How does shingles look when it first starts

About shingles

Shingles, also known as herpes zoster, is an infection of a nerve and the skin around it. It's caused by the varicella-zoster virus, which also causes chickenpox.

It's estimated that around one in every four people will have at least one episode of shingles during their life.

Symptoms of shingles

The main symptom of shingles is pain, followed by a rash that develops into itchy blisters, similar in appearance to chickenpox. New blisters may appear for up to a week, but a few days after appearing they become yellowish in colour, flatten and dry out.

Scabs then form where the blisters were, which may leave some slight scarring.

The pain may be a constant, dull or burning sensation and its intensity can vary from mild to severe. You may have sharp stabbing pains from time to time, and the affected area of skin will usually be tender.

In some cases, shingles may cause some early symptoms that develop a few days before the painful rash first appears. These early symptoms can include:

• a headache
• burning, tingling, numbness or itchiness of the skin in the affected area
• a feeling of being generally unwell
• a high temperature (fever)

An episode of shingles typically lasts around two to four weeks, however in some cases the pain may last for many weeks once the rash has disappeared. Shingles usually affects a specific area on one side of the body and doesn't cross over the midline of the body (an imaginary line running from between your eyes down past the belly button).

Any part of your body can be affected, including your face and eyes, but the chest and abdomen (tummy) are the most common areas.

When to get professional advice

Non-urgent advice: Speak to a pharmacist

Pharmacy First Scotland: Shingles treatment from your local pharmacy

Adults 18 years and over with symptoms of shingles can get advice and treatment directly from a pharmacy. If the pharmacist cannot treat you they may recommend you see your GP.

Find your local pharmacy on Scotland's Service directory.

Shingles isn’t usually serious, but see your pharmacist as soon as possible if you recognise the symptoms. In most cases your pharmacist should be able to provide treatment, however they may recommend that you need to contact your GP practice for treatment if required.

You should see your GP if you are under 18 years old, pregnant or have a weakened immune system (the body's natural defence system) and you think you have been exposed to someone with chickenpox or shingles and haven't had chickenpox before.

Early treatment may help reduce the severity of your symptoms and the risk of developing complications.

Referral to hospital

It's uncommon for someone with shingles to be referred to hospital, but your GP may consider seeking specialist advice if:

• they suspect a complication of shingles, such as meningitis or encephalitis
• shingles is affecting one of your eyes – there's a risk you could develop permanent vision problems if the condition isn't treated quickly
• a diagnosis isn't certain
• you have an unusually persistent case of shingles that's not responding to treatment
• you've been diagnosed with the condition more than twice
• you're pregnant
• you have a weakened immune system – particularly in severe cases or cases affecting children

Causes of shingles

Most people have chickenpox in childhood, but after the illness has gone, the varicella-zoster virus remains dormant (inactive) in the nervous system. The immune system keeps the virus in check, but later in life it can be reactivated and cause shingles.

It's possible to have shingles more than once, but it's very rare to get it more than twice. 

It's not known exactly why the shingles virus is reactivated at a later stage in life, but most cases are thought to be caused by having lowered immunity (protection against infections and diseases).

This may be the result of:

• old age – as you age, your immunity may decrease, and shingles most commonly occurs in people over 70 years old
• physical and emotional stress – the chemicals released by your body when you're stressed can prevent your immune system working properly
• HIV and AIDS – people with HIV are much more likely to get shingles than the rest of the population because their immune system is weak
• recently having a bone marrow transplant – the conditioning you require before the transplant weakens your immune system
• recently having an organ transplant – you may need to take medication to suppress your immune system so your body accepts the donated organ
• chemotherapy – chemotherapy medication, often used to treat cancer, can temporarily weaken your immune system

However, young people who appear otherwise healthy can also sometimes develop shingles.

Is shingles contagious?

It's not possible to catch shingles from someone with the condition or from someone with chickenpox. However, you can catch chickenpox from someone with shingles if you haven't had chickenpox before.

