The Different Phases of Herpes Zoster (Shingles) & How To Treat Them

 By Consultant Dermatologist, Prof. V. R. Janaki

Human Herpes viruses (HHV) are assuming more importance in the recent times. Herpes Zoster also known as ‘shingles ‘ is caused by Varicella Zoster virus (chicken pox virus). When we are exposed to the virus for the first time we develop chicken pox, one of the common viral rash in childhood. Occasionally a small percentage of adults also get chickenpox if they have not had it in childhood.

The suffering is more due to the severity of infection and complications. It is better to have viral infections in childhood and develop immunity as most of the viral infections confer lifelong immunity, after an attack. Even though vaccines are available for the prevention of chickenpox it is still preferable to develop immunity after suffering from the disease. Otherwise after the age 8 to 10 years, assess the antibody titre, because occasionally children might have suffered a subclinical form, and then give the vaccine.

The Chickenpox Virus:

Coming to Herpes Zoster, what is the role of the chicken pox virus? After an attack of chickenpox, the virus remains dormant or latent in the posterior nerve root ganglion, in the spinal cord region for years. At one point of time, this latent virus gets activated per se or due to some precipitating factors like diabetes, lymphomas, leukaemias, malignancies, and AIDS, where the body’s immune status suffers a big blow. The virus travels down the nerve, pierces the skin, and produces skin lesions.

The 3 phases of Herpes Zoster:

Clinically Herpes Zoster has three phases – Pre herpetic phase, Herpetic phase, and Postherpetic phase.

Pre-herpetic phase of Shingles: 

In the pre herpetic phase, the patients suffer from unexplained vague aching pain along with a dermatome, and it is easily passed off as unilateral headache, cervical spondylosis, pleurisy, atypical angina, sciatica etc. When the abdominal dermatomes are involved it may mimic an acute abdomen and patients seek the surgeon’s help. The moment the vesicles and bullae appear, diagnosis becomes obvious.  This phase lasts from three days to one week.

Herpetic phase of Shingles:

In the next phase, patients develop grouped vesicles on an inflamed base ( boil-like lesions ) strictly confined to one side, wherever it crops up -face , chest, back, abdomen, limbs and does not cross the midline. It has got a segmental distribution. The patient complains of pricking or burning pain in these areas and the pain really puts them off.

Post-herpetic phase of Shingles:

It lasts for about 1 to 3 weeks though the intensity may come down. Occasionally the pain persists after 8 weeks also and it is called postherpetic neuralgia. Even though the lesions dry up leaving a scar, the pain persists as the lesions in the vicinity of nerve take a long time to heal. But for this nagging pain, it runs an uneventful course.

In older individuals,  complications like severe infections, sloughing, gangrene, facial palsy (when it involves the face) and eye complications (when the nerve supplying the eyes are involved) are encountered. Due to eye complications, they may even lose vision. Dermatologists and Ophthalmologists should treat these patients together on a priority basis.

Treatment for shingles:

Most of the time it is a self-limiting disease and requires only analgesics, anodynes, antibiotics and vitamins. Anti-viral drugs like Acyclovir and Famciclovir have come as a boon for the management of Zoster. Early antiviral therapy helps in faster recovery and prevents the occurrence of complications.

One of the complications, Post-herpetic neuralgia is really a nightmare to the patients as the pain persists for months or even years, and poses a big challenge to the doctors. But time is the best healer as the majority of them recover in the course of time and the constant reassurance and symptomatic therapy with drugs intensity of pain becomes less and less. Very rarely they require neuro surgical  procedures.


A word of caution. Painting the vesicles of Zoster with Potter’s clay ( Semman– in Tamil ) is not at all advisable as you are introducing further infection by meddling. The moment you see the first crop of vesicles with pain, consult a dermatologist .