Shingles typically causes blisters and rashes on the skin. In rare cases, you may experience other symptoms without a rash. This is referred to as “internal shingles” or zoster sine herpete (ZSH).

The most common symptom of shingles is a rash that develops in a band around the chest and abdomen area on one side of the body.

In rare cases, you may have shingles but not develop a rash. This is known as zoster sine herpete (ZSH), or “internal shingles.”

Shingles and ZSH are caused by the varicella-zoster virus (VZV), which is the same virus that causes chickenpox.

ZSH is rare and likely underrecognized. There isn’t much statistical data on the condition. As a result, no specific treatment guidelines set it apart from typical shingles management.

That said, being aware of the unique symptoms and risk factors could help you identify internal shingles.

Keep reading to learn more.

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

Shingles can cause a painful rash (zoster) and be associated with other, more extensive conditions, such as:

Sometimes the rash is hidden (as in an ear canal) or not present at all.

Remember, internal shingles does not cause the rash commonly seen with shingles. Without the telltale rash, diagnosing internal shingles can be difficult, or it may be overlooked.

Some additional symptoms of internal shingles may include chest pain and headaches.

Like shingles, internal shingles happens when VZV reactivates.

After a bout of chickenpox, VZV becomes dormant in the body and settles in certain nerves and tissues 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 internal shingles. It’s also not fully understood how many people develop this form of shingles.

Internal shingles is easily misdiagnosed, which can lead to greater symptoms and more serious complications.

The biggest risk factor for shingles is whether you previously had chickenpox.

According to the Centers for Disease Control and Prevention (CDC), over 99% of people born before 1980 in the United States have had chickenpox.

Other risk factors may also increase the likelihood of internal shingles and shingles with a skin rash. According to the American Academy of Dermatology (AAD), these may include:

  • having a weakened immune system, such as from HIV or some cancers like leukemia
  • undergoing cancer treatment, such as chemotherapy
  • being older than age 50 years
  • taking certain medications, such as for psoriatic arthritis, or having had an organ transplant

Stress, fatigue, and trauma are also 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 may also increase your chances of getting the condition.

VZV, the virus that causes internal shingles, is only contagious to people who have not had chickenpox or received the varicella (chickenpox) vaccine.

If you have not had chickenpox or the chickenpox vaccine, someone with shingles may transmit the virus to you.

However, VZV will first develop as chickenpox and may only later develop as “internal” or classic shingles.

If you have internal shingles, the VZV virus may be transmitted through droplets that exit your lungs when you breathe, but more research is needed.

Shingles in rash form is transmitted by direct contact with the fluid oozing from the blisters.

Learn more about shingles and transmission.

Internal shingles symptoms may vary depending on which body system is most affected. This may include:

  • eyes
  • ears
  • nervous system
  • throat
  • stomach
  • lungs
  • brain

When shingles affects internal organs, it’s a serious complication that requires urgent medical attention.

Postherpetic neuralgia

Postherpetic neuralgia (PHN) is the most common complication of internal shingles. It affects up to 1 in 5 people with shingles.

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

PHN is when this pain persists after the infection has resolved.

A small 2018 study showed that participants with internal shingles experienced higher levels of PHN pain and required more opioid therapy than those with external shingles.

In serious cases, PHN may lead to long-term complications in the brain, as well as anxiety and depression.

Getting the shingles vaccine and early treatment during a shingles outbreak may help prevent PHN.

Eye complications

Shingles can affect the nerves of the face. A branch of one of these nerves includes the eye.

Research suggests that eye complications related to shingles have tripled in a 12-year period.

This may lead to injury of the eye or cornea, as well as significant inflammation in or around the eye. People with shingles or “internal” shingles may develop corneal abrasions.

It’s important to see a healthcare professional immediately if you experience eye complications and have internal shingles.

Treatment usually involves medicated eye drops and close follow-up to prevent permanent vision loss and damage.

Ramsay Hunt syndrome

Ramsay Hunt syndrome occurs when VZV reactivates within one of the facial nerves responsible for hearing.

This may lead to hearing loss, facial paralysis, and general facial pain. It might also result in severe ear pain, 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, it’s best to speak with a healthcare professional if you have internal shingles, especially if it develops around the face and neck.

Other organ systems

In rare cases, internal shingles may affect other organs and lead to life threatening complications, including:

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

There are no specific guidelines for diagnosing internal shingles. Due to the absence of a rash, it’s difficult to make a diagnosis from a physical evaluation alone.

A healthcare professional will request a medical history. It’s important to tell them whether you’re living with a chronic condition and take any medications.

They’ll ask you about your symptoms, including their nature, severity, and duration.

In particular, they may ask if you experienced facial or muscular paralysis and radicular pain. These are signs of internal shingles.

A doctor will most likely order the following tests to confirm an internal shingles diagnosis:

Learn more about how shingles is diagnosed.

Few studies have examined internal shingles and the best treatments. As such, doctors rely on standard treatment for classic shingles.

Prescription antiviral medications are available to help treat shingles.

The AAD reports that it’s important to see a doctor within 3 days of symptoms starting if you suspect you have shingles. Early treatment may reduce the risk of complications that could require hospitalization.

Common antiviral medications for shingles include:

Antiviral medications may be less effective in people with internal shingles than in people with classic shingles.

Other medications that may help include over-the-counter medications like ibuprofen (Advil) and acetaminophen (Tylenol) to help relieve pain.

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

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

People with internal shingles are more likely to receive a misdiagnosis and delayed treatment, making complications of the condition more severe.

According to the CDC, the most important prevention method is the shingles vaccine (Shingrix). It’s over 90% effective for preventing shingles in people with a healthy immune system and 68% to 91% for people who have a weakened immune system.

The CDC currently recommends getting the vaccine starting at age 50 years. The full benefits of the shingles vaccine last for at least 7 years.

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

  • getting adequate sleep
  • not smoking
  • properly managing any ongoing health problems
  • getting regular check-ups if you have a condition that affects your immune system
  • properly managing any disorders that weaken the immune system
  • sticking to your treatment regimen if you’ve already received a shingles diagnosis

Q:

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

Anonymous patient

A:

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.

What are the symptoms of internal shingles?

Symptoms of internal shingles may include muscle aches, numbness, tingling, stomach pain, facial palsy, hearing problems, and headache.

What kind of doctor treats internal shingles?

A primary care doctor may diagnose and prescribe medications for internal shingles. If complications develop, you may need to see a specialist. This will depend on the affected body part.

What are silent shingles?

“Silent shingles” is another term for zoster sine herpete, which is when you experience shingles without a visible rash.

What can mimic shingles pain?

Some conditions that could mimic shingles pain may include cellulitis, chickenpox, stomatitis, folliculitis, contact dermatitis, and impetigo, among others. However, it’s important to note these are all skin rashes and lesions, so they’re more likely to mimic classic shingles rather than internal shingles.

Zoster sine herpete, also known as internal shingles, is when you experience symptoms of shingles without a skin rash.

Although rare, this condition is often misdiagnosed. This could lead to several complications that could affect the eyes, nervous system, and brain.

If you think you may have internal shingles, speak with a healthcare professional as soon as possible. They can provide a proper diagnosis and treatment plan.