are affected most frequently (55%), followed by regions supplied by the trigeminal nerve (20%), and cervical (11%), lumbar (13%) and sacral (2%) dermatomes6

Symptom timeline

Prodromal phase

  • Typically lasts 2–3 days but may be as long as 7 days10

Acute phase

  • Maculopapular lesions develop into clusters of vesicles over 3–5 days3
  • Vesicles then burst and crust over within 7–10 days3
  • Healing occurs over 2–4 weeks3

Long term

  • Possible complications, such as post‑herpetic neuralgia, can occur or persist for the subsequent 3–6 months, and can last longer11

Find out more

Recognising complications

Potential complications and what to look out for

Other clinical patterns

A photo of herpes zoster ophthalmicus

Herpes zoster ophthalmicus (HZO)

HZO involves varicella zoster virus (VZV) reactivation in the ophthalmic division of the trigeminal nerve and is associated with a high rate of complications.6,12 The skin of the forehead, upper eyelids, and orbits of the eyes may be involved.9,12 Around 10–25% of people with shingles have HZO,12,13 but it is more frequent and sometimes more severe in immunocompromised patients12

Herpes zoster oticus (also known as Ramsay Hunt syndrome)

Herpes zoster oticus occurs when the VZV infection spreads from the facial nerve to the vestibulocochlear nerve of the ear.9 Although clinical presentation varies, herpes zoster oticus typically features pain in the ear canal, peripheral facial weakness and an auricular vesicular rash, but sometimes there is not rash at all.6,14 Other possible symptoms include vertigo (rotational dizziness) , hearing loss, sensitivity to sound, tinnitus, dysgeusia, loss of taste and osteonecrosis.6,13,14 Herpes zoster oticus is uncommon13

Zoster sine herpete

Shingles can occasionally present as unilateral dermatomal pain without a rash but with serological evidence of VZV infection6

Oral involvement

Shingles may occur in the mouth, causing vesicles or erosions, if the maxillary or mandibular division of the trigeminal nerve is affected. This may appear in combination with lesions on the skin served by the same nerve. Prodromal pain may be mistaken for toothache, leading to unnecessary dental treatment9

Atypical cutaneous presentations

In older adults, the rash may not be vesicular.3 Other cutaneous presentations have been described including verrucous, lichenoid, follicular or granulomatous rashes6

Severe rash

The rash may be severe or long-lasting in immunocompromised individuals3

Disseminated rash

While skin symptoms typically occur on the trunk in healthy people, immunocompromised individuals may have more widespread symptoms affecting more than one dermatome3

Differential diagnoses

A clinical diagnosis of shingles is easy to make when the classical presentation of unilateral, vesicular rash is present. However, diagnosis of other zosteriform rashes, such as herpes simplex virus (HSV), can be made erroneously6

Polymerase chain reaction (PCR) testing can be used to increase confidence in diagnosis and reduce errors when the presentation is atypical6

Dermatomal rash and pain?

The presence of a dermatomal rash and pain is typical of shingles. However, it may be difficult to diagnose shingles when patients are experiencing pain before skin symptoms develop in the prodromal phase3

Differential diagnoses include:

  • HSV: HSV can present with a unilateral, maculopapular, vesicular rash and pain. Multiple recurrences around the mouth and genital areas and a lack of chronic pain make HSV more likely3
  • Candidal skin infection: This infection can cause variable skin symptoms, including thin-walled pustules with a red base and pain3

Dermatomal pain but no rash?

Rarely, shingles can present with no rash, known as zoster sine herpete. Pain may be significant, and if it affects the face, facial palsy may be present3,6,14

Differential diagnoses include:

  • Appendicitis: Prodromal shingles pain or post-herpetic neuralgia affecting the trunk and right lower abdomen may mimic appendicitis3
  • Trigeminal neuralgia: Shingles affecting the nerves of the face can cause severe pain similar to trigeminal neuralgia. Trigeminal neuralgia may be more likely to have an obvious trigger3

Dermatomal rash but no pain?

A rash with no pain may signify another skin-related condition.3 However, shingles presenting as a rash with no pain can occur rarely, most often in children15

Differential diagnoses include:

  • Impetigo: This infection presents with vesicles that may burst and crust over3
  • Contact dermatitis: This condition is characterized by a localised rash or irritation3

References

  1. NHS. Shingles. https://www.nhs.uk/conditions/shingles/ (accessed February 2024).
  2. Primary Care Dermatology Society. Herpes zoster (syn. shingles). https://www.pcds.org.uk/clinical-guidance/herpes-zoster (accessed January 2024).
  3. National Institute for Health and Care Excellence. Clinical knowledge summary: Shingles. https://cks.nice.org.uk/topics/shingles/ (accessed February 2024).
  4. 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 2: Treatment. J Eur Acad Dermatol Venereol 2017;31:20-29.
  5. Johnson RW et al. The impact of herpes zoster and post-herpetic neuralgia on quality-of-life. BMC Med 2010;8:37.
  6. 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.
  7. Centers for Disease Control and Prevention. Zoster. https://www.cdc.gov/vaccines/pubs/pinkbook/herpes-zoster.html (accessed February 2024).
  8. Centers for Disease Control and Prevention. Shingles (herpes zoster). https://www.cdc.gov/shingles/index.html (accessed February 2024).
  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).
  10. Le P and Rothberg M. Herpes zoster infection. BMJ 2019;364:k5095.
  11. 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).
  12. Shaikh S and Ta CN. Evaluation and management of herpes zoster ophthalmicus. Am Fam Physician 2002;66:1723-1730.
  13. 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.
  14. Gershon AA et al. Varicella zoster virus infection. Nat Rev Dis Primers 2015;1:15016.
  15. DermNet PAO. Herpes zoster. https://dermnetnz.org/topics/herpes-zoster (accessed June 2024).

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July 2024 | NP-GB-HZU-WCNT-240026 (V1.0)