Is it possible to have only one sore with herpes zoster (shingles)?

Shingles (Herpes Zoster) with Single Lesion

Yes, it is possible to have shingles with only one sore, though this is an atypical presentation that can make diagnosis challenging. 1

Typical vs. Atypical Presentations

Shingles (herpes zoster) typically presents with:

• Multiple vesicular lesions in a unilateral dermatomal distribution
• Painful eruption preceded by prodromal symptoms (burning, itching, tingling)
• Progressive development of lesions over 4-6 days 2

However, atypical presentations can occur:

• Single isolated lesion
• Painless presentation (especially in elderly patients) 3
• Lesions appearing outside the typical dermatomal pattern

Diagnostic Considerations for Single-Lesion Shingles

When evaluating a patient with a single lesion suspected to be shingles:

1. Look for prodromal symptoms:

   • Burning, tingling, or pain in the area 24-72 hours before lesion appearance 2
   • These symptoms may be the key diagnostic clue in single-lesion cases

2. Consider patient risk factors:

   • Age over 50 years
   • Immunocompromised status
   • History of chickenpox
   • Recent illness or stress that could trigger reactivation

3. Examine lesion characteristics:

   • Vesicular appearance on an erythematous base
   • Unilateral location
   • Position along a dermatome (even if only one lesion)

Clinical Implications

The presence of only one lesion does not rule out shingles. The Infectious Diseases Society of America recognizes that herpes zoster can present with varying numbers of lesions, from a single vesicle to multiple clusters 2.

A single lesion may:

• Be the initial presentation before more lesions develop
• Represent an aborted outbreak in partially immune individuals
• Be the complete manifestation in some cases

Management Approach

Even with a single lesion, treatment should follow standard shingles protocols if diagnosed:

• Initiate antiviral therapy promptly (within 72 hours of rash onset):

  • Valacyclovir 1g three times daily for 7 days, OR
  • Famciclovir 500mg three times daily for 7 days, OR
  • Acyclovir 800mg five times daily for 7 days 1

• Provide appropriate pain management:

  • NSAIDs or acetaminophen for mild pain
  • Consider gabapentin, pregabalin, or tricyclic antidepressants for moderate to severe pain 1

Important Considerations

• Differential diagnosis is particularly important with single lesions:

  • Consider herpes simplex virus infection
  • Bacterial skin infections
  • Contact dermatitis
  • Other vesicular dermatoses

• Monitor for progression: A single lesion may be the first sign of a developing outbreak, so follow-up is important

• Complications: Even with a single lesion, patients remain at risk for postherpetic neuralgia, especially older adults 4

Prevention

For adults aged 60 years and older, zoster vaccination is recommended regardless of prior history of herpes zoster to prevent future outbreaks and complications 2.