Shingles and emotional stress

Stress Management Tips for Shingles Patients

Stress doesn’t technically cause shingles, but it can cause your immune system to weaken — and a weakened immune system can put you at risk for shingles.

A viral illness, shingles is caused by varicella zoster virus, the same virus that causes chickenpox. The virus lives in your body and reactivates more readily when your immune system is suppressed. According to the U.S. Centers for Disease Control and Prevention, approximately 1 million people in the United States experience a shingles outbreak every year.

If you get shingles, stress also can exacerbate your misery, by making the itching, burning, painful rash seem worse and lengthening your recovery time.

Shingles and Emotional Stress

Emotional stress is considered a trigger for shingles because it has been shown to weaken the body’s immune system. This can happen in those who have undergone a sudden shock, such as the death of a loved one, or people who face chronic work or life stress. An immune system weakened by stress provides the shingles virus with a window of opportunity. This is particularly true of people who already have challenged immune systems, either because they are older or because they have an immune deficiency or a chronic disease.

Stress also has been shown to alter a person’s perception of pain. People who are under stress are likely to feel the physical symptoms of a disease more acutely. The itching, burning, and aching normally associated with shingles becomes even more intolerable when a person is under stress

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Finally, continued stress can prolong the discomfort a shingles patient experiences. It can keep the immune system weak, preventing more rapid recovery. Studies have shown that stress also can lead to lingering complications from shingles. Some researchers have found that people under stress are more likely to experience prolonged pain as a result of postherpetic neuralgia, a complication in which shingles pain persists long after the rash has cleared.

Stress Management Tips to Outsmart Shingles

If you have shingles, try to avoid stress to aid the healing process and limit the possibility of complications. Practice these stress management tips as needed to get stress under control:

  • Talk out your feelings Expressing your feelings of stress to friends, loved ones, or a psychotherapist can help you tremendously.
  • Identify your stress triggers. Figure out what triggers stress in you, and try to avoid those situations or lessen their impact by dealing with them before they can affect you negatively.
  • Adopt a healthy lifestyle. Getting enough sleep, following a nutritious diet, and exercising regularly can go a long way toward managing stress. Avoid too much caffeine and alcohol.
  • Calm down. Find a meditation or relaxation technique that works for you, and use it when you start feeling overwhelmed by stress.
  • Find the right balance. Remind yourself of all the positives in your life when the negatives have you feeling stressed.

Practicing good stress management is smart self-care for everyone, but can be especially beneficial for people at risk of developing shingles or who already have the illness.

I Got Shingles as a Healthy 34-Year-Old, and It Was the Worst Pain I’ve Ever Felt

Science Source/Getty Images

A few weeks after my 34th birthday, my husband and I went for a Saturday hike—a weekly ritual we’d started after moving to New York State’s Catskill Mountains region a few months earlier. I’d been feeling a bit under the weather, and I hoped the fresh autumn air would do me good.

It didn’t. Later that night, I had chills and my skin felt strangely sensitive, like when you’re coming down with the flu. On top of that, it felt like I had pulled a muscle in my back or chest; when I breathed or stretched certain ways, I’d get shooting pains across my body. I blamed it on yoga.

Over the next two days, my body continued betraying me in weird ways. Painful red marks appeared under my armpit and my lower back; at first I chalked it up to the new sports bra I’d worn on my hike, but when they started growing in both size and pain, I wondered if a spider had bitten me in my sleep. When I tried foam-rolling away the strange muscular achiness in my back and chest, I swear I almost passed out—my back felt like it was on fire. At this point, I was marveling at my dumb luck: Who pulls a muscle, gets the flu, and gets attacked by bugs (or a really terrible sports bra) all in the same few days?

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Tuesday—which happened to be Election Day 2016—I woke up feeling no better, so my husband suggested that I should call a doctor. “You want to make sure you don’t have, like, shingles or something,” he said. I rolled my eyes. “I don’t have shingles,” I said. “People in their 30s don’t get shingles—at least not ones who run half marathons and write about health for a living.”

Still, I Googled. And when I read the description and saw photos, my mouth dropped. Red, painful rash on the upper torso, one side of the body. Flu-like symptoms. Sensitivity to touch. Chest pain. Holy crap: I had all the symptoms of shingles!

Being new in town, I ended up at the first doctor’s office that could squeeze me in. I could tell the first doctor who saw me doubted my self-diagnosis. After looking me over, she left the room to consult with a more senior physician.

That doctor was skeptical too, until he saw my back. Although the rash was in its early stages, he confirmed that it looked like shingles. And while it was surprising to see it in someone like me, it wasn’t unheard of.

