Editing Shingles (section)

==Signs and symptoms==
[[File:Fox Plate XCVI.jpg|thumb|Shingles in various locations]]
[[File:Shingles.JPG|thumb|upright=1.3|A case of shingles that demonstrates a typical [[dermatome (anatomy)#Important dermatomes and anatomical landmarks|dermatomal distribution, here C8/T1]].]]
The earliest symptoms of shingles, which include headache, fever, and malaise, are nonspecific, and may result in an incorrect diagnosis.<ref name=Dwo2007/><ref name=pmid11458545>{{cite journal| author=Zamula E| title=Shingles: an unwelcome encore| journal=[[FDA Consumer]]| volume=35| issue=3| pages=21–25| date=May–June 2001| pmid=11458545| url=http://permanent.access.gpo.gov/lps1609/www.fda.gov/fdac/features/2001/301_pox.html| access-date=5 January 2010| url-status=live| archive-url=https://web.archive.org/web/20091103045519/http://permanent.access.gpo.gov/lps1609/www.fda.gov/fdac/features/2001/301_pox.html| archive-date=3 November 2009}} Revised June 2005.</ref> These symptoms are commonly followed by sensations of burning pain, itching, [[hyperesthesia]] (oversensitivity), or [[paresthesia]] ("pins and needles": tingling, pricking, or numbness).<ref name=pmid10794584>{{cite journal| vauthors=Stankus SJ, Dlugopolski M, Packer D| title=Management of herpes zoster (shingles) and postherpetic neuralgia| journal=[[Am. Fam. Physician]]| volume=61| issue=8| pages=2437–2444, 2447–2448| year=2000| pmid=10794584| url=http://www.aafp.org/afp/20000415/2437.html| url-status=dead| archive-url=https://web.archive.org/web/20070929083747/http://www.aafp.org/afp/20000415/2437.html| archive-date=29 September 2007}}</ref> Pain can be mild to severe in the affected [[dermatome (anatomy)|dermatome]], with sensations that are often described as stinging, tingling, aching, numbing or throbbing, and can be interspersed with quick stabs of agonizing pain.<ref name=pmid15307000>{{cite journal |vauthors=Katz J, Cooper EM, Walther RR, Sweeney EW, Dworkin RH |title=Acute pain in herpes zoster and its impact on health-related quality of life |journal=[[Clin. Infect. Dis.]] |volume=39 |issue=3 |pages=342–348 |year=2004 |pmid=15307000 |doi=10.1086/421942|doi-access=free }}</ref>

Shingles in children is often painless, but people are more likely to get shingles as they age, and the disease tends to be more severe.<ref name="Hope-Simpson">{{cite journal|author=Hope-Simpson RE|title=The nature of herpes zoster: a long-term study and a new hypothesis|journal=[[Proceedings of the Royal Society of Medicine]]|year=1965|volume=58|pages=9–20|pmid=14267505|pmc=1898279|issue=1|doi=10.1177/003591576505800106}}</ref>

In most cases, after one to two days—but sometimes as long as three weeks—the initial phase is followed by the appearance of the characteristic skin rash. The pain and rash most commonly occur on the torso but can appear on the face, eyes, or other parts of the body. At first, the rash appears similar to the first appearance of [[hives]]; however, unlike hives, shingles causes skin changes limited to a dermatome, normally resulting in a stripe or belt-like pattern that is limited to one side of the body and does not cross the midline.<ref name=pmid10794584/> <!-- Do not delete anchor, links from Bell's Palsy -->{{Anchor|Zoster sine herpete}} ''Zoster sine herpete'' ("zoster without herpes") describes a person who has all of the symptoms of shingles except this characteristic rash.<ref name=pmid10980741>{{cite journal |vauthors=Furuta Y, Ohtani F, Mesuda Y, Fukuda S, Inuyama Y |title=Early diagnosis of zoster sine herpete and antiviral therapy for the treatment of facial palsy |journal=[[Neurology (journal)|Neurology]] |volume=55 |issue=5 |pages=708–710 |year=2000 |pmid=10980741 |doi=10.1212/WNL.55.5.708| s2cid = 29270135 }}</ref>

