The Stages of Shingles

The clinical manifestations of shingles can be divided into 3 phases.

Editor’s note: This article was originally published on January 14, 2021, and has since been updated.

Shingles, or herpes zoster, is an infection caused by the varicella zoster virus which remains in the body following an episode of chickenpox.1 After lying dormant and forgotten for decades in the neurons of a spinal nerve, it can reactivate as shingles.

shingles rash on abdomen | Image credit: Sunday Cat Studio -

Shingles is caused by the varicella zoster virus. | Image credit: Sunday Cat Studio -

The primary symptom associated with shingles is a painful red rash that erupts along 1 side of the body. Most commonly presenting as a band around the patient’s waistline or trunk, the rash can also break out in other locations like the face, neck, eyes, and ears.2

READ MORE: JAK Inhibitors May Increase Risk of Shingles in Patients With Immune-Mediated Inflammatory Diseases

Shingles’ clinical manifestations are divided into 3 distinct phases: preeruptive, acute eruptive, and chronic.3

Preeruptive Phase

The preeruptive phase—also known as the preherpetic neuralgia stage—usually lasts about 48 hours but can, in some cases, stretch to 10 days. It is characterized by sensory phenomena along 1 or more dermatomes, which correspond to an area of skin mainly supplied by a single spinal nerve. Symptoms common to this stage include headache, general fatigue, sensitivity to light, and fever.

Acute Eruptive Phase

The acute eruptive phase is marked by a continuation of the physical symptoms that began during the preeruptive phase, with the addition of severe pain and the emergence of lesions. The lesions start as macules—small circumscribed changes in the color of skin that are flat—and quickly progress to clusters of vesicles filled with fluid. New vesicles continue to form and rupture over a 3- to 5-day period. It is during this phase that the virus can be easily transmitted to others. The vesicles eventually dry up and crust over, and can take up to 4 weeks to heal. Pigmentation changes and scarring on the skin caused by the lesions may be permanent.

Chronic Phase

The chronic phase, also known as postherpetic neuralgia, occurs in up to 20% of all patients with shingles. This phase is defined by recurrent pain lasting more than 4 weeks after the vesicles have healed. Other symptoms include abnormal skin sensations such as tingling, burning, and numbness caused by pressure on a nerve (paresthesia) and nerve damage (dysesthesia). The resulting pain, which can be excruciating and disabling, can last months or even years.

The shingles rash is usually self-limited and resolves without medical intervention, but most patients require relief from the accompanying pain and discomfort. Physical symptoms can be managed with nonsteroidal anti-inflammatory drugs, wet dressings, and calamine lotion.4

Antiviral medications such as acyclovir (Sitavig, Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) are also very effective, especially when prescribed within 72 hours of the onset of symptoms.5 Hospital admission is reserved for patients with severe symptoms, immunosuppression, disseminated herpes zoster, ophthalmic involvement, and other serious complications.

Pain associated with postherpetic neuralgia is notoriously difficult to manage. Two options include the topical analgesics found in lidocaine and capsaicin transdermal patches.

In the United States, 99% of individuals aged 50 years and older carry the varicella zoster virus in their bodies after having chickenpox as a child. Approximately 1 million of these individuals will experience shingles each year.1

Once varicella zoster virus is in the body, the only way to protect against shingles and related complications is vaccination. Shingrix (zoster vaccine, recombinant, adjuvanted) is approved by the FDA for use in adults aged 50 years and older.6 Shingrix is administered in 2 doses, delivered 2 to 6 months apart; it is more than 90% effective in all age groups tested.

In addition to dramatically reducing an individual’s chances of developing shingles, Shingrix also reduces the likelihood that they will pass along the varicella zoster virus to those who are vulnerable to infection, such as young children and adults who have no immunity to the virus.

READ MORE: Shingles Resource Center

  1. About shingles. CDC. Accessed April 25, 2024.
  2. Shingles. Jons Hopkins Medicine. Accessed April 25, 2024.
  3. Pollock DM. The 3 stages of shingles: What to know. Optum. Updated July 19, 2023. Accessed April 25, 2024.
  4. Ludmann P. What are the signs and symptoms of shingles? American Academy of Dermatology. Updated January 3, 2024. Accessed April 25, 2024.
  5. Dooling K, Anderson T. Five things you should know about shingles. CDC. Reviewed May 9, 2023. Accessed April 25, 2024.
  6. What everyone should know about the shingles vaccine (Shingrix). CDC. Reviewed May 8, 2023. Accessed April 25, 2024.
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