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# Herpes zoster (shingles)

Shingles (herpes zoster) is a painful blistering rash in a band on one side of the body, caused by the chickenpox virus waking up in a nerve.

Updated 2026-10-30

## Structures involved

Tap one to see what it is and open it in 3D.

- [Dorsal root ganglia](https://durgical.com/en/anatomy/spinal-ganglion/)
- [Mid-back nerve roots](https://durgical.com/en/anatomy/anterior-root-of-spinal-nerve-spine-and-pelvis/)
- [Intercostal nerves](https://durgical.com/en/anatomy/intercostal-nerves/)
- [Neck nerve roots](https://durgical.com/en/anatomy/anterior-root-of-spinal-nerve/)
- [Spinal cord](https://durgical.com/en/anatomy/spinal-cord/)

## Microorganisms that cause it

- [Varicella-zoster virus](https://durgical.com/en/microbiology/varicella-zoster-virus/)

## In the clinical exam

- [Skin examination: primary and secondary lesions](https://durgical.com/en/clinical-exam/skin-examination-primary-and-secondary-lesions/)

## In physiology

- [Pain and temperature: pathways and modulation](https://durgical.com/en/physiology/pain-and-temperature-pathways-and-modulation/)

## Why it happens

- [Innate and adaptive immunity: overview](https://durgical.com/en/physiology/innate-and-adaptive-immunity-overview/)
- [Peripheral nerve: endoneurium, perineurium, epineurium; myelin](https://durgical.com/en/histology/peripheral-nerve-endoneurium-perineurium-epineurium-myelin/)

## What it is

Painful vesicular rash in one dermatome caused by reactivation of varicella-zoster virus that has stayed dormant in a sensory ganglion since chickenpox.

## Who gets it

Anyone who has had chickenpox can get it; risk rises sharply with age, especially after 50, and with weakened cellular immunity, including HIV in younger Latin American adults. A 2021 regional review found no general-population incidence studies; in higher-risk groups, rates ranged from 318 to 3,423 cases per 100,000 people per year.

## Causes

- Reactivation of varicella-zoster virus latent in a dorsal root ganglion or cranial nerve ganglion

## Risk factors

- Older age
- HIV infection
- Cancer, transplant, chemotherapy or immunosuppressive drugs, including corticosteroids
- Diabetes and chronic [kidney](https://durgical.com/en/anatomy/kidney/) disease
- Physical or emotional stress

## Pathophysiology

After chickenpox, the virus stays latent in sensory ganglia. When cellular immunity falls, it reactivates and travels down the sensory nerve to the [skin](https://durgical.com/en/anatomy/skin/), causing ganglion and nerve inflammation and a rash in that dermatome. Nerve damage can cause pain that lasts after the rash heals.

## Classification

- Thoracic zoster (the most common location)
- Herpes zoster ophthalmicus (first branch of the [trigeminal nerve](https://durgical.com/en/anatomy/trigeminal-nerve/))
- Ramsay Hunt syndrome (geniculate ganglion: facial palsy with ear vesicles)
- Disseminated zoster (in immunosuppressed patients)

## Symptoms and signs

- Prodrome of burning, tingling or itching pain in a band for a few days before the rash
- Clusters of vesicles on a red base in one dermatome, on one side, not crossing the midline
- Vesicles crust over in about one to two weeks
- Allodynia: pain with light touch
- Fever, headache and malaise in some patients

## Red flags

- Rash on the tip of the nose (Hutchinson sign) or eye symptoms: risk of eye involvement, urgent eye assessment
- Facial palsy, ear pain or hearing loss: Ramsay Hunt syndrome
- Widespread rash, many dermatomes or severe immunosuppression: disseminated disease
- Confusion, headache, stiff neck or weakness: possible encephalitis, meningitis or myelitis

## Diagnosis

**Clinical**
Usually clinical from the typical dermatomal rash and the pain before it.

**Tests**
PCR of vesicle fluid confirms it in atypical cases or immunosuppressed patients. HIV testing is considered, especially in younger adults.

