Can shingles (herpes zoster) occur without pain?

Painless Shingles: Atypical Presentation of Herpes Zoster

Yes, shingles (herpes zoster) can occur without pain, though this is an atypical presentation that is less commonly recognized in clinical practice. 1 While pain is a hallmark feature of herpes zoster infection, some cases may present without the characteristic painful symptoms.

Typical Clinical Presentation of Herpes Zoster

Herpes zoster typically presents with:

• Prodromal pain that often precedes the skin findings by 24-72 hours (and sometimes longer) 2
• Unilateral vesicular eruption in a dermatomal distribution 2
• Progression from erythematous macules to papules and then to vesicles 2
• Lesions that continue to erupt for 4-6 days in immunocompetent hosts 2
• Total disease duration of approximately 2 weeks in otherwise healthy individuals 2

Atypical Presentations

Several variations from the typical presentation can occur:

• Some patients may present with painless herpes zoster, particularly in elderly or immunocompromised patients 1
• Patients may present with nonspecific lesions that do not initially have the vesicular appearance of typical zoster 2
• The rash might be atypical, localized, faint, or evanescent in some cases 2
• In some individuals with darker skin pigmentation, the rash might be difficult to recognize 2

Risk Factors for Herpes Zoster

Certain populations are at higher risk for developing herpes zoster:

• Increasing age (particularly those over 60 years) 3, 4
• Conditions that decrease cell-mediated immunity 3
• Immunosuppressed patients (HIV infection, chemotherapy, malignancies, chronic corticosteroid use) 5
• Recipients of blood, bone marrow, or solid organ transplants 2

Diagnostic Considerations for Painless Zoster

When pain is absent, diagnosis may be more challenging:

• Presence of a unilateral vesicular rash in a dermatomal distribution should raise suspicion for herpes zoster even in the absence of pain 1
• Tzanck smear showing giant cells can be diagnostic for herpesvirus infection 2
• Vesicle fluid specimens can be obtained for immunofluorescence antigen testing, culture, or PCR to confirm diagnosis 2
• Consider alternative diagnoses that may mimic herpes zoster, especially in the absence of characteristic pain 2

Clinical Implications and Management

Management considerations for painless herpes zoster:

• Antiviral medications (acyclovir, valacyclovir, famciclovir) remain the treatment of choice, ideally started within 72 hours of rash onset 5, 3
• High-dose IV acyclovir is recommended for immunocompromised hosts 2
• Oral antiviral therapy can be used for mild cases in patients with transient immune suppression 2
• Even without pain, patients should be monitored for potential complications including secondary bacterial infections 2
• Prevention through vaccination is recommended for adults 60 years and older 3

Potential Complications

Even painless herpes zoster can lead to complications:

• Postherpetic neuralgia (PHN) can develop even after initially painless zoster 4
• Immunocompromised patients may develop chronic ulcerations with persistent viral replication 2
• Secondary bacterial and fungal superinfections can occur, particularly in immunocompromised hosts 2
• Ocular involvement requires prompt referral to an ophthalmologist to prevent vision-threatening complications 5

Clinical Pearls and Pitfalls

• Do not rule out herpes zoster based solely on the absence of pain 1
• Maintain a high index of suspicion for zoster in elderly or immunocompromised patients with a unilateral vesicular rash, even without pain 1
• Consider herpes zoster in cases of persistent radicular symptoms, even with prolonged prodromal periods 6
• Lack of rash or late-onset rash in herpes zoster has been associated with delays in diagnosis and increased mortality in some cases 2