The blisters that form contain live virus. If a person who has never had chickenpox makes direct contact with an open blister or something with the fluid on it, they can contract the virus and develop chickenpox.

Preventing the spread of the virus

If you have shingles, you're contagious until the last blister has dried and scabbed over. To help prevent the virus being passed on, avoid sharing towels or flannels, swimming, or playing contact sports. You should also avoid work or school if your rash is weeping (oozing fluid) and can't be covered.

Chickenpox can be particularly dangerous for certain groups of people. If you have shingles, avoid:

• women who are pregnant and haven't had chickenpox before as they could catch it from you, which may harm their unborn baby
• people who have a weak immune system, such as someone with HIV or AIDS
• babies less than one month old, unless it's your own baby, in which case your baby should have antibodies (proteins that fight infection) to protect them from the virus

Treating shingles

Although there's no cure for shingles, treatment is available to relieve the symptoms until the condition resolves. Most cases of shingles last around two to four weeks.

Treatment for shingles can include:

• covering the rash with clothing or a non-adherent (non-stick) dressing to reduce the risk of other people becoming infected with chickenpox - as it's very difficult to pass the virus on to someone else if the rash is covered
• painkilling medication, - such as paracetamol, ibuprofen or codeine
• antiviral medication to stop the virus multiplying - although not everyone will need this

Read more about treating shingles

Complications of shingles

Shingles can sometimes lead to complications, such as postherpetic neuralgia. This is where severe nerve pain lasts for several months or more after the rash has gone.

Complications such as this are usually in elderly people who have had the condition and those with a weakened immune system.

Read more about the complications of shingles

The shingles vaccine

It's not always possible to prevent shingles, but a vaccine called Zostavax can reduce your chances of developing the condition.

If you still develop shingles after having this vaccine, it may be milder and last for a shorter time than usual.

This vaccine's now routinely offered in Scotland as a single injection to people aged 70.

Read more about shingles vaccination

This vaccine's now routinely offered in Scotland as a single injection to people aged 70.

Read more about shingles vaccination

Ophthalmic shingles

Some cases of shingles can affect one of the eyes and are known as ophthalmic shingles. This occurs when the virus is reactivated in part of the trigeminal nerve, a nerve that controls sensation and movement in your face.

Symptoms can include:

• a rash over your forehead, nose and around your eye
• conjunctivitis – inflammation of your eye that causes it to become red and watery with a sticky coating on your eyelashes
• a red eye
• problems with your vision

Symptoms of shingles

An episode of shingles typically lasts around two to four weeks. The main symptoms are pain, followed by a rash.

Any part of your body can be affected, including your face and eyes, although the chest and abdomen (tummy) are the most common areas where shingles develops.

Early symptoms

In some cases, shingles may cause some early (prodromal) symptoms that develop a few days before the painful rash first appears. These early symptoms can include:

• a headache
• burning, tingling, numbness or itchiness of the skin in the affected area
• a feeling of being generally unwell
• a high temperature (fever)

Not everyone will experience these prodromal symptoms. A high temperature is particularly uncommon.

Pain

Eventually, most people with shingles experience a localised "band" of pain in the affected area.

The pain can be a constant, dull or burning sensation and its intensity can vary from mild to severe. You may have sharp stabbing pains from time to time, and the affected area of skin will usually be tender.

Pain is less common in young healthy people and is rare in children. It usually starts a few days before the rash appears and can remain for a few days or weeks after the rash has healed.

Rash

The shingles rash usually appears on one side of your body and develops on the area of skin related to the affected nerve.

Initially, the shingles rash appears as red blotches on your skin before developing into itchy blisters similar in appearance to chickenpox.

New blisters may appear for up to a week, but a few days after appearing they become yellowish in colour, flatten and dry out.

Scabs then form where the blisters were, which may leave some slight scarring. It usually takes two to four weeks for the rash to heal completely.

When to seek medical advice

Shingles is not usually serious, but you should see your GP as soon as possible if you recognise the symptoms. Early treatment may help reduce the severity of your symptoms and the risk of developing complications.

