Can you have internal shingles without a rash?

Internal Shingles Without a Rash

Yes, you can have internal shingles without a visible rash, which is known as "zoster sine herpete" - a form of shingles where viral reactivation occurs internally without the characteristic skin manifestations.

Understanding Internal Shingles

Shingles (herpes zoster) is caused by reactivation of the varicella-zoster virus (VZV) that remains dormant in nerve ganglia after a primary chickenpox infection. While most cases present with the classic painful, vesicular rash in a dermatomal distribution, some cases can manifest without visible skin lesions.

Clinical Presentation of Internal Shingles

When shingles occurs internally without a rash, patients may experience:

• Unexplained pain in a dermatomal distribution
• Burning, tingling, or itching sensations
• Fever and malaise
• Neurological symptoms specific to the affected nerves
• Abdominal pain (if affecting thoracic/abdominal dermatomes) 1

Diagnostic Challenges

Internal shingles presents significant diagnostic challenges:

• The absence of the characteristic rash makes clinical diagnosis difficult
• Symptoms may mimic other conditions like appendicitis, gallbladder disease, or other acute abdominal conditions 1
• Diagnosis often relies on:
  • History of dermatomal pain
  • Laboratory confirmation (PCR testing for VZV)
  • Exclusion of other causes

Risk Factors

Certain populations are at higher risk for developing internal shingles:

• Older adults (increasing incidence with age) 2
• Immunocompromised individuals, particularly:
  • HIV-infected persons (15-fold higher incidence) 3
  • Patients on chemotherapy
  • Transplant recipients
  • Those on chronic corticosteroids 2

Clinical Significance

Internal shingles without rash can lead to several complications:

• Postherpetic neuralgia (persistent pain after the infection resolves)
• Visceral involvement including pneumonia, hepatitis, or encephalitis (especially in immunocompromised patients) 4
• Neurological complications including motor neuropathies and Guillain-Barré syndrome 5

Management Considerations

Treatment should be initiated promptly when internal shingles is suspected:

• Antiviral medications (acyclovir, famciclovir, or valacyclovir) are most effective when started within 72 hours of symptom onset 2
• Pain management may require:
  • Analgesics
  • Tricyclic antidepressants or anticonvulsants for neuropathic pain
  • In severe cases, narcotics may be necessary 2

Special Populations

HIV-Infected Individuals

HIV-infected patients present unique challenges:

• Higher incidence of herpes zoster at any CD4+ count
• May experience prodromal pain and itching several days before any symptoms appear
• Can involve multiple dermatomes
• Higher risk of recurrence
• May develop chronic shingles 4

Elderly Patients

Elderly patients may have atypical presentations:

• Sometimes painless herpes zoster can occur 6
• Higher risk of postherpetic neuralgia
• May have more severe complications

Key Points for Clinicians

• Consider internal shingles in patients with unexplained dermatomal pain, especially in high-risk populations
• Early diagnosis and treatment improve outcomes and reduce complications
• Laboratory confirmation may be necessary in the absence of characteristic rash
• Maintain high clinical suspicion in immunocompromised patients with unexplained pain syndromes

Remember that while the classic triad of herpes zoster includes fever, rash, and reported pain, this triad is present in only a minority of patients during initial presentation 3. The absence of rash should not preclude consideration of zoster as a diagnosis.