Can You Have Shingles Without a Rash?

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

Most people who develop shingles have a telltale rash on one side of their body, but it is 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

Typical Early Shingles Symptoms 

The first signs of shingles caused by herpes zoster typically start before the classic shingles rash occurs.

For most people, the first sign of shingles is some sort of tactile sensation—like itching or pain—in the area where the rash will eventually appear. The feeling can go on for several days before the rash appears. 

Other early shingles symptoms may include:

  • Headache
  • Fever and chills
  • Gastrointestinal distress

Symptoms of Shingles Without a Rash

Because it doesn't cause a shingles rash, zoster sine herpete can be more challenging to diagnose. 

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 

One research study showed that ZSH pain was more intense than pain associated with traditional shingles (with a rash). 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.

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:

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

How Long Shingles Lasts

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

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 ZSH. However, 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 shingles rash. Another test is the direct fluorescent antibody (DFA) test. However, it’s not as sensitive as the PCR test.

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

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.

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. 

Frequently Asked Questions

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

    Yes. Shingles (with or without a rash) is caused when the same virus responsible for chickenpox, known as varicella-zoster virus (VZV), reactivates in the body. The exact reason for why some people experience a rash while others do not is unknown.

  • What conditions look similar to shingles?

    There are not many conditions that look similar to shingles. The rash produced by shingles is distinct from many other rashes, making it unlikely for a healthcare provider to misdiagnose the shingles virus. 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?

    One of the primary symptoms of shingles is pain. The level of pain caused by shingles varies by person. However, a common complication of shingles is long-term nerve pain, or postherpetic neuralgia (PHN). It can affect more than 10 percent of people with shingles. PHN can last for months or years after shingles resolves, and typically affects people over the age of 40.

  • Is shingles without a rash contagious?

    In general, no. A shingles rash can spread the varicella-zoster virus to people who do not have immunity against chickenpox. If you don't have a rash, then you can't spread the virus.

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8 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.
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  4. National Institute on Aging. Shingles.

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  8. Centers for Disease Control and Prevention. Shingles: Diagnosis & Testing.

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