Shingles typically causes blisters and rashes on the skin but may affect other body systems. These complications are sometimes referred to as “internal shingles” or zoster sine herpete (ZSH).

Internal shingles leads to unique symptoms and can involve a variety of organ systems. Read on to learn some of the unique risk factors of shingles as well as the symptoms that may occur when the virus affects more than the skin.

Learn more about shingles.

Internal shingles shares many symptoms with shingles on the skin, including:

  • pain
  • muscle aches
  • numbness and tingling
  • muscle weakness
  • itching and burning sensations
  • swelling of the lymph nodes, a sign that your body’s immune system is fighting the virus

In addition to these, symptoms of internal shingles are based on which body system is most affected. Body systems that can be affected include the eyes, ears, nervous system, throat, stomach, lungs, and brain.

Internal shingles can cause symptoms such as persistent pain, abdominal pain, weakness in facial muscles (Bell’s palsy), hearing loss or pain in the ear (Ramsay Hunt syndrome), and headache. When shingles affects internal organs, it’s a serious complication that requires urgent medical attention.

However, internal shingles doesn’t cause the rash (zoster) that’s commonly seen with shingles. Without the telltale rash, diagnosing internal shingles can be difficult, or it may be overlooked.

The varicella-zoster virus (VZV) causes shingles. It’s the same virus that causes chickenpox. After a bout of chickenpox, the virus becomes dormant in the body and settles in certain nerves and tissue of the nervous system. Later in life, the virus can reactivate and present itself as shingles.

It’s unclear why some people experience the classic form of shingles and others develop ZSH or internal shingles. It’s also not fully understood how many people develop this form of shingles.

In addition, because internal shingles is easily misdiagnosed, people with ZSH often have multiple rounds of virus activation. That means that VZV is able to be active in the body longer and many times over, which can lead to greater symptoms and more serious complications.

Many of the risk factors for internal shingles are the same as those for the skin rash of shingles. They include:

  • Having a weakened immune system: Having conditions such as HIV, having received an organ transplant, or having autoimmune conditions like lupus, rheumatoid arthritis, or inflammatory bowel disease can make you more susceptible to shingles.
  • Undergoing cancer treatment: Cancer, along with radiation and chemotherapy, also weaken your immune system and can increase your risk of VZV reactivation.
  • Being older than 60: Shingles can occur in people of any age. However, it’s more common in older adults. The annual rate of shingles in people over 60 in the United States is one case per 100 people.
  • Taking certain medications: Drugs that lower your chance of rejecting an organ transplant or that treat autoimmune diseases will increase your risk of shingles. Examples include cyclosporine (Sandimmune) and tacrolimus (Prograf). Extended use of steroids will also increase your risk. These medications suppress your immune system, making your body more vulnerable to VZV reactivation.
  • Stress and trauma. Stress, fatigue, and trauma are commonly related to shingles. It’s unclear how these events trigger shingles, but they’re known to depress the immune system.

Not receiving the shingles vaccine will also increase your chances of getting the condition. Even if you don’t remember ever having chickenpox, you should get the shingles vaccine.

Studies have shown that 99% of people over 40 have had chickenpox. According to the Centers for Disease Control and Prevention (CDC), there is no maximum age for the vaccine.

The virus that causes internal shingles is contagious to anyone who hasn’t had chickenpox or received the chickenpox vaccine.

You can’t get internal shingles itself from someone with shingles because the condition is a reactivation of the chickenpox virus. However, they can spread the chickenpox virus to you and you may later develop internal shingles.

If you have internal shingles, it’s possible that you could spread the virus through droplets that exit your lungs when you breathe, but more research is needed.

If you have shingles in rash form, you’re contagious until no new blisters have formed and until all blisters are scabbed over. A person with external shingles should maintain good hygiene, take any medication prescribed, and cover their lesions to minimize the possibility of spreading the infection.

Eye complications

Shingles can affect the nerves of the face. A branch of one of these nerves includes the eye. In fact, it’s increasingly common — one study found that cases of singles of the eye tripled in a 12-year period.

When this occurs, the condition can lead to injury of the eye and cornea, as well as significant inflammation in or around the eye. People with internal shingles may also develop lesions on the cornea of the eye.

Anyone with shingles involving the eye should be evaluated by an eye specialist as soon as possible. Treatment usually involves medicated eye drops and close follow-up to prevent permanent vision loss and damage.

Postherpetic neuralgia

Postherpetic neuralgia (PHN) is the most common complication of internal shingles. Research has shown that between 5% and 20% of people who develop shingles go on to develop PHN.

During a shingles outbreak, the nerve fibers where the virus has been dormant become inflamed. This leads to abnormal transmission of neural impulses. The result is pain.