You should also see your GP if you are pregnant or have a weakened immune system (the body's natural defence system) and you think you have been exposed to someone with chickenpox or shingles and haven't had chickenpox before.

Causes of shingles

Shingles is caused by the reactivation of the varicella-zoster virus, which is the virus that causes chickenpox.

After you have had chickenpox, the varicella-zoster virus lies dormant (inactive) inside your body. It can become reactivated at a later stage and cause shingles.

It is not known exactly why the virus is reactivated, but it is linked to having lowered immunity (protection against infection and diseases).

Your immunity to illness and infection can become lowered if there is a problem with your immune system (the body's natural defence system). This can happen as a result of:

• old age – as you age, your immunity may decrease, and shingles most commonly occurs in people over 70 years old
• physical and emotional stress – the chemicals released by your body when you are stressed can prevent your immune system working properly
• HIV and AIDS – people with HIV are much more likely to get shingles than the rest of the population because their immune system is weak
• recently having a bone marrow transplant – the conditioning you require before the transplant will weaken your immune system
• recently having an organ transplant – you may need to take medication to suppress your immune system so your body accepts the donated organ
• chemotherapy – chemotherapy medication, often used to treat cancer, can temporarily weaken your immune system

However, young people who appear otherwise healthy can also sometimes develop shingles.

Is shingles contagious?

It is not possible to catch shingles from someone else with the condition, or from someone with chickenpox.

However, it is possible for someone who has never had chickenpox to catch it from someone with shingles, as the shingles blisters contains the live virus.

In the UK, chickenpox is so common during childhood that 9 out of 10 adults have already had it and will not be at risk from someone with shingles.

Catching chickenpox

The blisters that develop as a result of shingles contain virus particles. If you have not had chickenpox before, you can catch it from direct contact with the fluid from the blisters of someone who has shingles, or from something that has the fluid on it, such as bed sheets or a towel.

If you have shingles, you are contagious until the last blister has scabbed over. This will usually occur after about 10 to 14 days.

Preventing the virus spreading

If you have the shingles rash, do not share towels or flannels, go swimming, or play contact sports. This will help prevent the virus being passed on to someone who has not had chickenpox.

You should also avoid work or school if your rash is weeping (oozing fluid) and cannot be covered.

Chickenpox can be particularly dangerous for certain groups of people. If you have shingles, avoid:

• women who are pregnant and have not had chickenpox before as they could catch it from you, which may harm their unborn baby
• people who have a weak immune system, such as someone with HIV or AIDS
• babies less than one month old, unless it is your own baby, in which case your baby should have antibodies (proteins that fight infection) to protect them from the virus

Once your blisters have dried and scabbed over, you are no longer contagious and will not need to avoid anyone.

Diagnosing shingles

Your GP or pharmacist will normally be able to diagnose shingles from your symptoms and the appearance of your rash. Testing is not usually necessary.

Referral

It is uncommon for someone with shingles to be referred to a specialist for further assessment and treatment, but your GP may consider seeking specialist advice or referring you if:

• they think you may have a complication of shingles, such as meningitis or encephalitis
• shingles is affecting one of your eyes – there is a risk you could develop permanent vision problems if the condition is not treated quickly
• you have a weakened immune system – particularly in severe cases or cases affecting children
• you are pregnant
• a diagnosis is not certain

You may also be referred to a specialist if you have an unusually persistent case of suspected shingles that is not responding to treatment, or if you have been diagnosed with the condition more than twice.

Who might I see?

Who you are referred to will depend on your circumstances. It could be:

• a paediatrician (a specialist in the care of babies and children) if your child is affected
• an ophthalmologist (a doctor who specialises in treating eye conditions) if shingles is affecting one of your eyes
• your own consultant (a specialist in a particular area of medicine) if you have one for an existing medical condition such as HIV or AIDS

Treating shingles

There is no cure for shingles, but treatment can help ease your symptoms until the condition improves. In many cases, shingles gets better within around two to four weeks.