Later the rash becomes [[Vesicle (dermatology)|vesicular]], forming small blisters filled with a [[serous exudate]], as the fever and general malaise continue. The painful vesicles eventually become cloudy or darkened as they fill with blood, and crust over within seven to ten days; usually the crusts fall off and the skin heals, but sometimes, after severe blistering, scarring and discolored skin remain.<ref name=pmid10794584/> The blister fluid contains varicella zoster virus, which can be transmitted through contact or inhalation of fluid droplets until the lesions crust over, which may take up to four weeks.<ref>{{cite web|url=https://www.health.ny.gov/diseases/communicable/shingles/fact_sheet.htm|title=Shingles (herpes zoster)|date=January 2023|publisher=New York State|website=Department of Health|access-date=9 March 2023}}</ref>

{| style="margin:auto;"
|+ '''Development of the shingles rash'''
! Day 1 !! Day 2 !! Day 5 !! Day 6
|- valign="top"
| [[Image:ShinglesDay1.JPG|143px]]
| [[Image:ShinglesDay2 ed.JPG|120px]]
| [[Image:ShinglesDay5 ed.JPG|145px]]
| [[Image:ShinglesDay6 ed.JPG|149px]]
|}

===Face===
Shingles may have additional symptoms, depending on the dermatome involved. The [[trigeminal nerve]] is the most commonly involved nerve,<!-- , accounting for 18–22% of shingles cases--><ref name=Gupta2015>{{cite journal| vauthors = Gupta S, Sreenivasan V, Patil PB |title = Dental complications of herpes zoster: Two case reports and review of literature |journal=[[Indian Journal of Dental Research]]|date=2015|volume=26|issue=2|pages=214–219|doi=10.4103/0970-9290.159175|pmid=26096121|doi-access=free}}</ref> of which the ophthalmic division is the most commonly involved branch.<ref name=Samaranayake2011>{{cite book|author=Samaranayake L|title=Essential Microbiology for Dentistry|url=https://books.google.com/books?id=xanRAQAAQBAJ&pg=PT638|edition=4th|year= 2011|publisher=Elsevier Health Sciences|isbn=978-0702046957|pages=638–642|url-status=live|archive-url=https://web.archive.org/web/20170908175310/https://books.google.com/books?id=xanRAQAAQBAJ&pg=PT638|archive-date=8 September 2017}}</ref> When the virus is reactivated in this nerve branch it is termed ''[[zoster ophthalmicus]]''. The skin of the forehead, upper eyelid and [[Orbit (anatomy)|orbit of the eye]] may be involved. Zoster ophthalmicus occurs in approximately 10% to 25% of cases. In some people, symptoms may include [[conjunctivitis]], [[keratitis]], [[uveitis]], and [[optic nerve]] [[:wikt:palsy|palsies]] that can sometimes cause chronic ocular inflammation, loss of vision, and debilitating pain.<ref name=pmid12449270>{{cite journal| vauthors=Shaikh S, Ta CN| title=Evaluation and management of herpes zoster ophthalmicus| journal=[[Am. Fam. Physician]]| year=2002| volume=66| issue=9| pages=1723–1730| pmid=12449270| url=http://www.aafp.org/afp/20021101/1723.html| url-status=live| archive-url=https://web.archive.org/web/20080514021237/http://www.aafp.org/afp/20021101/1723.html| archive-date=14 May 2008}}</ref>

''Shingles oticus'', also known as [[Ramsay Hunt syndrome type II]], involves the [[ear]]. It is thought to result from the virus spreading from the [[facial nerve]] to the [[vestibulocochlear nerve]]. Symptoms include [[hearing loss]] and [[Vertigo (medical)|vertigo]] (rotational dizziness).<ref name=pmid12676845/>

