Recognizing the Early Signs of Shingles

What Causes Shingles?

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Shingles (herpes zoster) along the mandibular branch of the trigemular nerve running along the cheek and ear. brownpau

Shingles (herpes zoster) is a viral disease characterized by a painful skin rash with blisters that appears along a band or stripe (called a dermatome) on either other one side of the body or the next.

The condition is caused by the reactivation of the varicella-zoster virus (VZV), an airborne virus which causes chickenpox (varicella) in initial infection.

With more than 99 percent of Americans having been infected with VZV, the risk of developing shingles is surprisingly high. In fact, according to the Centers for Disease Control and Prevention (CDC), nearly one out of three adults in the U.S. will develop shingles during the course of a lifetime.

Knowing the early signs and symptoms of shingles—as well as ways to avoid the risk of an outbreak—may help reduce the severity of this confounding and often painful condition.

What are the First Signs of Shingles?

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Day 1, 2 and 4 of a shingles outbreak running along the ophthalmic nerve. Burntfingers

The speed by which a shingles outbreak can develop can often be astonishing, with the progression from hives to rash to blisters often occurring before one's very eyes.

But even before the disease manifests physically, there often early signs that many people either miss or misdiagnosed. These typically occur 2-7 days before a rash actually appears but can take up to three weeks in some cases.

The very earliest signs of an outbreak can include:

  • General malaise, headache, and even slight fever, sometimes developing during periods of stress or physical exhaustion when you feel especially run down. A sensitivity to light (photophobia) is also known to occur in cases with ocular (eye) involvement and should suggest that this is something more than just a case of general malaise or exhaustion.
  • An uncomfortable to painful sensation is felt along a specific (localized) part of the body, which people often independently describe as being a burning, stinging, tingly, prickly, itchy, numbing, aching or shooting pain.
  • The pain can either be persistent or intermittent, but during the course of a day or so two things will become apparent: the pain will either be on the left or right side of the body in a stripe or belt-like pattern, rarely crossing over the mid-line; and the irritation will feel more like a nerve pain, involving more than just the skin and/or muscles.
  • Depending on the location of the pain, it can sometimes be mistaken for sciatica if running from the lower back down the leg; a herpes outbreak if occurring around the lips or cheeks; a migraine if running along the eye and ear; a kidney-associated pain if occurring on the lower back and sides; or a heart or lung problem if presenting on the upper torso.
  • When the rash first appears, it is generally hive-like in appearance with pale, raised, itchy bumps. It soon after enters the eruptive stage, characterized by vesicular blisters which can easily burst and crust over. Early antiviral therapy—by way of a  seven- to ​10-day course of acyclovir (Zovirax) or valacyclovir (Valtrex)—may significantly reduce the severity, duration and post-infection complications of a shingles outbreak.

Where Am I Most Likely to Get Shingles?

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Typical shingles rash distribution when occurring along the lateral pectoral nerves. James Helman, M.D.

Shingles most commonly occur on the torso, although it can develop along any specific region of the skin which is supplied by a single spinal nerve. This region is called a dermatome and helps explain the pattern of pain and rash in a shingles outbreak.

After a person is infected with VZV and has chickenpox, the virus will remain dormant on nerve cells, kept in check by antibodies specific to the virus which circulate in the body and prevent it from reactivating.

However, during periods when a person's immune function is low, the viruses along a specific nerve branch can reactivate. And since the branches don't cross the mid-line of the body, the condition will manifest with the classic, bilateral pattern on either one-half of the body or the next.

Outbreaks can also involve two adjacent dermatomes, but rarely two, non-adjacent dermatomes. The exception may be in severely immune comprised individuals, such as those with advanced HIV, who are at greater risk of disseminated shingles ( occurring in three or more dermatomes), shingles of the eyes or internal organs, and a recurrence of shingles within six months.

Am I at Risk of Getting Shingles?

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Classic presentation of vesicular herpes zoster blisters, generally appear 1-3 days after the development of the initial rash. AJC

Shingles most commonly affect adults over the age of 50. This is most likely due to reduced levels of cellular immunity, which tend to decline the older we get.

However, shingles are known to occur at most any age. It is believed that children, for example, who develop chickenpox during infancy are unable to develop an ample immune defense simply because their immune systems were immature at the time of infection. In these cases, shingles can present in when they are in their early adulthood or even in their childhood years.

But older age still remains the predominant risk factor associated with shingles, nearly quadrupling in risk among adults aged 65 and older when compared to the general U.S. population.

Additionally, 5% of those affected will likely experience a second attack. There is still little known as to what actually triggers a shingles outbreak.

Other risk factors can include:

  • HIV infection, which is associated with immune suppression
  • Cancer, especially leukemia and lymphoma
  • Depressed immune responsiveness caused by stress or a traumatic event
  • Prolonged exposure to steroids, such as prednisone
  • Transplant-related immunosuppressive medications

Shingles incidence also tend to be higher in men than women (4:3, respectively) and among whites vs. blacks (3:1, respectively).

Based on the current data, the U.S. Food and Drug Administration (FDA) has recommended the use of the shingles vaccine (Zostavax) for all adults 50 years of age and older. While it is typically avoided in people with HIV, there is growing support for its use in individuals with higher levels of immune function.


Blanks, L.; Polydefkis, M.; Moore, R.; et al. "Herpes zoster among persons living with HIV in the current antiretroviral therapy era." Journal of Acquired Immune Deficiency Syndromes. October 1, 2012; 61(2):203-207.