However, it's still important to see your GP or pharmacist as soon as possible if you recognise the symptoms of shingles, as early treatment may help reduce the severity of the condition and the risk of potential complications.

Self-care

If you develop the shingles rash, there are a number of things you can do to help relieve your symptoms, such as:

• keeping the rash as clean and dry as possible – this will reduce the risk of the rash becoming infected with bacteria
• wearing loose-fitting clothing – this may help you feel more comfortable
• not using topical (rub-on) antibiotics or adhesive dressings such as plasters – this can slow down the healing process
• using a non-adherent dressing (a dressing that will not stick to the rash) if you need to cover the blisters – this avoids passing the virus to anyone else

Calamine lotion has a soothing, cooling effect on the skin and can be used to relieve the itching.

If you have any weeping blisters, you can use a cool compress (a cloth or a flannel cooled with tap water) several times a day to help soothe the skin and keep blisters clean.

It's important to only use the compress for around 20 minutes at a time and stop using them once the blisters stop oozing. Don't share any cloths, towels or flannels if you have the shingles rash. 

Antiviral medication

As well as painkilling medication, some people with shingles may also be prescribed a course of antiviral tablets lasting 7 to 10 days. Commonly prescribed antiviral medicines include aciclovir, valaciclovir and famciclovir.

These medications cannot kill the shingles virus, but can help stop it multiplying. This may:

• reduce the severity of your shingles
• reduce how long your shingles lasts
• prevent complications of shingles, such as postherpetic neuralgia (although the evidence for this is uncertain)

Antiviral medicines are most effective when taken within 72 hours of your rash appearing, although they may be started up to a week after your rash appears if you are at risk of severe shingles or developing complications.

Side effects of antiviral medication are very uncommon, but can include:

• feeling sick
• vomiting
• diarrhoea
• abdominal (tummy) pain
• headaches
• dizziness

Who may be prescribed antiviral medication?

If you are over 50 years of age and have symptoms of shingles, it is likely you will be prescribed an antiviral medication.

You may also be prescribed antiviral medication if you have:

• shingles that affects one of your eyes
• a weakened immune system
• moderate to severe pain
• a moderate to severe rash

Pregnancy and antiviral medication

If you are pregnant and have shingles, it is likely your GP will discuss your case with a specialist to decide whether the benefits of antiviral medication significantly outweigh any possible risks. Shingles will not harm your unborn baby.

If you are under 50 years of age, you are at less risk of developing complications from shingles anyway, so you may not need antiviral medication.

Children and antiviral medication

Antiviral medication is not usually necessary for otherwise healthy children because they usually only experience mild symptoms of shingles and have a small risk of developing complications.

However, if your child has a weakened immune system, they may need to be admitted to hospital to receive antiviral medication directly into a vein (intravenously).

Painkilling medication

To ease the pain caused by shingles, your GP or pharmacist may recommend painkilling medication. Some of the main medications used to relieve pain associated with shingles are described below.

Paracetamol

The most commonly used painkiller is paracetamol, which is available without a prescription. Always read the manufacturer's instructions to make sure the medicine is suitable and you are taking the correct dose.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are an alternative type of painkilling medicine also available without a prescription.

However, NSAIDs may not be suitable if you:

• have stomach, liver or kidney problems, such as a stomach ulcer, or had them in the past
• have asthma
• are pregnant or breastfeeding

Ask your GP or pharmacist if you are unsure about whether you should take NSAIDs. 

Opioids

For more severe pain, your GP may prescribe an opioid, such as codeine. This is a stronger type of painkiller sometimes prescribed alongside paracetamol.

Occasionally, your GP may consider seeking specialist advice before prescribing an even stronger opioid, such as morphine.

Antidepressants

If you have severe pain as a result of shingles, you may be prescribed an antidepressant medicine. These medications are commonly used to treat depression, but they have also proven to be useful in relieving nerve pain, such as the pain associated with shingles.

The antidepressants most often used to treat shingles pain are known as tricyclic antidepressants (TCAs). Examples of TCAs most commonly prescribed for people with shingles are amitriptyline, imipramine and nortriptyline.

