Table of ContentsView AllTable of ContentsCausesWho Is at Risk for Shingles?ZSH SymptomsComplicationsDiagnosisTreatmentCoping
Table of ContentsView All
View All
Table of Contents
Causes
Who Is at Risk for Shingles?
ZSH Symptoms
Complications
Diagnosis
Treatment
Coping
Shingles without a rash is calledzoster sine herpete(ZSH) or internal shingles. This type of shingles is rare since most people withshinglesdevelop a telltale rash on one side of their body.
Even without a rash, you may still experience pain and itching. You may also have a headache, fatigue, nerve pain, and numbness. Treatments aim to manage these symptoms.
Oscar Wong / Getty Images
What Causes Shingles Without a Rash?
Once infected with chicken pox, the virus stays in your body forever, but it lies dormant most of the time. When it reactivates, it causes shingles.
Reactivation typically affects a single nerve (dermatome) and the itching and pain (and rash, in a typical case) are confined to the path of that nerve. That generally means symptoms develop in a stripe on one side of your body. However,disseminated zostermay affect multiple nerves in immunocompromised individuals.
Typical shingles develops from an infection in a sensory nerve (one that runs close to the surface of your skin and provides sensation).
In internal shingles, the infected nerve is deeper in the body, often in the digestive organs. It doesn’t cause a rash because those nerves don’t connect to your skin.
Anyone who has had chickenpox may develop typical or internal shingles later in life.However, certain populations are at greater risk.
These include:
Symptoms of Internal Shingles
Since the nerve is close to the skin’s surface in traditional shingles, the first sign of illness is tactile: itching or shooting, burning pain. Arashthen appears within several days.
In internal shingles, however, the first symptoms may include the other early symptoms associated with shingles that appears with a rash:
Even without the blisters, ZSH causes physical pain known as neuralgia.This is sometimes called nerve pain since it’s related to inflammation of nerves. The pain can be mild to severe and may interfere with everyday activities.
The effects of neuralgia can range from mild to severe and can interfere with your ability to concentrate or take care of your everyday needs.
One study suggested internal shingles pain is even more intense than typical shingles pain.It’s been associated with numbness, general achiness, and a deep sensation that affects the muscles and joints.
How Long Shingles LastsWithout treatment, shingles should only last three to five weeks. It can clear up much faster with treatment, especially if caught and treated early.
How Long Shingles Lasts
Without treatment, shingles should only last three to five weeks. It can clear up much faster with treatment, especially if caught and treated early.
Because ZSH is likely to be missed, patients may not receive treatment soon enough to prevent serious symptoms. This can lead to the continuous activation of the VZV.
Complications from these situations include recurrent neuralgia, including postherpetic neuralgia, which causes extreme pain in the hands, feet, arms, or legs.
Between 10% and 18% of people who have shingles are left with postherpetic neuralgia (PHN).It’s more common in older people.
With PHN, pain continues even after shingles is gone. It can produce lifelong effects that interfere with your quality of life.
Other potential complications include:
ZSH is often misdiagnosed because of the lack of rash. Any person with unexplained neuropathic pain, facial palsy, or muscle paralysis without a rash should see a healthcare provider right away for diagnosis and treatment.
A lab test can help diagnose a ZSH infection. This is especially helpful for detecting the virus when you don’t have conventional symptoms.
The test can use samples from:
The polymerase chain reaction (PCR) test is the most useful for detecting VZV in people without a shingles rash. A direct fluorescent antibody (DFA) test is sometimes used but it’s not as sensitive as PCR.
Differential Diagnoses
The location of your pain may suggest other conditions, as well. Your healthcare provider may perform multiple tests to rule out possible causes of your symptoms.
Research on ZSH treatments is limited. However, the typical treatment involves antiviral medications such as Valtrex (valacyclovir) or Zovirax (acyclovir).
Pain management is also an essential part of treating internal shingles. Some drugs that may help with nerve pain include:
Lesions and complications should also be treated.
Coping with the pain of shingles, regardless of type, can be harder than just taking pain medications. The discomfort may disrupt your life and make it hard to sleep. It can also cause depression.
You may want to ask your healthcare provider about asleep aidor antidepressants.
Topical painanditch relieversandoatmeal bathsthat help some people with typical shinglesmay or may not be effective for internal shingles, but they’re generally safe to try.
If you’re struggling to cope, talk to family and friends about what you’re going through. You may also want to find a support group, online or in your community, for people with shingles, PHN, or chronic pain.
Summary
Internal shingles doesn’t involve a rash like typical shingles. This is because it affects nerves that are deeper in the body and don’t connect to the skin. It still causes an itch and severe pain, and may even be more painful than a shingles rash.
Internal shingles is harder to recognize so people may go to a healthcare provider later, and healthcare providers may misdiagnose it. This delays treatment and can lead to complications such as postherpetic neuralgia.
Internal shingles is treated with antivirals and a variety of medications that help control pain. You may benefit from antidepressants and sleep drugs as well. A support group may help you cope.
