Can You Have Shingles Without a Rash?

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Most people who develop shingles have a tell-tale rash on one side of their body. But it’s possible to have shingles without a rash. This is known as zoster sine herpete (ZSH) or internal shingles. It is caused by the same virus, varicella-zoster virus (VZV), that causes shingles (herpes zoster). 

While it doesn’t produce a painful, itching rash, internal shingles does cause other symptoms. Because it may not be recognized as a shingles infection, the frequency of ZSH infections may be higher than previously thought.

Young Man Scratching Forearm With Fingers

Getty Images / Oscar Wong

Early Shingles 

With shingles or herpes zoster, symptoms typically start before the rash occurs. Most people will experience some sort of tactile sensation in the area where the rash will eventually appear. They may feel itching or pain. The feeling can go on for several days before the rash appears. 

Other early symptoms may include:

  • Headache
  • Fever and chills
  • Gastrointestinal distress

Zoster Sine Herpete (ZSH)

This type of shingles does not produce a rash. Because there’s no evident rash, it can be more challenging to diagnose. 

Risk Factors

People at risk of getting shingles include:

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

Symptoms

Symptoms of ZSH include:

  • Nerve pain 
  • Itching without rash
  • Burning sensation 
  • Lesions in mucous membranes, an ear canal, and internal organs like the stomach and intestines 

Some people describe the pain as being a deep sensation affecting the muscles and joints. People with internal lesions may experience abdominal pain or hoarseness. 

Treatment

There’s not a lot of research on shingles without a rash. However, the typical treatment involves antiviral medications such as acyclovir. 

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

  • Nonsteroidal anti-inflammatories (NSAIDs)
  • Opioids
  • Tricyclic antidepressants
  • Corticosteroids
  • Tramadol 
  • Nerve blocks

Complications

Some people with shingles may develop serious complications. One potential complication is postherpetic neuralgia (PHN). According to the Centers for Disease Control and Prevention (CDC), PNH affects about 10% to 18% of people who develop shingles. Older people are more likely to develop this complication. 

PHN involves pain that continues even after shingles is gone. It can produce lifelong effects that interfere with a person’s quality of life.

One case study suggests that complications such as PHN are more likely in people who develop shingles without a rash. This complication may be more likely because people who don’t have a rash may ignore their symptoms and not seek prompt treatment. 

Other potential complications may include:

  • Meningitis 
  • Ramsay Hunt syndrome
  • Polyneuritis cranialis (PNC), which affects the cranial nerves
  • Cerebellitis, an inflammation of the cerebellum
  • Myelopathy, a spinal cord injury caused by compression

Diagnosis

If you are experiencing nerve pain without a rash, you may have internal shingles. Of course, a doctor will want to rule out other causes of paralysis and nerve pain before diagnosing you with shingles. 

A lab test can help diagnose internal shingles. It’s possible to get a false negative result. Still, lab testing is a helpful tool for detecting VZV when a person does not have any apparent symptoms. 

To perform a lab test, a healthcare practitioner will need a sample. Samples may consist of:

  • A lesion swab
  • Cerebrospinal fluid
  • Blood
  • Saliva 

According to the CDC, the polymerase chain reaction (PCR) test is the most useful for detecting VZV in people who don’t have a rash. Another test is the direct fluorescent antibody (DFA) test. However, it’s not as sensitive as the PCR test.

Coping 

It may be difficult to recognize that you have internal shingles. The first step is to see a doctor to get a diagnosis. Coping with the pain and discomfort brought on by shingles may involve taking medications prescribed by a healthcare professional. Thankfully, with treatment, shingles should resolve within about three to five weeks, on average.

A Word From Verywell

While shingles usually produces a rash and subsequent blister-like lesions, some people who develop shingles may not have a rash. 

The absence of a rash makes diagnosis difficult. It also means if you are infected, you may go around spreading the virus without even knowing it. You’re also more likely to develop complications if you ignore potential early symptoms of internal shingles. 

If you experience burning pain and itching specific to one side of your body, you should see a medical professional to find out if you have shingles. Remember, you cannot get shingles unless you’ve had chickenpox. If you’ve never had chickenpox, your symptoms are the result of another condition. 

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  2. Centers for Disease Control and Prevention. Shingles: signs and symptoms. Reviewed July 1, 2019.

  3. Centers for Disease Control and Prevention. Complications of shingles. Reviewed July 1, 2019.

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  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. Centers for Disease Control and Prevention. Shingles: diagnosis & testing. Reviewed September 19, 2019.

  7. National Institute on Aging. Shingles. Reviewed February 1, 2021.

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