Signs and Symptoms
Typically, the first and the most common symptom of shingles is pain, which presents in approximately 75% of people who go on to develop a rash (Albrecht 2012c; Mayo Clinic 2011; Gharibo 2011). The pain is sometimes described as a burning, throbbing, or stabbing sensation that is localized to the area of the skin that will later be affected by the rash (Albrecht 2012c). During this time, which is also known as the “prodromal period”, patients may also experience headache, malaise, earache, sensitivity to light, and fever (Weaver 2009; Mayo Clinic 2011; Albrecht 2012c; Wallmann 2011). These symptoms may appear up to 5 days before the rash (Wallmann 2011).
Typically, after prodromal symptoms occur, a rash will develop. However, in some people, a rash may appear before they experience pain (Wallmann 2011). In addition, some patients will have pain, but will not develop a rash; this is called “zoster sine herpetica” (Albrecht 2012c; Sampathkumar 2009; Wallman 2011). It is important to be aware of this type of herpes zoster manifestation because, if the cause of the pain cannot be determined, an inaccurate diagnosis may be made and incorrect treatments given; for example, zoster sine herpetica may be misinterpreted as angina, heart attack, dental problems, or duodenal ulcer (Sampathkumar 2009; Wallmann 2011).
The rash of shingles typically begins as small, raised, reddish lesions that quickly evolve into groups of fluid-filled blisters that later break and form a crust or a scab (Mayo Clinic 2011; Sampathkumar 2009; Albrecht 2012c). Some patients will experience pain after mild or brushing contact to the affected skin areas, a phenomenon known as allodynia (Albrecht 2012c).
The lesions caused by shingles have a characteristic location and distribution: they may be limited to one side of the body and are localized to a “strip” of skin, also known as a dermatome, which represents the skin area that is served by the nerves of a single ganglion. In about 20% of patients, adjacent dermatomes can be affected. The most commonly affected areas are on the side of the trunk around the waistline and the second most common is the face around the eye/ forehead (Sampathkumar 2009; NINDS 2013). The skin lesions typically take 2 to 4 weeks, or sometimes even longer, to heal and they may cause permanent scarring or skin pigmentation changes. When shingles affects the eye, it can cause vision changes and sometimes even permanent blindness (Wallmann 2011).
Most herpes infections affect either the oral or genital regions. Sometimes, however, infections of other organs may occur without the signs of oral or genital herpes (Sköldenberg 1996; Stuart-Harris 1983; Lahat 1999; Chaudhuri 2002).
Typically, the first oral infection with HSV (usually HSV-1) will cause painful sores to appear in or around the mouth, also known as herpetic gingivostomatitis, but sometimes swollen gums are the only symptom, and other times no symptoms develop at all (Urban 2009, American Academy of Dermatology 2012). The most common location for these sores is the lips, the area around the mouth, and the tongue, though the blisters can appear on any skin-covered area (American Academy of Dermatology 2012; Ehrlic 2011a; Urban 2009).
During the prodromal period, before these sores appear, the skin may itch, tingle, or burn (American Academy of Dermatology 2012). The sores usually appear for the first time 1 to 3 weeks after contact with the infected person and may last up to 14 days (Urban 2009; Ehrlic 2011a). In addition, patients may have fever, a sore throat, and swollen neck lymph nodes, especially during the first episode, which can make eating and drinking difficult (Urban 2009; Mayo Clinic 2011; Mell 2008).
Genital herpes causes similar symptoms, with the appearance of sores on the penis, anus, buttocks, and around and inside the vagina (American Academy of Dermatology 2012; Mayo Clinic 2011; Mell 2008). These lesions may or may not cause pain (Ehrlic 2011a). Other symptoms include fever, malaise, muscle aches, swollen lymph nodes in the groin, pain or burning upon urination, and vaginal discharge (American Academy of Dermatology 2012; Urban 2009; Mell 2008; Mayo Clinic Staff 2011). As with oral herpes, patients may experience a prodromal period with tingling, burning, or itching of the affected areas (Urban 2009; American Academy of Dermatology 2012).
Herpes infections can also cause several complications. Herpes can spread to one or both eyes, and when the cornea is affected (herpes simplex keratitis), it causes pain, sensitivity to light, a gritty feeling in the eye, and discharge (American Academy of Dermatology 2012). Without treatment, scarring may result, which can lead to cloudy vision or even blindness, requiring corneal transplantation (Urban 2009; American Academy of Dermatology 2012).
Both HSV-1 and HSV-2 may also enter into a finger via breaks in the skin, causing a condition known as herpetic whitlow, in which the fingertip becomes swollen, red, and painful; this condition is most frequently seen in health care workers, such as dentists, who are exposed to body fluids while not wearing gloves (Urban 2009). Herpes can also infect the brain, leading to herpes encephalitis, which causes fever, confusion, and seizures; this condition can be fatal (Urban 2009). Other internal organs, such as the lungs and esophagus, can be infected as well, but this is rare.