Shingles Vs. Herpes: Symptoms, Causes, And Treatment

About one million new cases of shingles are diagnosed each year in the United States. On the other hand, about 572,000 people were diagnosed with a genital herpes infection in one year (from both the HSV-1 and HSV-2 viruses). It's also estimated that approximately 65% of the US population is infected with the HSV-1 virus, which mainly causes oral herpes.¹ ² ³

Is shingles a form of herpes?

Shingles is caused by a type of herpes virus called herpes zoster, more formally known as varicella-zoster virus (VZV). This is also the virus that causes chickenpox, and it's incurable. This means that it never leaves your body once you've been infected but instead goes into a dormant state after your chickenpox has cleared up. 

In adulthood (and sometimes during childhood), this virus can be triggered to reactivate. Instead of chickenpox, the reactivation of VZV causes a shingles outbreak.

Although a lot of people don't recall having chickenpox, the Centers for Disease Control and Prevention (CDC) estimate that over 99% of those born before 1980 have had a wild-type (non-vaccine induced) VZV infection. This means they are at risk of developing shingles. In total, about one in three people in the US will likely develop the condition in their lifetime.⁴ ⁵

Can you get shingles without having herpes?

Because herpes is caused by two strains of the herpes virus that are each different from the shingles virus strain, you can get shingles without having herpes.

The herpes simplex virus (HSV), including HSV-1 and HSV-2, causes herpes.

• HSV-1 most commonly causes oral herpes (also known as esophagitis, throat, or mouth herpes), although HSV-2 may also cause this condition.

• HSV-2 most commonly causes genital herpes, although HSV-1 can also cause this condition.

Is it possible to have both shingles and herpes?

Yes, you may be infected with both the varicella-zoster virus that causes shingles and the herpes simplex virus that causes herpes at the same time. They can also reactivate at the same time to cause symptoms.

Differences between shingles and herpes

Symptoms

The herpes simplex virus reactivates more frequently than the varicella-zoster virus that causes shingles. This means you may have several outbreaks throughout your lifetime. 

Symptoms for HSV can be mild or even nonexistent during this reactivation phase. When they do occur, they can include:

• Cold sores or small blisters around the lips, mouth, or inside the mouth (oral herpes)

• Small blisters around or on the genitalia (genital herpes)

• Tingling or uncomfortable skin sensations a few hours to a few days before blisters appear

• Fever, especially during the first outbreak

• Dehydration (oral herpes)

• Pain

• Trouble urinating (genital herpes)

• Swollen lymph nodes

• Body aches and headaches

• Chest pain and throat ulcers (oral herpes)

• Genital ulcers

• Herpes keratitis (eye infection)

• Sore throat (oral herpes)

The blisters and ulcers from herpes can be painful, but they only affect a few nerve cells in comparison to the shingles virus, which can affect multiple nerve cells. 

Symptoms of shingles may include:

• A painful or uncomfortable tingling or burning sensation at least 48 hours before an outbreak

• A red rash that starts as discoloration and can turn into larger blisters

• Pain that gains in intensity during the outbreak phase

• Headaches

• Fever

• Chills

• Ophthalmic shingles (eye infection)

• Temporary facial paralysis

• Pain after the outbreak clears up for up to 12 months or more, known as postherpetic neuralgia (PHN)

Since shingles, oral herpes, and genital herpes are all caused by infection with herpes viruses, they do share some symptoms in common. These include:

• Tingling or uncomfortable sensations on the skin before an outbreak

• Fever

• Headaches

• Eye infections

• Pain

What is the duration of the symptoms of shingles vs. herpes?

A shingles rash will usually start to dry up after about 7–10 days, and symptoms typically last between 2–4 weeks. About 10–18% of people also experience ongoing PHN pain for up to a year or more after a shingles outbreak has healed.⁶ ⁷

Herpes simplex virus (HSV-1 and HSV-2) blisters typically appear between 2–20 days after exposure to the infection. It can take 10–19 days to clear up the first time an oral herpes outbreak occurs. However, these blisters normally only take 5–10 days to crust over and heal for subsequent (recurring) outbreaks of herpes. The first outbreak of genital herpes is typically longer in duration than recurring outbreaks as well.

What does herpes zoster look like vs. herpes simplex?

