Can You Have Shingles Without a Rash?

Zoster sine herpete (ZSH) is a rare form of shingles that doesn't cause a rash

Most people with shingles have a telltale rash on one side of their body, but it is possible to have shingles without a rash. It's called zoster sine herpete (ZSH) or internal shingles. It's caused by the same virus, varicella-zoster virus (VZV), that causes chickenpox and typical shingles (herpes zoster). 

Internal shingles still causes pain and itching—just without the rash—along with other symptoms. Because healthcare providers may not recognize it as a shingles infection, ZSH infections may be more common than previously thought.

This article explores the differences in symptoms, the additional complications ZSH can cause, how it's diagnosed and treated, and how you can cope with it.

Young Man Scratching Forearm With Fingers

Oscar Wong / Getty Images

Why Two Types of Shingles?

Most people are infected with VZV at some point. This type of virus stays in your body forever, but it lies dormant most of the time. When it reactivates, it causes shingles.

The infection affects a single nerve and the itching and pain (and rash, in a typical case) are confined to the path of that nerve. That generally means symptoms in a stripe on one side of your body.

Typical shingles develops from an infection in a sensory nerve (one that runs close to the surface of your skin and provides sensation).

In internal shingles, the infected nerve is deeper in the body, often in the digestive organs. It doesn't cause a rash because those nerves don't connect to your skin.

Symptoms: Typical Shingles 

For most people, the first sign of shingles is some sort of tactile sensation—like itching or shooting, burning pain—in the area where the rash will appear, possibly several days later. 

Other early shingles symptoms may include:

  • Headache
  • Fever and chills
  • Upset stomach

Eventually, fluid-filled blisters develop on the skin.

Symptoms: Internal Shingles

Internal shingles doesn't have the same distinct two-phased presentation. Like traditional shingles, though, it affects the area controlled by a single nerve.

Internal shingles symptoms include:

  • Nerve pain 
  • An area of numbness
  • Itchy, burning sensations
  • Headache
  • Fatigue
  • General achiness
  • Lesions in mucous membranes, an ear canal, and internal organs (e.g., stomach, intestines) 
  • Abdominal pain or hoarseness caused by lesions

One study suggested internal shingles pain is even more intense than traditional shingles pain. Some people say it's a deep sensation that affects their muscles and joints.

How Long Shingles Lasts

With treatment, shingles should only last three to five weeks.

Complications

Some people with either type of shingles may develop serious complications.

Postherpetic Neuralgia

Between 10% and 18% of people who have shingles are left with postherpetic neuralgia (PHN). It's more common in older people. 

With PHN, pain continues even after shingles is gone. It can produce lifelong effects that interfere with your quality of life.

Other Complications

Other potential complications include:

  • Meningitis 
  • Ramsay Hunt syndrome
  • Polyneuritis cranialis (PNC), which affects the cranial nerves (nerves of the head)
  • Cerebellitis, an inflammation of the cerebellum (a region of the brain)
  • Myelopathy, a spinal cord injury caused by compression
  • Potentially fatal problems such as encephalitis and stroke

One case study suggests complications such as PHN are more likely in people who develop shingles without a rash. This may be because, without a rash, you're less likely to go to a healthcare provider right away. 

Diagnosis

If you have a strip of nerve pain without a rash, you may have internal shingles. You should see a healthcare provider right away for diagnosis and treatment.

A lab test can help diagnose a ZSH infection. It's especially helpful for detecting the virus when you don't have conventional symptoms. 

The test can use samples from:

The polymerase chain reaction (PCR) test is the most useful for detecting VZV in people without a shingles rash. A direct fluorescent antibody (DFA) test is sometimes used but it's not as sensitive as PCR.

Risk Factors

People at higher risk of getting shingles include:

  • Older adults
  • People with compromised immune systems
  • People with certain systemic diseases, such as kidney disease

Differential Diagnoses

Differential diagnosis is medical jargon for "what else could it be?" Differential diagnoses for the type of pain caused by ZSH include:

The location of your pain may suggest other conditions, as well. Your healthcare provider may perform multiple tests to rule out possible causes of your symptoms.