He asked if I’d been under a lot of stress lately, since shingles and stress are often linked. I laughed: I’d moved upstate to get away from stressful New York City life!

Then again, I’d recently bought a house, moved away from my friends, started a new work-from-home job, and gone from a dual-income household to a single-income one. (My husband left his job in the city and hadn’t landed a new one yet.) And I had been getting more worked up than normal about the election, especially on social media. So, yeah, I guess things were still stressful.

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The doc told me to avoid close contact with anyone who hadn’t had chicken pox. Shingles and chicken pox are caused by the same virus in the herpes family, varicella-zoster virus, which stays in the body for life. While shingles itself isn’t contagious, anyone who didn’t already have the virus could catch chickenpox from my rash. Good thing I didn’t feel up to visiting my baby niece and nephew that weekend anyway.

The doctor also prescribed me a week’s worth of antiviral medication along with over-the-counter pain relievers, and recommended I “try to avoid unnecessary stress.” (Did I mention it was Election Day? I think I slept two hours that night.)

Over the next two days, my diagnosis became excruciatingly clear. The rash spread from the middle of my back to the middle of my chest, and the pain when I breathed got 10 times worse. The day after my diagnosis, I struggled through a workday, signed off early, and collapsed on my bed, sobbing hysterically.

You might assume that the rash was the bad part, since it’s the most visible. And yeah, it felt like sunburn and bad bruising at the same time, and I couldn’t wear a bra for a week. But that stabbing sensation in my chest was now coming in waves, and it may have been the worst, scariest, pain I’ve ever felt. My doctor reassured me it was a normal part of shingles: Depending on which nerves are affected by the virus, the pain can sometimes be mistaken for heart, lung, or kidney problems.

Luckily, antiviral drugs can speed healing, especially if taken with the first three days after a rash appears. Over the next week or so my chest pain tapered off, and my rash blistered up and slowly started to fade.

By Saturday, a week after this whole thing started, I was able to get out for an easy hike. It was almost a month before I felt normal enough again to go for a run or do a high-intensity workout; when I finally did, I remember being so thankful I could breathe deeply without pain—something you don’t appreciate until you suddenly can’t! It took a few months for my rash to completely disappear, but it could have been worse: In some cases, shingles can cause permanent scarring or long-term nerve pain.

When I told people I had shingles, many were surprised. But more than a handful of friends—young women my age—chimed in to say they’d had it too. (One said she’d even heard about two other friends who’d also been diagnosed that week!)

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My doctor told me that once you get shingles, you’re at higher risk for recurrences. He suggested I look into a vaccine that could protect me against future flare-ups—but it costs a couple hundred dollars, and it’s unlikely that my insurance will cover it since I’m so young.

I know that shingles can come on randomly—that it probably wasn’t my lifestyle or some underlying condition that caused me to get sick. I suspect that stress may have contributed, but I also think that being healthy and fit helped me fight it off relatively quickly.

I also know that keeping my immunity up is smart no matter what. So for now, I’m just trying to take care of myself, even better than before. That means eating healthy, exercising regularly, keeping a consistent sleep schedule, and yes, trying to avoid unnecessary stress (and political rants!) whenever I can.

A red mark seemed like a bug bite two summers ago, so Kendra Jones dismissed the painful spot on her back. When it spread and the pain worsened, a doctor’s diagnosis surprised Jones, then 35. She had shingles.

“I went through this feeling of shock and disbelief because I was under the impression that was something that people who are older experienced,” said Jones. “I also asked a lot of questions about how it happened, and it came down to stress.”

At the time, she was planning an international trip, working more and putting in extra hours for a nonprofit. “I keep myself really busy. Even though I like my life to be like that, I think sometimes my body doesn’t.”

Shingles is caused by the varicella-zoster virus, which also causes chickenpox. Shingles symptoms include pain, itching or tingling of the skin, followed by a painful rash of blister-like sores. The condition occurs more commonly in people much older because the body’s immune system weakens with age.

If you’ve had chickenpox, the virus lies inactive in nerve tissue. Many years later, the virus can reactivate as shingles, which happens for about 1 in 3 people in the U.S. A newer shingles vaccine is recommended only for people at ages 50 and older.

A family medicine doctor at MultiCare Rockwood Quail Run Clinic, Dr. Gretchen LaSalle said she sees shingles in patients younger than 50. Rates in that population have risen since the 1940s, she said. Doctors have a few theories about why.

“Stress is thought to be a pretty big contributor,” LaSalle said, with either physical or emotional stress on the body – along with rising levels of the stress hormone cortisol – that can cause our immune system to weaken, she added.