Side effects of TCAs can include:

• constipation
• difficulty urinating
• blurred vision
• dry mouth
• weight gain
• drowsiness

If you have shingles, you will usually be prescribed a much lower dose of TCAs than if you were being treated for depression. This will usually be a tablet to take at night. Your dose may be increased until your pain settles down.

It may take several weeks before you start to feel the antidepressants working, although this is not always the case.

Anticonvulsants

Anticonvulsants are most commonly used to control seizures (fits) caused by epilepsy, but they are also useful in relieving nerve pain.

Gabapentin is the most commonly prescribed anticonvulsants for shingles pain.

Side effects of these medications can include:

• dizziness
• drowsiness
• increased appetite
• weight gain
• feeling sick
• vomiting

As with antidepressants, you may need to take anticonvulsants for several weeks before you notice it working.

If your pain does not improve, your dose may be gradually increased until your symptoms are effectively managed.

Complications of shingles

Complications can sometimes occur as a result of shingles. They are more likely if you have a weakened immune system (the body's natural defence system) or are elderly.

Some of the main complications associated with shingles are described below.

Postherpetic neuralgia

Postherpetic neuralgia is the most common complication of shingles. It's not clear exactly how many people are affected, but some estimates suggest that as many as one in five people over 50 could develop postherpetic neuralgia as the result of shingles.

Postherpetic neuralgia can cause severe nerve pain (neuralgia) and intense itching that persists after the rash and any other symptoms of shingles have gone.

Types of pain experienced by people with postherpetic neuralgia include:

• constant or intermittent burning, aching, throbbing, stabbing, or shooting pain
• allodynia – where you feel pain from something that should not be painful, such as changes in temperature or the wind
• hyperalgesia – where you are very sensitive to pain

Postherpetic neuralgia sometimes resolves after around three to six months, although it can last for years and some cases can be permanent. It can be treated with a number of different painkilling medicines.

Eye problems

If one of your eyes is affected by shingles (ophthalmic shingles), there is a risk you could develop further problems in the affected eye, such as:

• ulceration (sores) and permanent scarring of the surface of your eye (cornea)
• inflammation of the eye and optic nerve (the nerve that transmits signals from the eye to the brain)
• glaucoma – where pressure builds up inside the eye

If not treated promptly, there is a risk that ophthalmic shingles could cause a degree of permanent vision loss.

Ramsay Hunt syndrome

Ramsay Hunt syndrome is a complication that can occur if shingles affects certain nerves in your head.

In the US, Ramsay Hunt syndrome is estimated to affect 5 in 100,000 people every year and it may affect a similar number of people in the UK.

Ramsay Hunt syndrome can cause:

• earache 
• hearing loss 
• dizziness
• vertigo (the sensation that you or the environment around you is moving or spinning)
• tinnitus (hearing sounds coming from inside your body, rather than an outside source) 
• a rash around the ear
• loss of taste
• paralysis (weakness) of your face

Ramsay Hunt syndrome is usually treated with antiviral medication, corticosteroids and painkilling medication.

The earlier treatment is started, the better the outcome. Around three-quarters of people given antiviral medication within 72 hours of the start of their symptoms usually make a complete recovery.

If treatment is delayed, only about half of those treated will recover completely.

Those who don't make a full recovery may be left with permanent problems, such as a degree of permanent facial paralysis or hearing loss.

Other complications

A number of other possible problems can also sometimes develop as a result of shingles, including:

• the rash becoming infected with bacteria – see your GP if you develop a high temperature, as this could be a sign of a bacterial infection
• white patches (a loss of pigment) or scarring in the area of the rash
• inflammation of the lungs (pneumonia), liver (hepatitis), brain (encephalitis), spinal cord (transverse myelitis), or protective membranes that surround the brain and spinal cord (meningitis) – these complications are rare, however 

Shingles is rarely life threatening, but complications such as those mentioned above mean that around 1 in every 1,000 cases in adults over the age of 70 is fatal.