Skin Health Fungal, Bacterial & Viral Infections Shingles Shingles Guide Shingles Guide Symptoms Causes Diagnosis Treatment Prevention Coping Caregiving Causes and Risk Factors of Shingles By James Myhre & Dennis Sifris, MD Dennis Sifris, MD, is an HIV specialist and Medical Director of LifeSense Disease Management. James Myhre is an American journalist and HIV educator. Learn about our editorial process James Myhre & Dennis Sifris, MD Medically reviewed by Medically reviewed by Andy Miller, MD on July 19, 2019 Andy Miller, MD, is board-certified in infectious disease and internal medicine. He is an associate professor at Weill Cornell Medicine, associate attending physician at the Hospital for Special Surgery and New York Presbyterian Hospital and a fellow of the Infectious Disease Society of America. Learn about our Medical Review Board Andy Miller, MD Updated on July 23, 2019 Print Table of Contents View All Virus Reactivation Common Causes Risk Factors Next in Shingles Guide How Shingles Is Diagnosed Shingles results from reactivation of the varicella zoster virus (VZV), which, when it first infects the body, causes chickenpox and then goes into hiding in the nervous system. Why the virus re-emerges isn't entirely understood, but there are theories. Shingles is most common in older people, but anyone with the varicella zoster virus is at risk. In fact, reduced immunity is considered the biggest risk factor for shingles. Researchers believe that stress could also play a role for some people. Shingles is an especially unpleasant illness. It causes a painful and unsightly skin rash, as well as potential long-term complications, the most common one being a condition known as postherpetic neuralgia (PHN), which is characterized by a burning sensation where the shingles rash once was. That's why it's important to understand what causes chickenpox, who's most at risk of coming down with it, and how to protect yourself if you're exposed. © Verywell, 2018 Virus Reactivation After a person recovers from chickenpox, the symptoms disappear but the varicella virus that caused it retreats to cells in the nervous system, where it can hang out for decades without causing problems. When the virus re-emerges, it typically reactivates in clusters of nerve cells in the peripheral nervous system called a sensory ganglion. The ganglia most likely to host varicella are those in the cervical, thoracic, and lumbar spine. Varicella also often affects the trigeminal ganglion that provides sensation to the face. As its name suggests, this particular clump of nerves has three branches. The one associated with eye function, the ophthalmic branch, is 20 times more likely than the other two to be affected. The area with the particular nerve cells in which the virus reawakens is where the shingles symptoms—extreme pain, unsightly rash—will be concentrated. This photo contains content that some people may find graphic or disturbing. See Photo DermNet / CC BY-NC-ND Since the nervous system consists of tree-like branches of nerves, the blisters will follow the particular path of the nerves affected. That's why a shingles rash often resembles a swath of blisters in a very specific area, rather than spread all over the body (as in chickenpox). Shingles Doctor Discussion Guide Get our printable guide for your next doctor's appointment to help you ask the right questions. Download PDF Email the Guide Send to yourself or a loved one. Sign Up This Doctor Discussion Guide has been sent to {{form.email}}. There was an error. Please try again. Common Causes What prompts the varicella virus to reactivate isn't entirely understood. The virus is a member of the same family of microbes that cause herpes infections, such as genital herpes and cold sores, which also tend to come and go, so it's not surprising that varicella would behave similarly. The big difference is, while herpes infections can recur multiple times, most people only experience shingles once. In any event, there are two main causes of shingles: Weakened Immune System There is a clear association between shingles and weakened immunity to infection. Even though the varicella virus is not invading the body for the first time, the immune system still is responsible for keeping it at bay. Sometimes, however, it's unable to do that. What this means is that the varicella virus, which after causing the chickenpox rash in the skin had traveled to ganglia in the nervous system, becomes active again and heads back to the skin. Since it travels along the nervous system, the rash stays on one side of the body and appears in the shape of a strip or band that aligns with the shape of the nerves below the skin. Stress There's a long-held hypothesis that chronic stress or even a single episode of emotional distress can trigger the dormant varicella virus to become active again and bring on a shingles outbreak. Given that stress often is linked to any number of changes in health, including gastrointestinal problems, migraines, and eczema, this notion is not at all far-fetched. In fact, there is some evidence to support it. For example, an often-cited 1998 study of otherwise healthy adults over 60 found that those who had had shingles were more than twice as likely to have had a negative life event within six months of the outbreak as peers who didn't have shingles. When asked about events within the past two to three months specifically, those in the shingles group reported the same amount of negative life events as their unaffected counterparts. This suggests that perceiving an event as stressful, rather than the event itself, may be linked to increased rate