Shingles (Herpes Zoster)

Populations and Risk Factors

Usually affects adults over 50
Reactivation triggers: old age, stress, impaired immunity (HIV, chemotherapy, other diseases), severe trauma
Anyone who has had chickenpox carries dormant VZV
Vaccination (Zostavax) is recommended for adults over 50

VZV retreats to dorsal root ganglia (or geniculate ganglion of trigeminal nerve) after initial chickenpox infection
Upon reactivation, virus travels down dendrites of sensory neurons to the skin, causing intense inflammation and fluid-filled blisters
Chest and abdomen (thoracic dermatomes) are most frequently affected, appearing like a "belt" or "girdle"
Postherpetic neuralgia (PHN): Chronic pain outlasting blisters by at least 3 months. Affects 60-75% of patients over 60. Caused by destruction of large nerve fibers
Ramsay-Hunt syndrome: Trigeminal nerve involvement causing hearing loss, eye damage, or facial paralysis
Zoster sine herpete: Rare presentation with dermatomal pain but no visible blisters. Often misdiagnosed as herniated disc or heart attack

Prodrome: Burning pain, tingling, or extreme sensitivity (hyperpathia) preceding rash by 1-3 days
Dermatomal rash: Unilateral (one-sided) eruption of painful blisters on a red base following a specific sensory nerve path
Allodynia: Significant pain response to the touch of clothing or sheets
Hyperpathia: Extreme pain in response to non-noxious light touch
Sleep disturbances. Inability to perform daily tasks due to burning pain
Secondary bacterial infection of blisters is possible

Assessment Stage	Tests	Expected Findings	Rationale
History	Prodromal audit	Reports of burning or tingling in a narrow strip 1-3 days before rash	Identifies earliest signs of reactivation before visible lesions appear
History	Immunological scan	History of chickenpox; recent extreme stress or illness	Establishes VZV dormancy and identifies reactivation triggers
Visual Inspection	Dermatomal scan	Unilateral clusters of vesicles (blisters) on a red base following a nerve path	Hallmark sign differentiating shingles from bilateral rashes or non-viral dermatitis
Visual Inspection	Somatic check	Redness or grouped blisters along thoracic, cervical, or trigeminal paths	Identifies the specific dermatome affected and local contraindication sites
AROM	Psychosomatic audit	Allodynia: significant guarding or pain response to touch of clothing	Reflects extreme hypersensitivity of inflamed sensory neurons
Palpation (5 T's)	Sensitivity screen	Hyperpathia: extreme pain to non-noxious light touch	Directly confirms neural involvement; area must be avoided
Functional Tests	ADL impact audit	Sleep disturbances; inability to perform tasks due to burning pain	Quantifies functional impairment caused by neuralgia
Special Test	Diagnostic tests (reference)	Positive viral cultures or VZV antibody titers	Laboratory standards for confirming VZV reactivation

Unilateral dermatomal distribution of blisters is the hallmark differentiating feature
The prodrome (burning/tingling in a narrow strip) precedes visible lesions by 1-3 days
Zoster sine herpete (dermatomal pain without blisters) can be misdiagnosed as herniated disc or heart attack
If shingles affects the ophthalmic division of trigeminal nerve (tip of nose is a clue), it is a medical emergency due to blindness risk
PHN affects 60-75% of patients over 60. Older adults are more prone due to fewer large nerve fibers
Early antivirals (within 72 hours) are most effective

Local contraindication: Acute shingles locally contraindicates massage until all blisters have healed and skin is intact
Contagion risk: Blisters carry live virus. While most adults have immunity from chickenpox, there is risk of transmission to non-immune or immunocompromised contacts
PHN exception: For chronic postherpetic neuralgia, careful, soothing touch might be helpful for some clients, though touch is often unbearable for others
Viral shedding: Virus can be shed even before a lesion is fully visible
Referral trigger: Unexplained, unilateral burning pain along a rib or the face should prompt immediate medical referral (early antivirals within 72 hours are most effective)
Ophthalmic emergency: If shingles affects the tip of the nose (ophthalmic trigeminal division), it is a medical emergency due to risk of permanent blindness

Shingles is caused by reactivation of dormant VZV from the dorsal root ganglia. The hallmark is unilateral dermatomal blisters on a red base
Acute shingles is a local contraindication until all blisters have healed. Blisters carry live, transmissible virus
Postherpetic neuralgia affects 60-75% of patients over 60 and can cause debilitating chronic pain lasting months to years
Zoster sine herpete (pain without blisters) is a diagnostic trap, often misdiagnosed as disc herniation or heart attack
Ophthalmic involvement (tip of nose clue) is a medical emergency due to blindness risk. Early antivirals within 72 hours are most effective