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Shingles, also known as herpes zoster, is a viral infection that causes a painful rash with fluid-filled blisters. It is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. After recovering from chickenpox, the virus remains dormant in nerve tissue and can reactivate years later as shingles. The rash typically appears as a band on one side of the body, often on the torso or face, and can be extremely painful.

Shingles is more common in older adults and people with weakened immune systems. Most cases resolve within two to four weeks, but some people experience lingering nerve pain known as post-herpetic neuralgia (PHN). While there is no cure for shingles, early treatment can help reduce symptoms and complications.

Signs and Symptoms

Shingles symptoms typically develop in stages:

  1. Early symptoms (before the rash appears)
    • Pain, burning, or tingling in a specific area of the skin
    • Sensitivity to touch
    • Fatigue or general unwellness
    • Mild fever or headache
  2. Active phase (rash and blisters form)
    • A red rash develops, often in a stripe or band pattern along one side of the body
    • Small fluid-filled blisters appear, which can be itchy and painful
    • The rash may continue to spread for a few days
    • The blisters eventually burst, dry out, and form scabs
  3. Healing phase
    • The scabs gradually fall off over two to four weeks
    • Some people may be left with changes in skin pigmentation (lighter or darker skin)

Complications

  • Post-herpetic neuralgia (PHN): Persistent nerve pain lasting weeks, months, or even years after the rash has healed
  • Eye involvement (herpes zoster ophthalmicus): Can lead to vision problems or blindness if untreated
  • Facial paralysis or hearing loss: If the virus affects the facial nerves
  • Secondary bacterial infections: Scratching blisters may cause skin infections
  • Neurological complications: Rare but can include encephalitis (brain inflammation) or meningitis

Causes and Contributing Factors

Shingles occurs when the dormant varicella-zoster virus reactivates. The exact cause of reactivation is unclear, but factors that increase the risk include:

  • Age: Most common in people over 50
  • Weakened immune system: Due to conditions such as cancer, HIV/AIDS, or immunosuppressive treatments (e.g., chemotherapy, steroids)
  • Stress: Physical or emotional stress may trigger an outbreak
  • Recent illness or surgery: Can weaken the immune system and make reactivation more likely
  • Certain medications: Drugs that suppress the immune system, such as those used for organ transplants

Shingles is not contagious in the same way as a cold or flu. However, the virus can be transmitted to someone who has never had chickenpox, causing them to develop chickenpox (not shingles). This occurs through direct contact with the fluid from shingles blisters. Once the blisters scab over, the person is no longer contagious.

Prognosis

For most people, shingles resolves within two to four weeks without major complications. However, some individuals may experience prolonged pain (PHN) or other complications.

Factors that influence recovery include:

  • Age: Older individuals have a higher risk of complications
  • Immune status: Weakened immune systems can lead to more severe infections
  • Location of the rash: Shingles affecting the face or eyes can lead to more serious issues
  • Early treatment: Starting antiviral medication within 72 hours can improve outcomes and reduce the risk of PHN

Most people only experience shingles once, but in rare cases, it can recur.

Treatment

Medical Treatment

  1. Antiviral Medications:
    • Acyclovir, Valacyclovir, or Famciclovir can help shorten the duration of shingles and reduce complications. Best if started within 72 hours of rash onset.
  2. Pain Relief:
    • Paracetamol or ibuprofen for mild pain
    • Prescription medications, such as opioids or nerve pain medications (gabapentin or pregabalin), for severe cases
    • Topical creams (e.g., capsaicin, lidocaine patches) for nerve pain
  3. Antibiotics:
    • Only used if blisters become infected with bacteria

Skin Care

  • Keep the rash clean and dry to prevent infection
  • Apply cool compresses to relieve itching and discomfort
  • Avoid scratching to reduce the risk of scarring

Prevention

  • Shingles Vaccine:
    • The recombinant zoster vaccine (Shingrix) is recommended for adults over 50 and those with weakened immune systems
    • Helps prevent shingles or reduces severity if it occurs

The Role of Physiotherapy

Shingles is not a musculoskeletal condition and is therefore not treatable with physiotherapy. However, physiotherapists frequently see patients who present with pain that is actually caused by the shingles virus, particularly before the rash appears. In these cases, a physiotherapist can play an important role in:

  • Recognising the symptoms of shingles early and distinguishing it from musculoskeletal pain
  • Triage and referral to a GP or specialist for diagnosis and antiviral medication
  • Providing pain management strategies if post-herpetic neuralgia or nerve-related pain persists after the infection

Physiotherapy for Post-Herpetic Neuralgia

  • Transcutaneous Electrical Nerve Stimulation (TENS): May help reduce nerve pain
  • Gentle massage or manual therapy: Can improve circulation and reduce discomfort
  • Stretching and movement exercises: Helps maintain mobility, especially if pain has led to reduced movement
  • Desensitisation therapy: If the affected skin remains hypersensitive, gradual exposure to different textures can help

Since early antiviral treatment is crucial, a physiotherapist who suspects shingles will refer patients to a GP as soon as possible. Antiviral medications work best if taken within three days (and ideally within 24 hours) of the rash appearing, reducing the severity and duration of the infection. Fortunately, it is rare for someone to have more than one episode of shingles in their lifetime.

Information is provided for educational purposes only. Always consult your physiotherapist or other health professional.

References

de Oliveira Gomes J, Gagliardi AMZ, Andriolo BNG, Torloni MR, Andriolo RB, Puga ME, Canteiro Cruz E. Vaccines for preventing herpes zoster in older adults. Cochrane Database of Systematic Reviews TBD, Issue TBD. Art. No.: CD008858. DOI: 10.1002/14651858.CD008858.pub5.

Nair PA, Patel BC. Herpes Zoster. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441824/

InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Overview: Shingles. [Updated 2023 Feb 8]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279624/