“Our world is stressful, our jobs are stressful, and many of us don’t get enough sleep. We are glued to our technology. We’re missing out on that human connection and positive relationships that increase our well-being and decrease stress.”

Other factors include smoking, heavy alcohol consumption and not eating right, she said. Another theory is that people are living longer with cancer, HIV and other conditions that suppress the immune system, and they’re diagnosed younger. They are at higher risk for shingles.

LaSalle wrote a newly published book that is a clinicians’ guide to vaccines and vaccine hesitancy. She said another theory about shingles in younger people considers possible effects since chickenpox vaccinations started in 1996.

“For people who had chickenpox, it’s thought that adults get some benefit from being re-exposed to kids who have chickenpox,” she said. “It’s sort of a little immune booster.”

“The theory is now that we vaccinate and kids aren’t getting chickenpox, the adults aren’t getting that little boost in their immune system, but that doesn’t account for the rise we’ve seen since the ’40s because the chickenpox vaccine wasn’t out until 1996.”

The Centers for Disease Control and Prevention cites more cases of shingles for people ages 50 to 59 and some rise in the 30-49 category. “This trend continues among younger and middle-aged adults,” the agency says.

What to look for

Usually before the rash, symptoms can be anything from tingling and itching to burning, LaSalle said. It’s usually along a nerve root and on half the body, so on one side of the face, abdomen or down one leg.

Several days later, a rash appears as a cluster of blisters usually in a linear pattern. Look for a stripe across the belly, down a leg or an arm, LaSalle said, and don’t delay seeing a doctor. If shingles occurs, patients are given anti-viral medicines that are best to start as soon as possible after the rash appears, LaSalle said.

“The thing we really worry about is not so much the rash. That will go away,” she said. “About 10%-18% of people who get shingles will have nerve pain that comes with shingles that will linger for years or for the rest of their lives. It’s called postherpetic neuralgia.”

“We want to prevent that lingering nerve pain from happening, so if you start the anti-virals early, then it shortens the course and decreases the chance that you’ll have that lingering pain.”

It’s rare, but some people don’t develop the rash, LaSalle said. That happened for Holly Elmer, 52. She had a painful bump in January 2018 that spread on one side of her head. It was repeatedly misdiagnosed until she heard about shingles without an outbreak.

Elmer thinks stress was a factor. “I’m normally a healthy person, but I happened to wear myself out restoring two houses,” said Elmer, adding that she has lingering nerve problems and tinnitus.

Strategies

If you’re 50 or older, LaSalle recommends getting the Shingrix shingles vaccine, a two-shot series. After its approval in fall 2017, the manufacturer didn’t anticipate the high demand during 2018, and supplies were used up.

“Shingrix is still hard to find,” LaSalle said. “It’s kind of been on back order ever since. I think some of the pharmacies because they have national buying power are having some better luck getting it than the local clinics.”

You can get Shingrix even if you don’t remember having chickenpox. Studies show more than 99% of Americans ages 40 and older have had chickenpox even if they don’t remember.

Some patients mistakenly think because they’ve had shingles, they don’t need the vaccine. That’s not true, LaSalle said, because shingles can reoccur.

People need to go back for the second Shingrix shot two to six months after the first for maximum protection. After the two shots, Shingrix provides more than 90% protection against shingles. That protection stays above 85% for at least the first four years after you get vaccinated, the CDC says.

Most people get a sore arm with some pain after getting vaccinated. About 1 in 6 people have a strong reaction to this vaccine, LaSalle said, such as fever and aches for two to three days that prevent regular activities, then symptoms go away. If you’re younger than 50, then what?

“Other than clean, healthy living and trying to minimize stress in our world, I think just try to be healthy and do things that are stress-relieving and health-promoting,” she said.

Try for adequate sleep, regular exercise and outside time for fresh air and walks. Being in nature relieves stress, LaSalle added. For Jones, she improved after a doctor prescribed anti-viral medications, but she ended up with shingles a second time.

A few months after her first outbreak, a tingling returned to the same area. Her doctor’s office said because shingles affects the nerves, she’d likely have those sensations for up to a year.

“Then a year later, I felt that pain again, and it was real,” Jones said. “It’s incredibly frustrating because the (shingles) vaccine is not covered for people who are under 50.”

But Jones has made lifestyle changes to reduce stress. She joined the YMCA and does yoga.

“I joined a leadership development program, so I’ve learned a lot of tools about how to re-steer my train of thought if I’m kind of tending toward negative thoughts. And I reserve one night a week for myself to do whatever I want to do.

