Internal shingles still causes pain and itching—just without the rash—along with other symptoms. Because healthcare providers may not recognize it as a shingles infection, ZSH infections may be more common than previously thought.
This article explores the differences in symptoms, the additional complications ZSH can cause, how it’s diagnosed and treated, and how you can cope with it.
Why Two Types of Shingles?
Most people are infected with VZV at some point. This type of virus stays in your body forever, but it lies dormant most of the time. When it reactivates, it causes shingles.
Reactivation typically affects a single nerve (dermatome) and the itching and pain (and rash, in a typical case) are confined to the path of that nerve. That generally means symptoms in a stripe on one side of your body. Disseminated zoster affecting multiple dermatomes can occur in immunocompromised individuals.
Typical shingles develops from an infection in a sensory nerve (one that runs close to the surface of your skin and provides sensation).
In internal shingles, the infected nerve is deeper in the body, often in the digestive organs. It doesn’t cause a rash because those nerves don’t connect to your skin.
Symptoms: Typical Shingles
For most people, the first sign of shingles is some sort of tactile sensation—like itching or shooting, burning pain—in the area where the rash will appear, possibly several days later.
Other early shingles symptoms may include:
HeadacheFever and chillsUpset stomach
Eventually, fluid-filled blisters develop on the skin.
Symptoms: Internal Shingles
Internal shingles doesn’t have the same distinct two-phased presentation. Like traditional shingles, though, it affects the area controlled by a single nerve.
Internal shingles symptoms include:
Nerve pain An area of numbnessItchy, burning sensationsHeadacheFatigueGeneral achinessLesions in mucous membranes, an ear canal, and internal organs (e. g. , stomach, intestines) Abdominal pain or hoarseness caused by lesions
One study suggested internal shingles pain is even more intense than traditional shingles pain. Some people say it’s a deep sensation that affects their muscles and joints.
Complications
Some people with either type of shingles may develop serious complications.
Postherpetic Neuralgia
Between 10% and 18% of people who have shingles are left with postherpetic neuralgia (PHN). It’s more common in older people.
With PHN, pain continues even after shingles is gone. It can produce lifelong effects that interfere with your quality of life.
Other Complications
Other potential complications include:
Meningitis Ramsay Hunt syndrome Polyneuritis cranialis (PNC), which affects the cranial nerves (nerves of the head) Cerebellitis, an inflammation of the cerebellum (a region of the brain) Myelopathy, a spinal cord injury caused by compression Potentially fatal problems such as encephalitis and stroke
One case study suggests complications such as PHN are more likely in people who develop shingles without a rash. This may be because, without a rash, you’re less likely to go to a healthcare provider right away.
Diagnosis
If you have a strip of nerve pain without a rash, you may have internal shingles. You should see a healthcare provider right away for diagnosis and treatment.
A lab test can help diagnose a ZSH infection. It’s especially helpful for detecting the virus when you don’t have conventional symptoms.
The test can use samples from:
A swabbed lesion Cerebrospinal fluid Blood Saliva
The polymerase chain reaction (PCR) test is the most useful for detecting VZV in people without a shingles rash. A direct fluorescent antibody (DFA) test is sometimes used but it’s not as sensitive as PCR.
Differential Diagnoses
Differential diagnosis is medical jargon for “what else could it be?” Differential diagnoses for the type of pain caused by ZSH include:
Older adultsPeople with compromised immune systemsPeople with certain systemic diseases, such as kidney disease
Nerve impingement (pressure on a nerve) Neuropathy (pain from damaged nerves) Arthritis and other inflammatory diseases Bone spurs Spinal injury or infection Fibromyalgia
The location of your pain may suggest other conditions, as well. Your healthcare provider may perform multiple tests to rule out possible causes of your symptoms.
Internal Shingles Treatment
Research on ZSH treatments is limited. However, the typical treatment involves antiviral medications such as Valtrex (valacyclovir) or Zovirax (acyclovir).
Pain management is also an essential part of treating internal shingles. Some drugs that may help with nerve pain include:
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Advil (ibuprofen) or Aleve (naproxen) Tylenol (acetaminophen) Anti-seizure medications such as Neurontin (gabapentin) or Lyrica (pregabalin) Tricyclic antidepressants such as amitriptyline, Norpramin (desipramine), Pamelor (nortriptyline) Corticosteroids such as prednisone, hydrocortisone, methylprednisolone Nerve blocks (injections of anesthetics near the spinal column) Opioids such as Vicodin (hydrocodone/acetaminophen), OxyContin (oxycodone), Ultram (tramadol)
Lesions and complications should also be treated.
Coping
Coping with the pain of shingles, regardless of type, can be harder than just taking pain medications. The discomfort may disrupt your life and make it hard to sleep. It can also cause depression.
You may want to ask your healthcare provider about a sleep aid or antidepressants.
Topical pain and itch relievers and oatmeal baths that help some people with typical shingles may or may not be effective for internal shingles, but they’re generally safe to try.
If you’re struggling to cope, talk to family and friends about what you’re going through. You may also want to find a support group, online or in your community, for people with shingles, PHN, or chronic pain.
Summary
Internal shingles doesn’t involve a rash like typical shingles. This is because it affects nerves that are deeper in the body and don’t connect to the skin. It still causes an itch and severe pain, and may even be more painful than a shingles rash.
Internal shingles is harder to recognize so people may go to a healthcare provider later, and healthcare providers may misdiagnose it. This delays treatment and can lead to complications such as postherpetic neuralgia.
Internal shingles is treated with antivirals and a variety of medications that help control pain. You may benefit from antidepressants and sleep drugs, as well. A support group may help you cope.
Since internal shingles does not leave a skin rash, it can be trickier to diagnose and may require a lab test.
A shingles complication called postherpetic neuralgia (PHN) can cause intense, long-term nerve pain. This can last for months or years after shingles resolves.
