Signs and Symptoms of Shingles Rash

The most well-known symptom of shingles (herpes zoster) is a severe skin rash. However, before any signs of blisters, you may feel as if you're only coming down with the flu.

You may experience chills and fever, as well as intense pain. It's not until a few days later that a rash finally joins these shingles symptoms, with clusters of tiny, pimple-like blisters progressing quickly once they appear.

If you're familiar with the signs and symptoms of shingles, you'll be able to recognize what's going on, get a diagnosis quickly, and deal with it without delay. Doing so makes you less likely to develop complications, such as nerve issues or bacterial skin infections.

This article reviews the symptoms of shingles and what you need to know about potential complications.

Shingles Symptoms Before Rash

Shingles develops in two stages. The first is called the prodromal period.

Shingles is a reactivation of the varicella virus, which is what causes chickenpox. After an initial infection, the virus lays dormant in the body. Once reactivated, which can happen years down the line, shingles results.

Often, the earliest signs this is occurring are similar to what you'd expect at the start of any infection. These symptoms sometimes occur at times when you're feeling stressed or run down. They are also systemic, meaning they affect the whole body.

You may assume you're just overtired or coming down with a cold when you actually have shingles.

The most telling first symptom of shingles typically is the pain. Often excruciating, the discomfort has been described as burning, stinging, tingly, prickly, itchy, numbing, achy, or shooting. It can be persistent or intermittent, but will always be limited to one side of the body.

Because the pain from shingles is localized, it can be mistaken for other conditions depending on where it's focused.

For example, a stabbing or persistent pain on one side of the lower back may mistakenly be attributed to sciatica or a kidney problem. Shingles pain around the lips could suggest a cold sore coming on, while pain focused on the eye or ear might seem like the start of a migraine.

Appearance of the Shingles Rash

The eruptive stage of shingles begins a few days later. This is when a rash appears.

The skin in the area of the prodromal pain caused by shingles will often be sensitive to the touch and reddish in appearance. As these symptoms get worse, it may begin to feel like a sunburn.

Within three to five days of the initial pain, a few tiny pimple-like spots appear and quickly multiply into clusters, forming a rash that feels prickly to the touch.

From there, sometimes within hours, the pimples develop into water-filled blisters, or vesicles, that then consolidate into larger blisters. Often, redness and swelling accompany the rash.

The shingles rash looks very much like the chickenpox rash, with a key difference: Chickenpox blisters are widely scattered over the entire body. With shingles, the rash almost always occupies a finite strip of skin.

Ultimately, the pain of shingles may get so excruciating that simply grazing the skin with clothing can set off what feels like an electric shock.

Where a Shingles Rash Forms

A shingles rash typically occurs on the face, neck, or chest, on just one side of the body.

The affected area of skin is called a dermatome, a region supplied by the sensory fibers of a specific spinal nerve. Outbreaks can involve two adjacent dermatomes, but rarely two non-adjacent dermatomes.

The exception may be in people whose immune systems are severely comprised, such as those with advanced HIV infection. They're often at 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.

Common Complications

Aside from the discomfort that can come along with shingles, it is particularly concerning because of its potential complications.

Postherpetic Neuralgia

The most common complication of shingles is a potentially debilitating condition called postherpetic neuralgia (PHN) that develops when nerve fibers become damaged. It's characterized by persistent pain in the area where a shingles rash has been. For instance, when shingles affect nerves in the head, tenacious facial pain may continue for long after the rash clears up.

Symptoms of PHN can be severe enough to interfere with daily life and include:

• Burning, sharp, or deep, achy pain that lasts for three months or longer after the shingles rash has healed
• Allodynia (sensitivity to light touch): Even the sensation of clothing on the skin can be excruciating. 
• Itching and numbness
• Difficulty sensing temperature and vibration

Other risk factors include experiencing a particularly severe and painful shingles rash. Having the rash on the face or torso also increases the risk of the condition. 

