Shingles

Introduction

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Anyone who has already had chickenpox can develop shingles later on. Both are caused by the same virus, known as the varicella-zoster . This stays dormant (inactive) in the body after a chickenpox . But it can become active again years later and cause shingles (herpes zoster): a rash with blisters that usually forms a band across the skin and is often very painful. The rash normally only affects one side of the body.

Shingles is particularly common in older people. Although it can be very unpleasant, it’s usually over in about two to four weeks if there are no complications.

As of 2018, a shingles is recommended for people over the age of 60. People who have a weakened or a chronic disease are advised to have the when they have reached the age of 50.

Shingles is contagious, but only for people who have never had chickenpox. In that case the only causes chickenpox at first, and not shingles.

Symptoms

Before the rash breaks out you usually feel tired and run-down. You may also have a slight fever and tingling sensations under your skin. The typical symptoms of shingles start 2 or 3 days later:

  • moderate to severe stinging or burning pain in the affected area,
  • followed by slightly reddish patches of skin with small bumps,
  • which then turn into small blisters that may be itchy in just a few hours.

This stage can last up to five days. After that, the blisters dry up in 2 to 10 days, leaving behind yellowish scabs.

The shingles rash generally affects only one side of the body, and typically forms a band across the skin.

Illustration: Shingles: Typical rash on one side of the body only

Shingles: Typical rash on one side of the body only

Shingles most commonly affects the torso or chest. But it can develop just about anywhere, like on your arms, head or face. Sometimes it can also affect your eyes or ears. Blisters may develop over larger areas in some people.

Causes

After a chickenpox clears up, the varicella-zoster viruses settle undetected in the nerve roots along the spinal cord or at the base of the skull. They remain there for the rest of your life, but usually go unnoticed.

If the immune system is weakened – for instance, as a result of a cold, extreme stress or old age – the viruses may multiply again and move along the affected nerve, eventually reaching the skin. When the viruses multiply in skin cells, they cause and the typical shingles rash. The in the nerve is what causes the pain.

Illustration: Nerve infected by the virus, and inflamed area of skin

Nerve infected by the virus, and inflamed area of skin

People who have never had chickenpox can be infected with the varicella-zoster by coming into contact with the fluid from inside shingles blisters. The can then only cause chickenpox at first, and not shingles. You are no longer contagious once all of the blisters have dried up and all of the scabs have fallen off.

People who have been vaccinated against chickenpox can get shingles, though – but it seems to be less common than in people who have had chickenpox.

Prevalence

It is estimated that about 2 out of 10 people who have had chickenpox develop shingles sometime later in life. Most people who get shingles are over 50. The risk of shingles increases with age because our immune systems become weaker as we grow older. About 300,000 people get shingles in Germany every year.

Outlook

In normal cases, without complications, shingles usually goes away after 2 to 4 weeks in adults. Children and young people generally have milder cases. Most adults only get shingles once in their life.

In very rare cases, the blisters spread to nearby areas of skin or even over the whole body. This may happen if the is very weak, for instance due to a serious disease like cancer or AIDS. Under those circumstances, shingles can be life-threatening.

Effects

Breaking the itchy blisters open by scratching them may lead to a bacterial in the skin and leave scars. Other longer-term effects of shingles include overly sensitive skin or changes in skin pigmentation – leaving it darker or lighter than the surrounding skin.

Shingles in the face can spread to the eye too, causing of the (keratitis). If auditory (hearing) nerves or facial nerves are involved, shingles may also lead to hearing loss or paralysis in the face. This usually goes away once the shingles has cleared up.

About 10 to 20 out of 100 people still have quite severe pain from nerve damage even after the rash has gone away. This pain is referred to as "post-herpetic neuralgia." It can last anywhere from a few weeks or months up to several years.

People with a very weak are at greater risk of developing serious complications. The possible complications include a lung (pneumonia), of the membranes covering the brain and spinal cord (meningitis) or a liver (hepatitis).

Unlike chickenpox, shingles is not dangerous for unborn children during pregnancy.

Diagnosis

Shingles can also be difficult to diagnose in the early stages because the typical rash often only appears after the pain starts. Depending on what part of your body is affected, other causes might be suspected at first, like an of the appendix (appendicitis) or an of the gallbladder (cholecystitis), a slipped disk or even a heart attack.

Many people who have shingles first think that it might be a non-contagious skin condition like . This may delay the because they might think that they don’t need to see a doctor about it.

