What Shingles Looks Like

A shingles rash looks like a cluster of tiny, fast-growing blisters on a red base of skin that quickly merge, rupture, and crust over. A shingles outbreak almost always develops on side of the body and follows a string of nerves servicing a specific part of the body (called a dermatome).

There are a total of 30 dermatomes in the body that individually service parts of the face, scalp, arms, chest, abdomen, back, buttocks, groin, tailbone, genitals, and feet. Shingles is typically constrained to one of these areas, causing a rash that looks similar to chickenpox.

Despite these tell-tale signs, shingles is often confused with other skin conditions. This can result in delayed treatment, which, in turn, can lead to a longer or more severe outbreak.

This article describes what a shingle rash looks like at different stages of the infection. It also lists other conditions that look like shingles and explains what to expect after a shingles rash has cleared.

Symptoms Before Rash

Shingles is caused by the reactivation of the chickenpox virus, called the varicella-zoster virus (VZV). After someone gets chickenpox, VZV embeds itself in the nerve roots of the spine where it can lie dormant for decades.

In later years, VZV can reactivate and quickly multiply, moving from the spinal nerve root to the branches of nerves in the skin.

When VZV first reactivates, a person can experience so-called prodromal symptoms as the body reacts to the emergent virus. Prodromal symptoms are those that are non-specific and occur before the main symptoms appear.

With shingles, the prodromal symptoms include:

• Headache
• Mild fever
• A burning, tingling, numbness, or itchiness on a specific part of the body
• Malaise (a general feeling of unwellness)

Initial Rash

Soon after the onset of prodromal symptoms, slightly reddish patches of skin with small bumps (papules) will develop in a cluster in the areas of pain. These often look like pimples or an allergic rash but are differentiated by sharp, needle-like pain, particularly if you scratch or pick at them.

The pain is caused by both the inflammation and the overstimulation of nerves by the virus. This differs from rashes that originate in skin cells in which nerves are affected collaterally rather than directly.

Moreover, the nerves that VZV inhabits are sensory ganglia whose function is to send sensory information from the skin to the brain.

As the infection progresses, more bumpy patches can develop, often following a visible pathway along the nerve string.

Vesicles Rash

As VZV migrates to the skin, the virus will multiply rapidly in the outermost (epidermal) layer of the skin. Following the appearance of bumps, tiny blisters (vesicles) will appear within 12 to 24 hours. These vesicles form when swelling is significant enough to cause blister formation.

Blisters

The rapid development of blister clusters will reveal one of the hallmarks of a shingles infection, namely the so-called "shingle belt." This manifests as a single stripe that runs along one side of the body (such as one side of the trunk, one side of the face, or down one thigh).

Only one side is affected because there are two separate nerve roots on each side of the spine, each of which services the same body part on the opposite side.

Though rare, shingles can affect more than multiple dermatomes. This can lead to widespread shingles across the body. When shingles occur in more than one dermatome, it may be an indication of immunosuppression.

Over the course of the next 48 hours, the blisters will start to turn cloudy and increase in number and size. Many will converge into larger blisters and/or rupture, leaving behind a raw, indented, oozing ulcer.

At this stage, the pain can be extreme, making movement or even the lightest touch excruciating.

Scabs and Crusting

Once a herpes blister ruptures, the secreted fluid will crystalize and form a honey-colored crust. A scab will form underneath, stemming the oozing fluid and allowing the ulcer to heal. The healing of the sore and shedding of the scab takes a week to 10 days.

A lesion is no longer considered contagious once the rash has crusted over.

But even as sores begin to heal, new clusters of blisters can continue to form. Depending on the severity of an outbreak, shingles can three to five weeks to progress through all of its stages.

Eye Shingles

Ophthalmic shingles, also known as herpes zoster ophthalmicus (HZO), occur when the shingles develops in or around the eye. It is a severe variant that affects 20% of people with shingles. People with compromised immune symptoms, such as those with advanced HIV, are at the highest risk.

HZO causes a blistering rash around the eyes and eyelids. The infection can extend to the cornea (the transparent layer in front of the eye), causing scarring and potentially severe vision loss. If you develop a shingles rash near the eye, contact your healthcare provider without delay.

Eye damage can also occur when shingles involves the retina or optic nerve in the back of the eye without causing a skin rash or other symptoms at the surface of the eye. This is called viral retinitis.

Damage in viral retinitis is due to inflammation of the blood vessels servicing the eye. The rupture of these vessels can deprive these nerves (including the optic nerve) of the oxygen and nutrients they need to survive. Damage to these nerves can also affect vision.

Is It Shingles or Something Else?

A shingles rash may seem pretty self-evident, but there are other conditions that can also cause a blistering, painful rash.

While your healthcare provider may prescribe treatment based on the presumption of shingles, it is important to undergo a complete evaluation to ensure some other condition (requiring a whole different course of treatment) is not involved.

These include conditions like:

• Genital herpes
• Contact dermatitis
• Poison ivy
• Dermatitis herpetiformis (celiac disease rash)
• Allergic drug reactions
• Autoimmune blistering diseases like pemphigus and pemphigoid

Other Symptoms

Scratching shingles blisters—or scabs as the rash heals—increases your risk of a secondary bacterial infection. Secondary infections are relatively easy to establish when bacteria beneath the fingernails are introduced into exposed tissue within a sore. This can slow healing times and even lead to permanent scarring.

Never scratch a shingles rash. Instead, tap the skin or apply a cool, moist cloth to help ease the itch. Over-the-counter remedies like calamine lotion and colloidal oatmeal baths may also help.

Call a healthcare provider immediately if you experience signs of a secondary skin infection, including fever, a pus-like discharge, or increasing redness, swelling, or heat.

Symptoms After the Rash Disappears

Even after a shingles outbreak resolves, you may experience long-lasting nerve pain due to the inflammatory damage caused to nerves.

This condition, known as postherpetic neuralgia, is the most common complication of shingles. It causes burning pain that can last for months and years after the infection has cleared.

People over 60s are at the greatest risk, which is why shingles vaccination is recommended for adults 50s and over. There is no cure for postherpetic neuralgia, but different medications can help ease the pain.

There is also some evidence that the early use of antiviral drugs during the early stages of the infection can reduce the risk or severity of postherpetic neuralgia compared to people who have not received treatment.

For most people, postherpetic neuralgia gets better over time.

Shingles Doctor Discussion Guide

Get our printable guide for your next appointment with a healthcare provider to help you ask the right questions.

Download PDF

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