When he was 29 years old, James Gillespie felt some tenderness in his left shoulder and neck. When he went to massage it, he felt blisters. His reaction was about what you’d expect. “I was like, what the heck is this?!”

Luckily, he managed to see a dermatologist the next day. At his appointment, the physician asked Gillespie if he’d ever had chicken pox and was experiencing any stress. Gillespie had indeed had chicken pox as a child. And with a full-time job, an imminent move, and a band in danger of breaking up, he was experiencing quite a bit of stress. From that information, his physician made a diagnosis of something Gillespie had never even heard of: shingles.

Almost 1 in 3 people in the United States develop shingles in their lifetime. Also known as herpes zoster or zoster, shingles is caused by the reactivation of the varicella-zoster virus (VZV) in those who have had chicken pox, aka varicella. Once chicken pox has resolved, the virus remains dormant in the dorsal root ganglia—the nerve cell bodies residing in the root of a spinal nerve.1

Because more than 99 percent of Americans 40 years and older have had chicken pox, just about anyone is at risk for developing shingles.2 Most people get shingles only once, but it is possible to have two or three episodes.1

Time and time again

Those most likely to get shingles are those who, in addition to having had chicken pox, are at least 50 years old, already ill or injured, under intense stress, or immunocompromised.3

While shingles is often treated by a dermatologist, its roots run more than skin-deep. “Shingles is a viral infection of the skin but also of the nervous system, as this particular virus lies dormant in the spinal nerves and reactivates through a peripheral nerve,” notes Lindsay C. Strowd, MD, FAAD, assistant professor of dermatology at Wake Forest Baptist Health in Winston-Salem, North Carolina.

Skin may be itchy, tingly, or painful days or weeks before the characteristic painful, blistering rash appears in the same area.1 This rash generally limits itself to one side of the body or dermatome (an area of skin in which sensory nerves derive from a single spinal nerve4), or sometimes to two adjacent dermatomes.1 These cases are called localized zoster, which occurs in approximately 20 percent of shingles cases. In total, there are 30 dermatomes on the body.4 In the rare times in which the rash affects three or more dermatomes—generally in those with compromised or suppressed immune systems—it is called disseminated zoster and may be difficult to differentiate from chicken pox.1

Other symptoms in the prodromal phase—after the incubation period and before the illness takes hold—may include headaches or sensitivity to light.1

Shingles is generally diagnosed by its appearance and patient history. When in doubt, the physician may take a skin culture or fluid from a blister and send it to the laboratory for testing.5 “Some patients may get this itching, blistering rash confused with poison ivy, but dermatologists are trained to recognize and differentiate the symptoms,” says Kim Flowers, CMA (AAMA), Wayne State University Physician Group and Dermatology Residency Program, Dearborn, Michigan.

“Shingles tends to have a classic presentation in the majority of cases with a unilateral vesicular eruption confined to a dermatome of the skin and causing fairly severe pain and/or itching of the skin,” says Dr. Strowd. “It may be harder to diagnose shingles if patients present very early in the course—i.e., before the rash appears—or very late in the course, after the vesicles have crusted over.”

Blisters usually heal within two to four weeks and remain infectious until they dry and crust over.1 Shingles is much less contagious than chicken pox, but someone who has never had chicken pox can get the virus through contact with open blisters. However, if such a person is infected, the virus will present as chicken pox, not shingles.3

Rash action

Once the varicella-zoster virus reactivates, the condition can be quite painful—not surprising, considering that it resides in the dorsal root ganglia. Gillespie recalls it as just short of excruciating and always present. Timing is crucial, notes Flowers: “When a patient calls and explains these symptoms, … get them in as soon as possible to begin treatment.”

Antiviral medications can temper symptoms, shorten their duration, and possibly even prevent long-term nerve pain—particularly when started within 72 hours of the rash’s appearance.6 Such medications include famciclovir (Famvir), acyclovir (Zovirax), and valacyclovir (Valtrex).5

Prescribed painkillers or even nerve blocks (with a numbing anesthetic and sometimes a corticosteroid) may be needed for intense pain.5 Physicians may prescribe corticosteroids as a pill to be taken with antivirals to decrease swelling and pain, but this is rare, as they may further diffuse the rash.5

From bad to worse

Postherpetic neuralgia (PHN), a severe pain that can last years, is the most common complication of shingles.5 The condition may present as numbness, itching, or tingling5 and is more likely to affect older adults. The complication affects approximately 13 percent of patients 60 and older, while it is extremely rare in those younger than 40.1

Several other unpleasant complications are possible:

  • Ocular shingles, or herpes zoster ophthalmicus, involves blisters, redness, or swelling around the eye or on the eyelid, eye pain, and photosensitivity. Blisters on the tip of the nose can be a warning sign. Timely treatment is necessary; otherwise glaucoma, scarring, blindness, or a higher risk of stroke may result.
  • Bacterial infection due to infected blisters can delay healing and possibly lead to scarring. Antibiotics may be necessary.5
  • Visceral side effects, such as hepatitis, pneumonitis, and meningoencephalitis, are also possible.1

One complication is too often understated: stigma. Gillespie’s band canceled a gig fearing he would infect them. Strangers on the train moved far from him. Although health professionals cannot always prevent such reactions from patients’ peers, they can help decrease stigma by educating patients on how shingles spreads and help mitigate patients’ emotional—and physical—toll by providing timely, patient-centered care.