Doctors diagnose shingles based on its typical one-sided rash and the accompanying pain or abnormal sensations. If they aren’t sure whether it’s shingles, the fluid inside the blisters can be tested to see whether it contains the . Doctors can also check if the blood contains more than the usual numbers of antibodies needed to fight the varicella-zoster .

Prevention

As of late 2018, the German Standing Committee on Vaccination (STIKO) recommends that everyone over the age of 60 be vaccinated against shingles with an inactivated herpes zoster vaccine. This inactivated vaccine contains certain parts of the instead of weakened viruses. This vaccine is already recommended for people aged 50 and over who have chronic diseases such as diabetes, rheumatoid arthritis or immunodeficiency. It consists of two doses, given 2 to 6 months apart.

Studies show that the vaccine can significantly lower the risk of healthy people getting shingles. But it’s hard to say whether the protection against shingles lasts longer than four years because the inactivated vaccine is still relatively new. The may cause side effects, including reddened skin and rashes, and pain or swelling where the vaccine was injected.

In Germany, the costs of this are covered by statutory health insurers.

Treatment

Beschwerden Symptoms like pain and fever can be relieved with pain-relieving and fever-lowering medication such as acetaminophen (paracetamol). Prescription painkillers like opioids are sometimes used to relieve more severe pain.

Thorough skin care is recommended if you have shingles. Antiseptic or anti-itch lotions, gels and powders are often used to relieve the itching and dry out the blisters. Most of them contain tanins, zinc, menthol or polidocanol. If blisters have already formed, people are sometimes advised to use cooling wet wraps. But there’s no good scientific research on how well these treatments work in shingles.

Special medications for the herpes zoster (antiviral drugs) are recommended only if:

  • you are over the age of 50,
  • the shingles affects your head and neck region,
  • you have a weakened ,
  • you have kidney failure,
  • the symptoms are severe or there is a higher risk of complications.

If antiviral medication is taken early on, it can make shingles go away faster and decrease the time that it is painful. So it makes sense to start antiviral therapy no later than 72 hours after the rash starts. In severe cases the medicine can also be given through a drip into a vein (intravenous infusion). If the ear is affected, steroids are often used too. But it still isn’t clear what pros and cons this kind of combination therapy may have.

Everyday life

It is important to not scratch the blisters if possible: The fluid in them is contagious, and blisters that have been torn open can leave scars. As long as it's still contagious – that is, until the very last blisters have gone away – people who have shingles should avoid direct contact with others if they don't know whether the other people are immune to chickenpox. This is particularly important when it comes to people with a weakened and pregnant women. You can help keep shingles from spreading by covering the blisters with a bandage.

Further Information

When people are ill or need medical advice, they usually go to see their family doctor first. Read about how to find the right doctor, how to prepare for the appointment and what to remember.

Chen N, Li Q, Yang J, Zhou M, Zhou D, He L. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2014; (2): CD006866.

Deutsche Dermatologische Gesellschaft (DDG). Diagnostik und Therapie des Zoster und der Postzosterneuralgie (S2k-Leitlinie). AWMF-Registernr.: 013-023. 24.05.2019.

Gagliardi AM, Andriolo BN, Torloni MR, Soares BG. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev 2016; (3): CD008858.

Han Y, Zhang J, Chen N, He L, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2013; (3): CD005582.

McDonald EM, de Kock J, Ram FS. Antivirals for management of herpes zoster including ophthalmicus: a systematic review of high-quality randomized controlled trials. Antivir Ther 2012; 17(2): 255-264.

Robert Koch Institute (RKI). Gürtelrose (Herpes zoster): Antworten auf häufig gestellte Fragen zu Erkrankung und Impfung. January 24, 2019.

Robert Koch Institute (RKI). RKI-Ratgeber: Windpocken (Varizellen), Gürtelrose (Herpes zoster). December 13, 2018.

Ständige Impfkommission (STIKO). Wissenschaftliche Begründung für die Entscheidung, die Herpeszoster-Lebendimpfung nicht als Standardimpfung zu empfehlen. September 7, 2017. (Epidemiologisches Bulletin; Volume 36).

Ständige Impfkommission (STIKO). Wissenschaftliche Begründung zur Empfehlung einer Impfung mit dem Herpes zoster-subunit-Totimpfstoff. December 13, 2018. (Epidemiologisches Bulletin; Volume 50).

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

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Updated on November 21, 2019
Next planned update: 2022

Authors/Publishers:

Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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