9 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.National Institutes of Health, National Institute on Aging.Shingles.Zhou J, Li J, Ma L, Cao S.Zoster sine herpete: a review.Korean J Pain. 2020;33(3):208-215. doi:10.3344/kjp.2020.33.3.208Centers for Disease Control and Prevention.Shingles: Signs and symptoms.Drago F, Herzum A, Ciccarese G, Broccolo F, Rebora A, Parodi A.Acute pain and postherpetic neuralgia related to Varicella zoster virus reactivation: Comparison between typical herpes zoster and zoster sine herpete.J Med Virol. 2019;91(2):287-295. doi:10.1002/jmv.25304Castelli G, Desai KM, Cantone RE.Peripheral neuropathy: evaluation and differential diagnosis.Am Fam Physician.2020;102(12):732-739.Centers for Disease Control and Prevention.Complications of shingles.Centers for Disease Control and Prevention.Shingles: Diagnosis & testing.University of Pennsylvania: Penn Medicine.Nerve root pain.Harte SE, Harris RE, Clauw DJ.The neurobiology of central sensitization.J Applied Behav Res.2018;23(2):e12137. doi:10.1111/jabr.12137Additional ReadingAmerican Academy of Dermatology.Shingles: Signs and symptoms.Zhou J, Li J, Ma L, Cao S.Zoster sine herpete: a review.Korean J Pain. 2020;33(3):208-215. doi:10.3344/kjp.2020.33.3.208
9 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.National Institutes of Health, National Institute on Aging.Shingles.Zhou J, Li J, Ma L, Cao S.Zoster sine herpete: a review.Korean J Pain. 2020;33(3):208-215. doi:10.3344/kjp.2020.33.3.208Centers for Disease Control and Prevention.Shingles: Signs and symptoms.Drago F, Herzum A, Ciccarese G, Broccolo F, Rebora A, Parodi A.Acute pain and postherpetic neuralgia related to Varicella zoster virus reactivation: Comparison between typical herpes zoster and zoster sine herpete.J Med Virol. 2019;91(2):287-295. doi:10.1002/jmv.25304Castelli G, Desai KM, Cantone RE.Peripheral neuropathy: evaluation and differential diagnosis.Am Fam Physician.2020;102(12):732-739.Centers for Disease Control and Prevention.Complications of shingles.Centers for Disease Control and Prevention.Shingles: Diagnosis & testing.University of Pennsylvania: Penn Medicine.Nerve root pain.Harte SE, Harris RE, Clauw DJ.The neurobiology of central sensitization.J Applied Behav Res.2018;23(2):e12137. doi:10.1111/jabr.12137Additional ReadingAmerican Academy of Dermatology.Shingles: Signs and symptoms.Zhou J, Li J, Ma L, Cao S.Zoster sine herpete: a review.Korean J Pain. 2020;33(3):208-215. doi:10.3344/kjp.2020.33.3.208
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
National Institutes of Health, National Institute on Aging.Shingles.Zhou J, Li J, Ma L, Cao S.Zoster sine herpete: a review.Korean J Pain. 2020;33(3):208-215. doi:10.3344/kjp.2020.33.3.208Centers for Disease Control and Prevention.Shingles: Signs and symptoms.Drago F, Herzum A, Ciccarese G, Broccolo F, Rebora A, Parodi A.Acute pain and postherpetic neuralgia related to Varicella zoster virus reactivation: Comparison between typical herpes zoster and zoster sine herpete.J Med Virol. 2019;91(2):287-295. doi:10.1002/jmv.25304Castelli G, Desai KM, Cantone RE.Peripheral neuropathy: evaluation and differential diagnosis.Am Fam Physician.2020;102(12):732-739.Centers for Disease Control and Prevention.Complications of shingles.Centers for Disease Control and Prevention.Shingles: Diagnosis & testing.University of Pennsylvania: Penn Medicine.Nerve root pain.Harte SE, Harris RE, Clauw DJ.The neurobiology of central sensitization.J Applied Behav Res.2018;23(2):e12137. doi:10.1111/jabr.12137
National Institutes of Health, National Institute on Aging.Shingles.
Zhou J, Li J, Ma L, Cao S.Zoster sine herpete: a review.Korean J Pain. 2020;33(3):208-215. doi:10.3344/kjp.2020.33.3.208
Centers for Disease Control and Prevention.Shingles: Signs and symptoms.
Drago F, Herzum A, Ciccarese G, Broccolo F, Rebora A, Parodi A.Acute pain and postherpetic neuralgia related to Varicella zoster virus reactivation: Comparison between typical herpes zoster and zoster sine herpete.J Med Virol. 2019;91(2):287-295. doi:10.1002/jmv.25304
Castelli G, Desai KM, Cantone RE.Peripheral neuropathy: evaluation and differential diagnosis.Am Fam Physician.2020;102(12):732-739.
Centers for Disease Control and Prevention.Complications of shingles.
Centers for Disease Control and Prevention.Shingles: Diagnosis & testing.
University of Pennsylvania: Penn Medicine.Nerve root pain.
Harte SE, Harris RE, Clauw DJ.The neurobiology of central sensitization.J Applied Behav Res.2018;23(2):e12137. doi:10.1111/jabr.12137
American Academy of Dermatology.Shingles: Signs and symptoms.Zhou J, Li J, Ma L, Cao S.Zoster sine herpete: a review.Korean J Pain. 2020;33(3):208-215. doi:10.3344/kjp.2020.33.3.208
American Academy of Dermatology.Shingles: Signs and symptoms.
Meet Our Medical Expert Board
Share Feedback
Was this page helpful?Thanks for your feedback!What is your feedback?OtherHelpfulReport an ErrorSubmit
Was this page helpful?
Thanks for your feedback!
What is your feedback?OtherHelpfulReport an ErrorSubmit
What is your feedback?