However, once the infection has resolved, the pain can continue. This is known as PHN. It can lead to constant localized pain along with numbness and tingling for months after the shingle blisters have healed. Other symptoms can include off-and-on pain and increased sensitivity to touch.

In more severe cases, the symptoms can last for years. Besides getting the shingles vaccine, treatment early on during a shingles outbreak may help prevent this complication.

Ramsay Hunt syndrome

Ramsay Hunt syndrome occurs when the virus reactivates within one of the facial nerves responsible for hearing. This can lead to hearing loss, facial paralysis, and general pain in the face. It can also result in severe pain in the ear, and people with internal shingles may also develop lesions in the ear canal.

Ramsay Hunt syndrome is usually temporary and should subside over time. However, you’re encouraged to seek medical help for shingles, especially if it develops around the face and neck.

Other organ systems

In rare cases, shingles can affect other organs. This leads to more serious complications that can be life threatening.

In the brain, it can cause encephalitis. In the liver, it can cause hepatitis.

For people with internal shingles, a rare complication is VZV vasculopathy, or a viral infection of the arteries. If not treated properly, this can lead to a heart attack or stroke.

VZV meningitis is also a complication of internal shingles. In this condition, the protective membranes of the spinal cord and brain become inflamed. This puts pressure on the brain, and it can be life threatening.

These serious complications need urgent medical attention, rapid treatment, and hospitalization.

As with most other diseases, doctors will typically review your symptoms first. Be sure to take note of your exact symptoms, how long you’ve experienced them, and their severity.

Doctors may suspect internal shingles if your symptoms involve more than your skin. They’ll often suspect eye or nervous system involvement based on the location of the shingles rash, if you have one.

However, if you have no rash but have a cough, severe headache, or abdominal pain, you may have internal shingles or a more serious complication.

Doctors may perform the following tests to confirm your diagnosis of shingles:

  • direct fluorescence antibody stain
  • polymerase chain reaction
  • virus culture
  • VZV DNA test

There have been few trial studies that have examined internal shingles or the best treatments for this particular type of shingles. That’s why there are currently no guidelines for treatment. Instead, doctors rely on standard treatment for classic shingles.

Even though shingles is a virus, this is a case where there are antiviral medications available by prescription. That’s why it’s important to see a doctor right away if you suspect you have shingles. Early treatment may reduce the risk of complications, like PHN. Serious complications require hospitalization.

Common antiviral medications for shingles include:

  • acyclovir (Zovirax)
  • valacyclovir (Valtrex)
  • famciclovir (Famvir)

Depending on the location and severity of shingles, steroids may also help. Anti-inflammatory medications like ibuprofen (Advil) and pain-relieving medication such as acetaminophen (Tylenol) or other prescription pain medication can help in easing pain experienced from shingles.

People who’ve had multiple bouts with internal shingles may be less reactive to antiviral drugs. This makes early and swift treatment important.

Shingles affects an estimated 1 in 3 people in the United States throughout their lifetime, according to the CDC. In certain cases, the virus can cause more severe infections, inflammation, or complications.

It’s unclear how many people experience internal shingles, but it’s a rare condition. However, depending on the organ system affected, it can be life threatening.

Plus, people with internal shingles are more likely to receive a misdiagnosis and delayed treatment. That can make the complications of the condition more severe. It’s important to see a doctor as soon as you suspect you may have internal shingles.

They can provide a series of effective ways to manage symptoms and treat the virus. They can also check you to make sure you don’t have a more serious complication.

Shingles is a highly preventable disease. The most important prevention method is the shingles vaccine (Shingrix).

This vaccine is over 90% effective for prevention of shingles in those with healthy immune systems. The CDC currently recommends getting the vaccine starting at age 50. The full benefits of the shingles vaccine last for at least 7 years.

Along with vaccination, other ways you may help prevent internal shingles include:

  • getting adequate sleep
  • not smoking
  • properly managing any ongoing health problems
  • getting checked regularly by a doctor if you have a condition that affects your immune system
  • properly managing any disorders that compromise the immune system
  • sticking to your treatment regimen if shingles has already been diagnosed


How soon do I need to see a doctor if I have shingles?

Anonymous patient


It’s important to see a doctor right away if you suspect shingles. If you have … headache, fever, cough, or abdominal pain, get immediate medical attention. These can be signs of a complicated or systemic shingles infection. You may need blood tests, an X-ray, a lumbar puncture, or a CT scan to determine your diagnosis. If you have a complicated shingles infection, you’ll need urgent treatment and hospitalization.

Judith Marcin, MDAnswers represent the opinions of our medical experts. All content is strictly informational and shouldn’t be considered medical advice.
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