Herpes Zoster Without Dermatomal Rash

Yes, you can get shingles without a dermatomal rash, a condition known as zoster sine herpete (shingles without rash). 1

Clinical Presentation of Atypical Herpes Zoster

Zoster sine herpete is characterized by radicular pain in a dermatomal distribution without the typical vesicular eruption 1
Patients may experience prodromal symptoms similar to typical herpes zoster, including malaise, headache, and abnormal skin sensations, but without subsequent rash development 2
Some patients may present with nonspecific lesions that do not initially have the vesicular appearance typical of herpes zoster 3
The rash might be atypical, localized, faint, or evanescent in some cases, making diagnosis challenging 3

Immunocompromised status significantly increases the risk of developing atypical presentations of herpes zoster 4
Patients with conditions that decrease cell-mediated immunity are 20 to 100 times more likely to develop herpes zoster, including atypical forms 2
Advanced age is associated with increased risk of herpes zoster reactivation and atypical presentations 4
Recipients of blood, bone marrow, or solid organ transplants are at higher risk for developing herpes zoster with potential atypical manifestations 3, 4

In cases of suspected zoster sine herpete, diagnostic confirmation is challenging and may require virus isolation and serological tests 5
Tzanck smear showing giant cells can be diagnostic for herpesvirus infection even in atypical presentations 3
Vesicle fluid specimens (if any lesions are present) can be obtained for immunofluorescence antigen testing, culture, or PCR to confirm diagnosis 3
VZV DNA may be detected in blood mononuclear cells of elderly individuals even in the absence of skin lesions 1

High-dose IV acyclovir is recommended for immunocompromised hosts with suspected herpes zoster, even without typical rash 3, 6
Oral antiviral therapy with acyclovir, valacyclovir, or famciclovir should be initiated as soon as possible after diagnosis, even in atypical presentations 6
Treatment should ideally begin within 72 hours of symptom onset to reduce viral replication and prevent complications 2
Lack of rash or late-onset rash in herpes zoster has been associated with delays in diagnosis and increased mortality in some cases 3

Postherpetic neuralgia can develop even in cases without visible rash, occurring in approximately 20% of herpes zoster patients 2
Immunocompromised patients may develop chronic complications with persistent viral replication, even with atypical presentations 3, 4
Secondary bacterial and fungal superinfections can occur, particularly in immunocompromised hosts 3
Neurological complications including various motor neuropathies, encephalitis, and Guillain-Barré syndrome can occur with or without typical rash 5

Elderly patients may develop painless herpes zoster, another atypical presentation that can further complicate diagnosis 7
Consider herpes zoster in the differential diagnosis for patients with unexplained dermatomal pain, even without visible rash 1
VZV can produce neurologic and visceral diseases in the absence of rash or radicular pain 1
Antiviral resistance should be investigated if symptoms persist despite appropriate therapy, especially in immunocompromised patients 4