Can shingles pain present without vesicles?

Can Shingles Pain Present Without Vesicles?

Yes, shingles pain can absolutely present without vesicles—this condition is called zoster sine herpete (ZSH), and it may actually cause more severe and prolonged pain than typical herpes zoster with rash. 1, 2

Understanding Zoster Sine Herpete

Zoster sine herpete is an uncommon but well-documented manifestation of varicella-zoster virus (VZV) reactivation that presents with unilateral dermatomal pain but without the characteristic vesicular rash. 3, 2

Key Clinical Features:

• Patients experience typical prodromal dermatomal pain that would normally precede skin findings by 24-72 hours, but the vesicular eruption never appears 1
• The pain follows the same unilateral dermatomal distribution as typical herpes zoster 3, 2
• Laboratory confirmation showing VZV reactivation is essential for diagnosis, as the absence of rash makes clinical diagnosis challenging 1, 2

Pain Characteristics in ZSH vs. Typical Herpes Zoster

Importantly, ZSH patients experience significantly more severe pain than those with typical herpes zoster rash. 2

• ZSH patients average VAS pain scores of 76.88 compared to 66.88 in typical HZ patients (statistically significant difference) 2
• ZSH patients require significantly more opioid therapy than HZ patients (9-fold increased odds) 2
• Pain duration is longer in ZSH, with VZV DNA persisting significantly longer in serum (1 month after onset) compared to typical HZ 2

Diagnostic Approach

The American Geriatrics Society recommends confirmatory testing for atypical presentations, including absence of characteristic pain or rash. 1

Recommended diagnostic tests include:

• Tzanck preparation (shows giant cells confirming herpesvirus but cannot distinguish HSV from VZV) 1, 4
• Immunofluorescent viral antigen studies 1
• PCR for VZV DNA (most sensitive and specific) 1, 4
• Viral culture 1
• Serological testing showing elevated VZV IgG levels 3

Critical Clinical Pitfalls

A high index of suspicion is necessary when patients present with unilateral dermatomal pain without rash, as delayed diagnosis can lead to serious complications. 1, 3

• Lack of rash or late-onset rash has been associated with delays in diagnosis and increased mortality in some cases 1
• ZSH can cause serious complications including lateral sinus thrombosis, encephalitis, and other neurological sequelae even without visible skin lesions 3
• The condition is particularly challenging in immunocompromised patients who may present with chronic ulcerations lacking the vesicular component entirely 1, 4

Management Considerations

Even without visible rash, antiviral therapy should be initiated promptly when ZSH is suspected based on clinical presentation and confirmed by laboratory testing. 1, 5

• High-dose IV acyclovir is recommended for immunocompromised hosts 1
• Oral antivirals (famciclovir, valacyclovir, or acyclovir) are effective if started within 3 days of symptom onset 5
• Aggressive pain management is particularly important in ZSH given the greater severity and duration of pain 2
• Screen for underlying immunosuppression (HIV, diabetes, malignancy, immunosuppressive medications) as these increase risk and severity 1

Monitor closely for postherpetic neuralgia development, as ZSH patients appear to have higher risk given their more severe acute pain presentation. 2