“Just those few small changes have really helped with my stress level. I’m really hoping that makes an impact in my life as far as stress and shingles.”

Shingles

  • they suspect a complication of shingles, such as meningitis or encephalitis
  • shingles is affecting one of your eyes – there’s a risk you could develop permanent vision problems if the condition isn’t treated quickly
  • a diagnosis isn’t certain
  • you have an unusually persistent case of shingles that’s not responding to treatment
  • you’ve been diagnosed with the condition more than twice
  • you’re pregnant
  • you have a weakened immune system – particularly in severe cases or cases affecting children

Causes of shingles

Most people have chickenpox in childhood, but after the illness has gone, the varicella-zoster virus remains dormant (inactive) in the nervous system. The immune system keeps the virus in check, but later in life it can be reactivated and cause shingles.

It’s possible to have shingles more than once, but it’s very rare to get it more than twice.

It’s not known exactly why the shingles virus is reactivated at a later stage in life, but most cases are thought to be caused by having lowered immunity (protection against infections and diseases).

This may be the result of:

  • old age – as you age, your immunity may decrease, and shingles most commonly occurs in people over 70 years old
  • physical and emotional stress – the chemicals released by your body when you’re stressed can prevent your immune system working properly
  • HIV and AIDS – people with HIV are much more likely to get shingles than the rest of the population because their immune system is weak
  • recently having a bone marrow transplant – the conditioning you require before the transplant weakens your immune system
  • recently having an organ transplant – you may need to take medication to suppress your immune system so your body accepts the donated organ
  • chemotherapy – chemotherapy medication, often used to treat cancer, can temporarily weaken your immune system

However, young people who appear otherwise healthy can also sometimes develop shingles.

Is shingles contagious?

It’s not possible to catch shingles from someone with the condition or from someone with chickenpox. However, you can catch chickenpox from someone with shingles if you haven’t had chickenpox before.

The blisters that form contain live virus. If a person who has never had chickenpox makes direct contact with an open blister or something with the fluid on it, they can contract the virus and develop chickenpox.

Preventing the spread of the virus

If you have shingles, you’re contagious until the last blister has dried and scabbed over. To help prevent the virus being passed on, avoid sharing towels or flannels, swimming, or playing contact sports. You should also avoid work or school if your rash is weeping (oozing fluid) and can’t be covered.

Chickenpox can be particularly dangerous for certain groups of people. If you have shingles, avoid:

  • women who are pregnant and haven’t had chickenpox before as they could catch it from you, which may harm their unborn baby
  • people who have a weak immune system, such as someone with HIV or AIDS
  • babies less than one month old, unless it’s your own baby, in which case your baby should have antibodies (proteins that fight infection) to protect them from the virus

Treating shingles

Although there’s no cure for shingles, treatment is available to relieve the symptoms until the condition resolves. Most cases of shingles last around two to four weeks.

Treatment for shingles can include:

  • covering the rash with clothing or a non-adherent (non-stick) dressing to reduce the risk of other people becoming infected with chickenpox – as it’s very difficult to pass the virus on to someone else if the rash is covered
  • painkilling medication, – such as paracetamol, ibuprofen or codeine
  • antiviral medication to stop the virus multiplying – although not everyone will need this

Read more about treating shingles

Complications of shingles

Shingles can sometimes lead to complications, such as postherpetic neuralgia. This is where severe nerve pain lasts for several months or more after the rash has gone.

Complications such as this are usually in elderly people who have had the condition and those with a weakened immune system.

Read more about the complications of shingles

The shingles vaccine

It’s not always possible to prevent shingles, but a vaccine called Zostavax can reduce your chances of developing the condition.

If you still develop shingles after having this vaccine, it may be milder and last for a shorter time than usual.

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  • It’s estimated that around one in every four people will have at least one episode of shingles during their life, but what causes the infection and what are the symptoms?

    We’ve covered this and everything else you need to know – including how and why shingles makes you feel tired – in the article below.

    What causes shingles?

    Also known as herpes zoster, it is an infection of a nerve and the skin around it. It is caused by the varicella-zoster virus, which also causes chickenpox.

    Older adults and individuals with a weakened immune system are at greatest risk. It is not possible to have shingles if you have never been exposed to chickenpox or the varicella virus that causes it.

    Once exposed, the virus can lay dormant for years. But most adults with the dormant virus never experience an outbreak or any further problems. However, in some individuals, it may reactivate multiple times.

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    What are the symptoms of shingles in adults?