Shingles may occur in the mouth if the maxillary or mandibular division of the trigeminal nerve is affected,<ref name=Neville2008/> in which the rash may appear on the [[mucous membrane]] of the upper jaw (usually the palate, sometimes the gums of the upper teeth) or the lower jaw (tongue or gums of the lower teeth) respectively.<ref name=Glick2014/> Oral involvement may occur alone or in combination with a rash on the skin over the cutaneous distribution of the same trigeminal branch.<ref name=Neville2008/> As with shingles of the skin, the lesions tend to only involve one side, distinguishing it from other oral blistering conditions.<ref name=Glick2014/> In the mouth, shingles appears initially as 1–4&nbsp;mm opaque blisters (vesicles),<ref name=Neville2008/> which break down quickly to leave [[mouth ulcer|ulcers]] that heal within 10–14 days.<ref name=Glick2014/> The prodromal pain (before the rash) may be confused with [[toothache]].<ref name=Neville2008>{{cite book| vauthors = Chi AC, Damm DD, Neville BW, Allen CM, Bouquot J | chapter = Viral Infections |title=Oral and Maxillofacial Pathology|year=2008|publisher=Elsevier Health Sciences|isbn=978-1437721973|pages=250–253| chapter-url = https://books.google.com/books?id=5QIEAQAAQBAJ&pg=P250 |url-status=live|archive-url=https://web.archive.org/web/20170908175310/https://books.google.com/books?id=5QIEAQAAQBAJ&pg=P250|archive-date=8 September 2017}}</ref> Sometimes this leads to unnecessary dental treatment.<ref name=Glick2014>{{cite book|author=Glick M|title=Burket's oral medicine|url=https://books.google.com/books?id=cBEqCAAAQBAJ&pg=PA62|edition=12th|year=2015|publisher=coco|isbn=978-1607951889|pages=62–65}}</ref> Post-herpetic neuralgia uncommonly is associated with shingles in the mouth.<ref name=Glick2014/> Unusual complications may occur with intra-oral shingles that are not seen elsewhere. Due to the close relationship of blood vessels to nerves, the virus can spread to involve the blood vessels and compromise the blood supply, sometimes causing [[ischemia|ischemic]] [[necrosis]].<ref name=Neville2008/> In rare cases, oral involvement causes complications such as [[osteonecrosis]], [[tooth loss]], [[periodontitis]] (gum disease), pulp calcification, [[pulp necrosis]], [[periapical periodontitis|periapical lesions]] and tooth developmental anomalies.<ref name=Gupta2015/>

===Disseminated shingles===
{{anchor|Disseminated}}In those with deficits in immune function, ''disseminated shingles'' may occur (wide rash).<ref name=Pink2015/> 
It is defined as more than 20 [[skin lesion]]s appearing outside either the primarily affected dermatome or dermatomes directly adjacent to it. Besides the skin, other organs, such as the [[liver]] or [[brain]], may also be affected (causing [[hepatitis]] or [[encephalitis]],<ref>{{cite journal |vauthors=Chai W, Ho MG |title=Disseminated varicella zoster virus encephalitis |journal=Lancet |volume=384 |issue=9955 |pages=1698 |date=November 2014 |pmid=24999086 |doi=10.1016/S0140-6736(14)60755-8 |doi-access=free}}</ref><ref>{{cite journal| vauthors = Grahn A, Studahl M |title = Varicella-zoster virus infections of the central nervous system – Prognosis, diagnostics and treatment |journal=[[Journal of Infection]]|date=September 2015|volume=71|issue=3|pages=281–293|pmid=26073188|doi=10.1016/j.jinf.2015.06.004}}</ref> respectively), making the condition potentially lethal.<ref name="Andrews">{{cite book |vauthors=Elston DM, Berger TG, James WD |title=Andrews' Diseases of the Skin: Clinical Dermatology |publisher=Saunders Elsevier |year=2006 |isbn=978-0721629216 }}</ref>{{rp|380}}