Treating PHN can be complicated, but it's important, as the condition can lead to further complications such as depression, fatigue, trouble concentrating, sleep issues, and appetite loss. There's no one-size-fits-all approach, however, and it often takes several medications to relieve the pain and other symptoms. Among the drugs used most often to treat PHN are:

• Lidocaine patches (sold under the brand name Lidoderm)
• Capsaicin, a natural derivative of chili peppers, in the form of a cream or patch
• Anticonvulsant medications such as Neurontin (gabapentin) and Lyrica (pregabalin)
• Antidepressants, including Aventyl (nortriptyline) and Cymbalta (duloxetine)
• Opioids like Oxycontin (oxycodone) and morphine
• Steroid injections

Bacterial Skin Infections

The blisters caused by shingles can leave open sores, making skin vulnerable to microbes that can cause what the CDC describes as "bacterial superinfection of the lesions." The bugs most often responsible for such infections are Staphylococcus aureus and group A beta hemolytic streptococcus.

One bacterial skin infection sometimes associated with shingles is impetigo, which most often affects children. It starts with itchy sores that burst and then form honey-colored crusts. Impetigo is extremely contagious but can be treated effectively with antibiotics.

Cellulitis is another skin infection known to result from shingles. Unlike impetigo, which affects the outermost layer of skin, cellulitis is an infection of the deeper layers and even the tissue beneath the skin, according to the American Academy of Dermatology.

It starts with an area that's red, swollen, and feels warm and tender to the touch. If it's not treated, cellulitis can spread quickly and even affect the lymph nodes, eventually leading to a blood infection. As long as it's treated right away with oral antibiotics and good care of the affected skin, cellulitis is highly curable and unlikely to leave permanent damage.

Facial Pain and Eye Damage

Between 10% and 15% of the time, shingles affects the trigeminal ganglion—a triple-branched nerve that provides sensation to structures in the face. The medical term for head or facial pain due to shingles is "painful trigeminal neuropathy attributed to herpes zoster."

Specifically, the trigeminal ganglion involves the eye (the ophthalmic branch); the cheek (the maxillary branch); and the mandibular branch (the jaw). Of these, the ophthalmic branch is the one most commonly affected by herpes zoster. 

HZO can affect any part of the eye, from the optic nerve to the conjunctiva (the membrane that covers the front of the eye and lines the eyelid). Without antiviral treatment, almost half of people who have shingles near the eye will experience eye damage or even lose an eye, so it's vital to see an ophthalmologist immediately.

Uncommon Complications

Another potential, though uncommon, health problems caused by shingles include:

Ramsay Hunt Syndrome 

Otherwise known as herpes zoster oticus, this is inflammation of a facial nerve near one of the ears. The symptoms include facial paralysis, ear pain, and small, fluid-filled blisters (called vesicles) inside the ear canal. People with Ramsay Hunt often experience dizziness or lack of balance. The condition also can cause permanent hearing loss if not treated promptly.

Meningitis

This is an infection of the meninges. Symptoms include fever, severe headache, sensitivity to light, and achy muscles. Because this type of meningitis is caused by a virus, it is treated with antiviral medications.

Encephalitis

Like meningitis, this is a secondary viral infection. It affects the brain and can cause symptoms such as a headache, memory loss, fever, and changes in personality.

Motor Neuropathy

Normally the varicella virus affects only sensation in the skin, but, in rare cases, it can go deeper into muscle tissue, causing weakness or atrophy. Most patients experiencing motor neuropathy will regain motor function.

When to See a Doctor

If you suspect you have shingles, you should see a doctor right away. You can then begin appropriate treatment that will help relieve your symptoms, speed your recovery, and lower your risk of complications. This is especially important if you:

• Are over age 60
• Have a condition that has caused you to have a weakened immune system, such as HIV
• Take medication that may diminish your body's immune response (e.g. chemotherapy drugs, steroids, or immunosuppressants after an organ transplant)
• You share a home with someone who has a weakened immune system
• The rash is on your face: Blisters near your eye could lead to serious eye damage or even cause you to lose sight in that eye.

Shingles Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

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If while you're dealing with shingles you experience any of the following, let the doctor who's treating you know right away:

• You aren't getting relief from the pain with treatment.
• The pain doesn't go away after three to four weeks.
• The rash spreads beyond the initial area. 
• You begin to have symptoms of a secondary infection, such as a very high fever, chills, and severe headache.​

Your healthcare provider will help you determine the right treatment for you. This may include antiviral drugs, antidepressant medications, and pain medications.