    The first sign can be a tingling or painful feeling in an area of skin, or a headache or feeling generally unwell. A rash will then appear a few days later.

    Most often people get shingles on the left or right side of the torso, on a patch of skin served by nerves from a single ganglion. This often follows the line of a rib. You can also get shingles on your face, eyes and genitals.

    What do shingles look like?

    Red patches on the skin are usually the first sign of the shingles rash appearing. You may also have fluid filled blisters that burst and weep and turn into sores.

    They may not come up all at once, but form and slowly heal over a period of two to five weeks. The skin then crusts over and heals, apart from a little sensitivity or ‘nerve ache’ which soon disappears.

    This may signal the end of the episode for many people, but some people develop post herpetic neuralgia (PHN).

    Does shingles make you tired?

    Many individuals often say they feel extremely tired during, and even after, the infection. Sufferers will normally feel fatigued, but it’s not the shingles that have made them feel that way.

    Marian Nicholson, Director of Shingles Support Society, explains: “It’s more likely that whatever has been the trigger for your outbreak has made you tired. For example we often find that a person was unwell or overtired, or had an operation or even a bereavement, before the shingles appeared.”

    MORE: The worrying effect your phone is having on your brain

    How long does shingles last?

    It can take up to four weeks for the rash to heal. The skin can be painful for weeks after the rash has gone, but it usually settles over time. Individuals with shingles should stay away from pregnant women who have not had chickenpox before, people with a weakened immune systems, and babies less than one month old – unless it’s your own baby.

    Psychological Stress as a Trigger for Herpes Zoster: Might the Conventional Wisdom Be Wrong?

    Abstract

    The causes for zoster remain largely unknown. Psychological stress is one commonly considered risk factor. We used self-controlled case series methods to look for increases in zoster following death or catastrophic health event occurring in a previously healthy spouse. We found no increase, although this stressor led to increased mental health visits.

    Herpes zoster (HZ) is a localized painful rash illness that is caused by reactivation of latent varicella zoster virus (VZV) and can lead to considerable morbidity and disability . One million persons experience HZ annually in the United States. Whereas there is consensus that T-cell immunity plays a key role in controlling reactivation, proximate causes for HZ remain poorly defined . Well-documented risk factors include older age and immunodeficiency, but these factors do not distinguish most of the 30% of persons who experience HZ during their lifetime from those who do not . Other risk factors for HZ have been evaluated, but are unsubstantiated or of insufficient prevalence or magnitude to explain most episodes . Psychological stress has commonly been considered to be a trigger for HZ ; this contention has been supported by several, but not all, studies . We used data from a large dataset to investigate this premise.

    METHODS

    Overview

    We evaluated the association of psychological stress with HZ in adults using a self-controlled analysis by comparing episodes of HZ after vs before an acute stressor, defined as unexpected death or catastrophic health event occurring in a patient’s previously healthy spouse. Because individuals may be less likely to seek medical attention for HZ following such life-altering events, we also assessed HZ as a proportion of all healthcare services after vs before the stressor. We also evaluated prespecified mental health visits after vs before the stressor to serve as a positive control and provide evidence that our definition for stress was valid.

    Study Design

    We used self-controlled case series methods to assess for increases in HZ risk . These methods compare risks during prespecified risk and control periods within individuals, and eliminate effects of time-invariant confounders (Figure 1). We compared the risk of HZ and mental health visits during a 3-month risk period (days 1–90 following stressor) vs a 3-month control period (days 120–31 before stressor), assessing risk both as incidence (ie, number of episodes) and proportion (ie, divided by all outpatient healthcare services). We also evaluated risk periods of other durations up to 4 months.

    Figure 1.

    Self-controlled case series analysis.

    Figure 1.

    Self-controlled case series analysis.

    Data Source

    We used claims data from 2002 to 2011 Truven Health MarketScan Commercial and Medicare Databases, which include beneficiary and co-beneficiary data from employers, health insurance plans, and Medicare. The enrolled population resided in all states and ranged in size from 6 million (2002) to 50 million (2011).

    Study Population

    The study cohort consisted of MarketScan enrollees aged ≥25 years who experienced stress and a study outcome (HZ, mental health visit) during the observation period.