Internal Shingles Treatment

Research on ZSH treatments is limited. However, the typical treatment involves antiviral medications such as Valtrex (valacyclovir) or Zovirax (acyclovir).

Pain management is also an essential part of treating internal shingles. Some drugs that may help with nerve pain include:

Lesions and complications should also be treated.

Prevalence

In the U.S., typical shingles affects three or four out of every thousand people each year (about a million cases). More than 95% of young adults carry the virus. Experts don't know how common internal shingles is but it's likely underdiagnosed.

Coping 

Coping with the pain of shingles, regardless of type, can be harder than just taking pain medications. The discomfort may disrupt your life and make it hard to sleep. It can also cause depression.

You may want to ask your healthcare provider about a sleep aid or antidepressants.

Topical pain and itch relievers and oatmeal baths that help some people with typical shingles may or may not be effective for internal shingles, but they're generally safe to try.

If you're struggling to cope, talk to family and friends about what you're going through. You may also want to find a support group, online or in your community, for people with shingles, PHN, or chronic pain.

Summary

Internal shingles doesn't involve a rash like typical shingles. This is because it affects nerves that are deeper in the body and don't connect to the skin. It still causes an itch and severe pain, and may even be more painful than a shingles rash.

Internal shingles is harder to recognize so people may go to a healthcare provider later, and healthcare providers may misdiagnose it. This delays treatment and can lead to complications such as postherpetic neuralgia.

Internal shingles is treated with antivirals and a variety of medications that help control pain. You may benefit from antidepressants and sleep drugs, as well. A support group may help you cope.

Frequently Asked Questions

  • Are classic shingles and internal shingles caused the same way?

    Yes. All cases of shingles are caused when varicella-zoster virus (VZV), the same virus responsible for chickenpox, reactivates in the body.

  • What conditions look similar to shingles?

    Not many. The rash produced by shingles is distinct, making it unlikely for a healthcare provider to misdiagnose it.

    Since internal shingles does not leave a skin rash, it can be trickier to diagnose and may require a lab test.

  • How painful is shingles?

    Shingles pain can range from dull and mild to severe and burning.

    A shingles complication called postherpetic neuralgia (PHN) can cause intense, long-term nerve pain. This can last for months or years after shingles resolves.

  • Is shingles without a rash contagious?

    In general, no. A shingles rash can spread the varicella-zoster virus to other people. If you don't have a rash, then you can't spread the virus.

9 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.
  1. Centers for Disease Control and Prevention. Shingles: Signs and symptoms.

  2. Drago F, Herzum A, Ciccarese G, Broccolo F, Rebora A, Parodi A. Acute pain and postherpetic neuralgia related to Varicella zoster virus reactivation: Comparison between typical herpes zoster and zoster sine herpete. J Med Virol. 2019;91(2):287-295. doi:10.1002/jmv.25304

  3. National Institutes of Health, National Institute on Aging. Shingles.

  4. Centers for Disease Control and Prevention. Complications of shingles.

  5. Gilden, D, et al. Neurological disease produced by varicella zoster virus reactivation without rash. Curr Top Microbiol Immunol. 2011;342:243-253. doi:10.1007/82_2009_3

  6. Lee, JY, et al. Spinal arteriovenous malformation masquerading zoster sine herpete. Korean J Pain. 2013;26(1):72-75. doi:10.3344/kjp.2013.26.1.72

  7. Centers for Disease Control and Prevention. Shingles: Diagnosis & testing.

  8. University of Pennsylvania: Penn Medicine. Nerve root pain.

  9. Harte SE, Harris RE, Clauw DJ. The neurobiology of central sensitizationJ Applied Behav Res. 2018 Jun;23(2):e12137. doi:10.1111/jabr.12137

Additional Reading

By Steph Coelho
Steph Coelho is a freelance health writer, web producer, and editor based in Montreal. She specializes in covering general wellness and chronic illness.