Shingles without the rash?

Dear Alice,

Can one have shingles without any visible manifestation on the skin? Is the extreme sensitivity/pain sufficient or could that be the first symptom with rash to follow? How about several days of pain on the skin/sensitivity to touch without the rash or any other manifestation?

— Friend of Stricken

Dear Friend of Stricken,

There is, in fact, a condition called zoster sine herpete (ZSH) that is an atypical form of the disease shingles (herpes zoster). Shingles typically manifests with a very characteristic rash accompanied by pain; people with ZSH, by contrast, typically experience the pain but no rash. This can make ZSH more difficult to diagnose since there may be many other potential causes of neuropathic pain that also have to be considered and ruled out. Much like in patients with shingles, ZSH could cause more serious complications if left untreated, such as meningitis, encephalitis, and other nerve damage. Despite the rare incidence of ZSH, more research is needed to fully understand why it occurs in some people in order to provide better diagnoses and treatments.

Shingles is caused by the varicella-zoster virus (the same virus that causes chickenpox), which many people contract in childhood. When someone is infected with and subsequently recovers from chickenpox, their body fights off the virus but doesn’t fully eradicate it. Instead, the varicella-zoster virus remains in the body’s nervous system, lying dormant for years with no ill effects. In some people, the virus may reactivate many years later and cause shingles. Not everyone who has had chickenpox will develop shingles, and the exact reason for reactivation is unclear. However, shingles does occur more often in older individuals and those with impaired immune systems. The most common symptom of shingles is the representative rash that typically appears as a red rash or blisters in a stripe pattern over one side of the torso, though the rash may also occur around an eye, on the face or neck, or on another part of the body. The rash is also commonly accompanied by pain, which may begin a few days before the rash appears and may linger past when the rash otherwise heals. However, some people do experience the pain of shingles without ever developing the distinctive rash, which is sometimes diagnosed as ZSH. Other symptoms of shingles include:

  • Skin sensitivity to touch (sometimes also occurring prior to the appearance of a rash)
  • Itching
  • Blisters that may break open and scab
  • Fever or fatigue
  • Light sensitivity or headache

Though shingles isn't considered a life-threatening condition, it may still be very painful and could cause long-term complications. For example, shingles may cause postherpetic neuralgia, a form of nerve damage characterized by a persistent burning sensation in the skin. People who experience postherpetic neuralgia often also report sensitivity to touch, itchiness, and numbness that could last for three months or longer after the other symptoms of shingles clear up. Early diagnosis and treatment of shingles using antiviral medications is associated with a lower risk of complications (such as postherpetic neuralgia) and an overall shorter illness duration (in other words, the rash and pain resolve faster). Early treatment is helpful even in shingles and ZSH patients who haven't yet (or never) developed the characteristic rash, so it’s recommended to talk to a health care provider as soon as possible after noticing potentially shingles-related symptoms.

While worrying about your friend’s ailments, you may also be wondering how you could avoid shingles yourself. Luckily, there’s no way to “catch” shingles from someone else since the disease is caused by the reactivation of a virus that’s already present and dormant in the body. Being around your friend (if they do indeed have shingles) isn’t going to activate shingles in you too! That said, someone who has never been exposed to the varicella-zoster virus (in other words, they never had chickenpox as a kid and never received the chickenpox vaccine) could contract chickenpox by coming into direct contact with the open sores and blisters of a shingles rash, so someone with an active shingles infection may wish to avoid pregnant people, newborns, and others who are at risk for contracting chickenpox.

Ongoing research is dedicated to understanding the biology of shingles infections in order to improve methods of diagnosis, treatment, and prevention. Thankfully, there is an approved shingles vaccine that is over 90 percent effective at preventing shingles and postherpetic neuralgia. The vaccine is currently recommended for most healthy people over the age of 50. It is not recommended for people who currently have shingles, are pregnant or breastfeeding, or are allergic to any component of the vaccine. Additionally, the vaccine is only effective for people who currently have the varicella-zoster virus dormant in their nervous systems from a prior chickenpox infection or vaccination; in the United States, 99 percent of people aged 40 and older have had chickenpox, so the shingles vaccine is appropriate in the vast majority of circumstances. However, the few people who test negative for immunity to varicella-zoster (in other words, were never infected with or vaccinated for chickenpox) are recommended to receive the chickenpox vaccine instead of the shingles vaccine.

In your and your friend’s case, your next step may include visiting your local health care provider. They’ll be able to determine if your friend does, in fact, have shingles or ZSH and will be able to help determine the best course of treatment from there.

Good luck!

Last updated Aug 12, 2022
Originally published Dec 13, 1996

Submit a new comment


This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

The answer you entered for the CAPTCHA was not correct.