    Study Definitions

    Stress

    Life-event researchers treat spousal death as the most extreme commonly encountered stress, with catastrophic health event in a spouse also being highly stressful . We based our definition of stress on this consensus. We first identified MarketScan enrollees aged ≥30 years who were not hospitalized or institutionalized during a 365-day washout period (ie, previously healthy) who died or experienced a catastrophic health event during 2003–2010. We captured deaths via death discharge codes from the emergency department or within 14 days of a hospital admission. Catastrophic health events consisted of medical intensive care unit (ICU) stays ≥14 days, and surgical/neurosurgical ICU stays ≥14 days following emergency surgery or injuries (ie, International Classification of Diseases, Ninth Revision E codes). The stress index date was the first date with the relevant claim during the study period. We defined “spouses” as co-beneficiaries of the opposite sex and within 5 years of age.

    Herpes Zoster

    We defined HZ as outpatient claims with ICD-9 diagnostic codes of 053.xx (excluding 053.12 and 053.13) in the first 2 diagnostic positions. We only included the first HZ episode during the study period.

    Mental Health Visits

    Statistical Analysis

    We used conditional Poisson regression to compare rates and proportion of visits in risk vs control periods. Data were analyzed using SAS 9.2 statistical software. The proc genmod procedure was used to calculate relative incidence (RI), 95% confidence intervals (CIs), and P values. To compare proportions of HZ vs all outpatient healthcare services in the cohort, we used the generalized estimating equation methods for analysis of repeated data as enrollees may have contributed data for multiple visits; these results were reported as relative risk (RR), also with corresponding 95% CIs.

    RESULTS

    Among 39 811 persons experiencing stressful events, 137 developed HZ during the observation period (Table 1). HZ RI in this cohort was not increased during the 90-day risk period (0.76 ). Because, plausibly, individuals are less likely to seek care for HZ and other conditions soon after life-altering events, we also evaluated HZ episodes as a proportion of healthcare services during the risk vs control periods, but the RR was not increased (0.99 ).

    Table 1.

    Medically Attended Herpes Zoster and Mental Health Visits During Risk Versus Control Periods

    Abbreviations: CI, confidence interval; HZ, herpes zoster.

    a Used generalized estimating equation methods for analysis of repeated data to adjust for enrollees contributing data for multiple visits.

    Table 1.

    Medically Attended Herpes Zoster and Mental Health Visits During Risk Versus Control Periods

    Abbreviations: CI, confidence interval; HZ, herpes zoster.

    a Used generalized estimating equation methods for analysis of repeated data to adjust for enrollees contributing data for multiple visits.

    We used a positive control to confirm that the events we selected were in fact associated with clinical evidence of stress. We evaluated the impact of these events on stress-related mental health visits during the risk period and found, as expected, that the risk was increased, whether measured as episodes (RI, 1.75 ) or proportions (RR, 1.87 ).

    We stratified our cohort into ages ≥60 and <60 years, and also explored other risk periods ranging from 1 to 4 months, but still found no evidence for increased HZ risk (Table 1). We evaluated HZ in persons who experienced HZ associated with the unexpected death of their spouse (subset of our case definition for stress); they comprised 20 of the 137 episodes. The RI was <1.0, but with large confidence intervals (data not shown).

    DISCUSSION

    Clinicians and patients alike have assumed that HZ can be triggered by psychological stress, but few studies have explored this hypothesis directly . We used case-only methods to investigate this premise, and found no evidence that stress triggers HZ. Case-only methods are powerful because they are self-matched, eliminating effects of selection bias and measured or unmeasured time-invariant confounders . We selected specific, well-established stressors to test this hypothesis —a catastrophic health event or death occurring to a spouse—and validated the stressors by showing they increased stress-related mental health visits. We assessed risk as incidence and as proportion of total healthcare services to account for the possibility that the stressor might lead patients to postpone or forego all healthcare services, including those for HZ. Our conclusions remained unchanged with different time windows and age strata.

    Three earlier studies explored the impact of stress on HZ; all involved survey methods . Two case-control studies found a higher portion of HZ patients reporting negative (by self-definition) life events within 2, 3, and 6 months prior to HZ . However, a follow-up cohort study by one of these research teams found no HZ increase following self-identified negative life events when the recall period was as long as 3 years . Aside from the lack of interviewer blinding in these studies, serious limitations have been described for this type of research (termed life-events research), particularly when they involve retrospective methods . Limitations include recall bias, subjective weighting of different life events, and uncertainty regarding how to categorize and aggregate life events. Indeed, the positive findings of retrospective life-events studies are often repudiated when reevaluated using prospective studies .

    Other studies relate indirectly to impacts of stress on HZ. Measures of VZV-specific immunity are blunted among persons with depression, although implications of these changes on HZ risk are unknown . Virologic evidence of VZV reactivation has been detected in astronauts during space travel and children in ICUs , but implications of these findings for development of HZ are unclear, and the relationship of these provocations to psychological stress are conjectural. Finally, evidence that psychological stress can cause reactivation of the closely related herpes simplex viruses and trigger herpes labialis or genitalis has been equivocal .