## Differential diagnosis

- Herpes simplex (zosteriform)
- Contact dermatitis
- Cellulitis or impetigo
- Before the rash: myocardial infarction, biliary colic, radiculopathy or kidney stones

## Goal of treatment

Speed healing, control acute pain, protect the eye and other organs, and reduce the risk of postherpetic neuralgia.

## Treatment

**Medical**
Oral antiviral drugs (nucleoside analogues), ideally started within 72 hours of rash onset, and later in older, immunosuppressed patients or with eye involvement; intravenous antivirals for severe or disseminated disease.

**Medical**
Pain control with analgesics; neuropathic pain drugs (gabapentinoids, tricyclic antidepressants) and topical agents for postherpetic neuralgia.

**Conservative**
Keeping lesions clean and covered; avoiding contact with pregnant women, newborns and immunosuppressed people who have not had chickenpox until lesions crust.

**Follow-up**
Urgent eye review for ophthalmic zoster, and follow-up for complications in immunosuppressed patients.

## Drugs for this condition

- [Aciclovir](https://durgical.com/en/pharmacology/aciclovir/)
- [Valaciclovir](https://durgical.com/en/pharmacology/valaciclovir/)
- [Famciclovir](https://durgical.com/en/pharmacology/famciclovir/)
- [Gabapentin](https://durgical.com/en/pharmacology/gabapentin/)
- [Pregabalin](https://durgical.com/en/pharmacology/pregabalin/)
- [Amitriptyline](https://durgical.com/en/pharmacology/amitriptyline/)
- [Zoster vaccine (recombinant)](https://durgical.com/en/pharmacology/zoster-vaccine/)

## Complications

- Postherpetic neuralgia (the most common complication, especially in older adults)
- Eye damage: keratitis, uveitis and vision loss
- Ramsay Hunt syndrome with facial palsy and hearing loss
- Bacterial skin infection and scarring
- Stroke, encephalitis or myelitis (rare)

## Prognosis

The rash usually heals in a few weeks. Pain persisting for months after the rash (postherpetic neuralgia) is the main burden and is more frequent with age. Recurrence is possible.

## Prevention

- Recombinant zoster vaccine for older adults and for immunosuppressed adults, as national schedules set
- Childhood varicella vaccination

## Test yourself

Think of the answer, then tap the question to see it.

## Where does varicella-zoster virus lie dormant before herpes zoster?

In sensory ganglia: dorsal root ganglia or cranial nerve ganglia.

## What is the most common complication of herpes zoster?

Postherpetic neuralgia: pain that persists after the rash has healed, more common with age.

## What is the Hutchinson sign?

Vesicles on the tip or side of the nose, which signal involvement of the nasociliary nerve and a high risk of eye involvement.

## Within what time from rash onset are antivirals classically started for herpes zoster?

Within 72 hours, though they are also given later in older, immunosuppressed patients or with eye involvement.

## Which syndrome combines facial palsy with vesicles in the ear?

Ramsay Hunt syndrome, from reactivation in the geniculate ganglion.

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## Related conditions

- [HIV infection and AIDS](https://durgical.com/en/conditions/hiv-infection-and-aids/)
- [Bell palsy](https://durgical.com/en/conditions/bell-palsy/)
- [Trigeminal neuralgia](https://durgical.com/en/conditions/trigeminal-neuralgia/)
- [Otitis externa](https://durgical.com/en/conditions/otitis-externa/)
- [Uveitis](https://durgical.com/en/conditions/uveitis/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Herpes Zoster](https://www.ncbi.nlm.nih.gov/books/NBK441824/) (StatPearls (NCBI Bookshelf), 2026); [Herpes zoster epidemiology in Latin America: A systematic review and meta-analysis](https://europepmc.org/article/PMC/PMC8360515) (PloS one, 2021) · adapted, [CC BY 4.0](https://creativecommons.org/licenses/by/4.0/).

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Source: https://durgical.com/en/conditions/herpes-zoster/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/herpes-zoster/