of shingles. More recent research has largely supported this concept. Some have taken this to mean that the overall perception of stress and the ability to cope with it, may add to the underlying factors that create the perfect storm for a shingles outbreak. Risk Factors Since compromised immunity is the most common trigger for a latent varicella virus to become active, any factor associated with a weakened immune system can increase the risk of shingles. Important risk factors for shingles include: Being 50 or over. With age, there is a natural decline in cell-mediated immunity.Infection from human immunodeficiency virus (HIV). Although most people who develop shingles have the infection just once, it's not uncommon for someone with HIV to have recurrent shingles infections.A chronic medical condition. Cancer (especially leukemia or lymphoma) or diabetes are examples.Medication that suppresses the immune system. Some examples of these include chemotherapy drugs and systemic steroids, such as prednisone.Having an organ transplant. The medications that are necessary for preventing organ rejection suppress the immune response. Note that many of these risk factors are as likely to apply to young people and children as they are to older people. So, even though shingles often is regarded as an illness of advancing age, this isn't always the case. How Shingles Is Diagnosed Was this page helpful? Thanks for your feedback! Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. Sign Up You're in! Thank you, {{form.email}}, for signing up. There was an error. Please try again. What are your concerns? Other Inaccurate Hard to Understand Submit Article Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Harpaz R, Leung JW, Brown CJ, Zhou FJ. Psychological stress as a trigger for herpes zoster: might the conventional wisdom be wrong?. Clin Infect Dis. 2015;60(5):781-5. Nair PA, Patel BC. Herpes Zoster (Shingles) [Updated 2019 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441824/ Shrestha M, Chen A. Modalities in managing postherpetic neuralgia. Korean J Pain. 2018;31(4):235–243. doi:10.3344/kjp.2018.31.4.235 Gilden D, Nagel M, Cohrs R, Mahalingam R, Baird N. Varicella Zoster Virus in the Nervous System. F1000Res. 2015;4:F1000 Faculty Rev-1356. Published 2015 Nov 26. doi:10.12688/f1000research.7153.1 Gilden D, Mahalingam R, Nagel MA, Pugazhenthi S, Cohrs RJ. Review: The neurobiology of varicella zoster virus infection. Neuropathol Appl Neurobiol. 2011;37(5):441–463. doi:10.1111/j.1365-2990.2011.01167.x Sampathkumar P, Drage LA, Martin DP. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009;84(3):274–280. doi:10.1016/S0025-6196(11)61146-4 Cohen KR, Salbu RL, Frank J, Israel I. Presentation and management of herpes zoster (shingles) in the geriatric population. P T. 2013;38(4):217–227. Gilden D, Cohrs RJ, Mahalingam R, Nagel MA. Neurological disease produced by varicella zoster virus reactivation without rash. Curr Top Microbiol Immunol. 2010;342:243–253. doi:10.1007/82_2009_3 National Institute of Neurological Disorders and Stroke. Singles: Hope Through Research. August 13, 2019 Schmader K, George LK, Burchett BM, Hamilton JD, Pieper CF. Race and stress in the incidence of herpes zoster in older adults. J Am Geriatr Soc. 1998;46(8):973-7. Rafael Harpaz, Jessica W. Leung, Cedric J. Brown, Fang Jun Zhou, Psychological Stress as a Trigger for Herpes Zoster: Might the Conventional Wisdom Be Wrong?, Clinical Infectious Diseases, Volume 60, Issue 5, 1 March 2015, Pages 781–785, https://doi.org/10.1093/cid/ciu889 Kawai K, Yawn BP. Risk Factors for Herpes Zoster: a Systematic Review and Meta-Analysis. Open Forum Infect Dis. 2017;4(Suppl 1):S313–S314. Published 2017 Oct 4. doi:10.1093/ofid/ofx163.733 Oxman MN. Herpes zoster pathogenesis and cell-mediated immunity and immunosenescence. J Am Osteopath Assoc. 2009;109(6 Suppl 2):S13-7. Hansson E, Forbes HJ, Langan SM, Smeeth L, Bhaskaran K. Herpes zoster risk after 21 specific cancers: population-based case-control study. Br J Cancer. 2017;116(12):1643–1651. doi:10.1038/bjc.2017.124 Pavlopoulou ID, Poulopoulou S, Melexopoulou C, Papazaharia I, Zavos G, Boletis IN. Incidence and risk factors of herpes zoster among adult renal transplant recipients receiving universal antiviral prophylaxis. BMC Infect Dis. 2015;15:285. Published 2015 Jul 24. doi:10.1186/s12879-015-1038-1 Additional Reading Blanks, L.; Polydefkis, M.; Moore, R.; et al. Herpes Zoster Among Persons Living With HIV in the Current Antiretroviral Therapy Era. J Acquir Immune Defic Syndr. Oct 1, 2012; 61(2):203-207. DOI: 10.1097/QAI.0b013e318266cd3c Eshleman Emily; Shahzad, Aamir; and Chohrs, Randall J. Varicella Zoster Virus Latency. Future Virol. Mar 2011; 6(3): 341-355. Harpaz, R.; Leung, J.; Brown, C.; et al. Psychological Stress as a Trigger for Herpes Zoster: Might the Conventional Wisdom Be Wrong? Clinical Infectious Diseases. November 10, 2014; 60(5):781-785. DOI: org/10.1093/cid/ciu889. Irwin, MR; Olmstead, R; Oxman, MN. Augmenting Immune Responses to Varicella Zoster Virus in Older Adults: A Randomized, Controlled Trial of Tai Chi. J Am Geratr Soc. Apr 2007;55(4):511-7. DOI: 10.1111/j.1532-5415.2007.01109.x Ke CC, Lai HC, Lin CH, Hung CJ, Chen DY, Sheu WH, Lui PW. Increased Risk of Herpes Zoster in Diabetic Patients Comorbid with Coronary Artery Disease and Microvascular Disorders: A Population-Based Study in Taiwan. PLoS One. 2016 Jan 11;11(1):e0146750. DOI: 10.1371/journal.pone.0146750. Schmader, K, George, LK, Burchett, BM, Hamilton, JD, and Pieper, CF. Race and Stress in the Incidence of Herpes Zoster in Older Adults. J Am Geriatr Soc. Aug 1998; 46(8): 973-977.