    Our study has limitations. It is based on administrative data, so misclassifications (eg, of HZ, catastrophic health event, spouse) are possible, but do not necessarily bias our conclusions. Persons would plausibly neglect to seek care for HZ following our stressor; indeed, HZ episodes declined during our risk period, significantly at times, consistent with this phenomenon. Our findings are a reminder that the confounding role of variable healthcare-seeking on study outcomes should be considered in health services research. We controlled for the phenomenon by evaluating HZ as a proportion of healthcare services, reasoning that many or most services would be similarly deferred. Assessed this way, the RRs approached unity. Although this approach remains crude as deferral of healthcare-seeking would likely vary for different services, we feel comfortable that it would be hard to hide a stress-related increased risk of HZ in our results, particularly because population surveys suggest that in general, ∼95% of patients with HZ seek healthcare .

    We found no evidence that psychological stress triggers HZ. The risk factors for HZ remain unknown, as are the molecular pathophysiological triggers for reactivation of VZV; these are areas of ongoing study. Patients should, however, immediately seek care for suspected HZ so that the illness can be controlled and curtailed with timely antiviral treatment and pain management, regardless of the underlying HZ trigger. Meanwhile, for persons aged 60 years and older, an effective vaccine is available that can help prevent this disabling disease .

    Notes

    Acknowledgments. We acknowledge with gratitude the uncompensated contribution of Sally W. Thompson, MD, for her input in the selection of diagnoses and diagnostic codes for mental health visits that would reflect psychological stress following a death or catastrophic health event occurring in one’s spouse.

    Author contributions. J. W. L. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: R. H. Acquisition of data: J. W. L. Analysis and interpretation of data: all authors. Drafting of the manuscript: R. H. Critical revision of the manuscript for important intellectual content: R. H., J. W. L. Statistical analysis: All authors. Study supervision: R. H.

    Disclaimer. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

    Potential conflicts of interest. All authors: No potential conflicts.

    All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

    1 Harpaz R , Ortega-Sanchez IR , Seward JF . Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC) Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR Recomm Rep, 2008, vol. 57 (pg. 1-30) 2 Yawn BP , Saddier P , Wollan PC , St Sauver JL , Kurland MJ , Sy LS . A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction, Mayo Clin Proc, 2007, vol. 82 (pg. 1341-9) Erratum in: Mayo Clin Proc 2008; 83:255 3 Thomas SL , Hall AJ . What does epidemiology tell us about risk factors for herpes zoster?, Lancet Infect Dis, 2004, vol. 4 (pg. 26-33) 4 NIHSeniorHealth. Shingles causes and risk factors Available at: http://nihseniorhealth.gov/shingles/causesandriskfactors/01.html. Accessed 14 July 2014 5 Schmader K , Studenski S , MacMillan J , Grufferman S , Cohen HJ . Are stressful life events risk factors for herpes zoster?, J Am Geriatr Soc, 1990, vol. 38 (pg. 1188-94) 6 Schmader K , George LK , Burchett BM , Pieper CF . Racial and psychosocial risk factors for herpes zoster in the elderly, J Infect Dis, 1998, vol. 178 suppl 1(pg. S67-70) 7 Schmader K , George LK , Burchett BM , Hamilton JD , Pieper CF . Race and stress in the incidence of herpes zoster in older adults, J Am Geriatr Soc, 1998, vol. 46 (pg. 973-7) 8 Lasserre A , Blaizeau F , Gorwood P , et al. Herpes zoster: family history and psychological stress-case-control study, J Clin Virol, 2012, vol. 55 (pg. 153-7) 9 Whitaker HJ , Hocine MN , Farrington CP . The methodology of self-controlled case series studies, Stat Methods Med Res, 2009, vol. 18 (pg. 7-26) 10 Holmes TH , Rahe RH . The Social Readjustment Rating Scale, J Psychosom Res, 1967, vol. 11 (pg. 213-8) 11 Jones C , Skirrow P , Griffiths RD , et al. Post-traumatic stress disorder-related symptoms in relatives of patients following intensive care, Intensive Care Med, 2004, vol. 30 (pg. 456-60) 12 Paparrigopoulos T , Melissaki A , Efthymiou A , et al. Short-term psychological impact on family members of intensive care unit patients, J Psychosom Res, 2006, vol. 61 (pg. 719-22) 13 Irwin MR , Levin MJ , Carrillo C , et al. Major depressive disorder and immunity to varicella-zoster virus in the elderly, Brain Behav Immunity, 2011, vol. 25 (pg. 759-66) 14 Mehta SK , Cohrs RJ , Forghani B , Zerbe G , Gilden DH , Pierson DL . Stress-induced subclinical reactivation of varicella zoster virus in astronauts, J Med Virol, 2004, vol. 72 (pg. 174-9) 15 Cohrs RJ , Mehta SK , Schmid DS , Gilden DH , Pierson DL . Asymptomatic reactivation and shed of infectious varicella zoster virus in astronauts, J Med Virol, 2008, vol. 80 (pg. 1116-22) 16 Papaevangelou V , Quinlivan M , Lockwood J , et al. Subclinical VZV reactivation in immunocompetent children hospitalized in the ICU associated with prolonged fever duration, Clin Microbiol Infect, 2013, vol. 19 (pg. E245-51) 17 Lu PJ , Euler G , Jumaan A , Harpaz R . Herpes zoster vaccination among adults aged 60 years or older in the United States, 2007: Uptake of the first new vaccine to target seniors, Vaccine, 2009, vol. 27 (pg. 882-7) Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.

