Shingles happens when the varicella zoster virus, dormant in a nerve root since chickenpox, wakes up and travels along one nerve to the skin. It is most common in older adults and people with weak immunity, and nerve pain can last for months after the rash heals.
Key symptoms
- Burning, stabbing or tingling pain on one side a few days before the rash
- Band of blisters on one side of the body that does not cross the midline
- Itching and skin that hurts with light touch
- Mild fever, headache or feeling unwell
- Pain that lasts after the rash heals (postherpetic neuralgia)
What you find on exam
- Grouped blisters on a red base following one dermatome
- Crusted lesions after 7 to 10 days
- Rash on the tip of the nose suggests eye involvement (Hutchinson sign)
- Rash in the ear with facial weakness suggests Ramsay Hunt syndrome
- Check for spread to several dermatomes or across the body
Tests
- Usually diagnosed by the typical rash
- PCR swab of a blister if the rash is atypical
- Urgent eye exam with a slit lamp if the forehead or nose is involved
- HIV test or immune workup if young or with widespread disease
Treatment basics
- Oral valacyclovir for 7 days, best started within 72 hours of the rash
- Pain control with acetaminophen or NSAIDs, and gabapentin for nerve pain
- IV acyclovir for widespread disease, eye or nerve complications or weak immunity
- Cover lesions and avoid pregnant women, newborns and immunocompromised people until crusted
- Recombinant zoster vaccine for adults 50 and older, or 19 and older with weak immunity
Red flags
- Rash near the eye or on the nose tip, or any vision change
- Facial weakness, ear pain or hearing loss
- Widespread rash, confusion or a patient with weak immunity
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.