    What is shingles?

    Share on PinterestShingles results from the same virus that causes chicken pox.

    Shingles usually affects one side of the body. This is most often the waist, chest, abdomen, or back. Symptoms can also appear on the face and in the eyes, mouth, ears. The virus can also affect some internal organs.

    Shingles typically affects a single sensory nerve ganglion near the spinal cord, called a dorsal root ganglion. This is why the symptoms occur in specific areas of the body, rather than all over it. The pain results from nerve involvement, rather than the rash itself.

    In fact, some people have pain but no rash. Others, meanwhile, may have a rash with pain that is accompanied by other symptoms, such as fever, chills, or headache.

    Symptoms can vary in nature, depending on where on the body they appear.

    Common symptoms

    Some of the most common symptoms of shingles include:

    • a constant dull, burning, or gnawing pain, or a sharp, stabbing pain that comes and goes
    • a skin rash that resembles a chickenpox rash but only affects certain areas
    • fluid-filled blisters that develop as part of the rash

    Symptoms on the body

    A blistering skin rash may appear in one or more distinct bands with sensory nerves of the skin, called dermatomes.

    Common locations for this include:

    • the chest
    • the abdomen
    • the back
    • around the waist

    It usually occurs only on one side of the body.

    The location of the symptoms will depend on which dermatome distribution the virus affects.

    Facial symptoms

    If the rash affects the face, symptoms usually appear on one side only — usually around one eye and the forehead.

    They can include:

    • pain over the affected dermatome
    • a rash
    • muscle weakness
    • headache

    Eye symptoms

    If the virus affects an ophthalmic nerve, it means that a person has herpes zoster ophthalmicus.

    This can cause pain, redness, and swelling in and around the eye, as well as temporary or permanent loss of vision.

    Ear symptoms

    Shingles can also occur in or around the ear, leading to problems with balance and hearing, as well as muscle weakness on the affected side of the face.

    These changes can be long term or even permanent. A person who develops symptoms in or around the ears and eyes should seek immediate medical attention to reduce the risk of complications.

    Mouth symptoms

    If shingles affects the mouth, a person may experience:

    • facial tenderness
    • pain in the mouth
    • toothache
    • lesions in hard and soft palate tissues

    The pain and discomfort of these symptoms can make it difficult to eat or drink.

    Internal shingles

    Shingles can also affect the internal organs. There will not be a rash, but other problems can arise.

    For example, researchers have found evidence of shingles in the digestive system, which can lead to gastrointestinal dysfunction, and in the arteries in the brain, which may increase the risk of stroke and dementia.

    Other symptoms

    There may also be other symptoms, including:

    • fever
    • fatigue
    • chills
    • headache
    • upset stomach

    Symptom progression

    Symptoms typically progress as follows:

    • Pain, tingling, numbness, and itching start to affect a specific part of the skin.
    • After up to 2 weeks, a rash appears.
    • Red blotches and itchy, fluid-filled blisters develop and continue to do so for 3-5 days.
    • The blisters may merge, forming a solid red band that looks similar to a severe burn. The gentlest touch may be painful.
    • Inflammation may affect the soft tissue under and around the rash.
    • After 7–10 days, the blisters gradually dry up and form scabs or crusts. As the blisters disappear, they may leave minor scarring.

    Shingles usually lasts around 2–4 weeks. It is contagious until the blisters dry up and crust over.

    Most people will only have an episode of shingles once, but it can recur in some people.

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