A person with shingles outbreak will notice that the rash may form a partial ring, especially around the torso or chest, and develop on just one side of the body (although this isn't always the case). The rash is flat and discolored towards the beginning of the acute phase, and raised blisters may appear as this stage progresses. These will break open and crust over as the outbreak heals.

When comparing the rash between shingles and herpes, herpes simplex virus (HSV) blisters tend to be smaller than shingles blisters. There's also not an initial flat rash with herpes like there is with shingles. The blisters can look similar to shingles' blisters, but they tend to form on the lips, inside the mouth and esophagus, on the genitalia and anus, and sometimes on other areas such as around the eyes.

What are the causes?

The reactivation of the virus that causes chickenpox is responsible for shingles, and this reactivation is linked to compromised immunity. Those with a weak immune system or a declining antibody response to the virus (which can occur over time) may be susceptible. The CDC estimates that about 30% of those who are hospitalized with herpes zoster have a suppressed immune system.⁸ ⁹ ¹⁰

Just like with shingles, reactivation of the virus that causes the condition — in this case, herpes simplex — is responsible for recurring oral and genital herpes. 

The first infection is caused by contact with skin, fluid, saliva, or mucous that contains the virus. Reactivation of the virus can be triggered by a number of physical traumas, including:

• Cuts or nicks in the areas where outbreaks occur

• Too much sun (UV exposure) on the skin or lips

• Dental work

• Stress

• Fever

• Infection

• Hormonal Imbalances

• A suppressed immune system

Risk factors

Herpes simplex virus reactivation and outbreak occur frequently in children, adolescents, and young adults, and the risk of reactivation has been shown to decrease as you age. By contrast,  a shingles (VZV) outbreak usually only occurs once in a person's lifetime (although it can recur), and the risk of having an outbreak increases for people who are aged 50 and older.¹¹

That's not the only difference in risk factors for the conditions. Herpes zoster is at least 50% less common in black populations than in white populations, while both HSV-1 and HSV-2 are less common in white populations than in black populations.¹² ¹³

In the United States, both HSV and VZV have been shown to be more common in women than in men. CDC data collected between 2015–2016 revealed that HSV-1 prevalence among people aged 14–49 was 50.9% in females and 45.2% in males, and HSV-2 prevalence was 15.9% in females and 8.2% in males. Likewise, a multi-year study that analyzed the data of over 27 million people found that women accounted for 62% of shingles (herpes zoster) diagnoses as compared to 38% of men.¹⁴ ¹⁵

For shingles, additional risk factors may include health conditions, medications, or lifestyle habits that can compromise the immune system, such as:

• HIV infections

• Cancer and cancer treatments

• Stress

One case-controlled study of about half a million people found that prescription antibiotic use may be linked to shingles virus reactivation as well.¹⁶

For the herpes simplex virus, sexual activity can increase the risk of infection, particularly of HSV-2. People who work in healthcare settings are also at a higher risk of exposure to both types of this virus.¹⁷

What is more dangerous: shingles or herpes?

The herpes simplex virus (HSV-1 and HSV-2) is considered highly contagious, especially when sores or blisters are present. However, even when no symptoms appear, the virus may be present on your skin and transferred to others.

HSV-1 is typically transmitted during childhood and adolescence and is spread by direct contact with the infected skin or by contact with the fluid in the blisters. To help reduce the spread of herpes, it's recommended to:

• Wash your hands regularly and after each time you touch a cold sore or blister

• Don't share hygiene or clothing items if you know you're infected with HSV

• Avoid physical contact until after the outbreak has healed

Genital herpes is considered a sexually transmitted disease (STD) and is spread either by skin-to-skin contact or through saliva and genital fluids during sexual activity. Oral herpes may also be spread in this manner. To reduce the risk of spread, it's recommended to wear a condom during sexual activity, avoid sex when symptoms are present, and take medication to treat the herpes virus.

Just like the herpes simplex virus, the shingles’ varicella-zoster virus is also contagious, although keeping the rash covered can significantly reduce the risk of spread. It is transmitted by infected droplets that enter the body or by direct contact with the fluid in skin blisters.

Complications of shingles and herpes

People who've had shingles may experience a number of complications, particularly if the rash developed on your face, neck, or around your eyes or ears. 

Recurring eye infections can happen due to scarring of the cornea or damage to nerves that respond to the light, and these may lead to vision loss if not properly treated. 

For shingles that spreads to the face, muscle weakness can occur. Balance issues and hearing loss can also be a complication if the outbreak develops around the ear.

In addition, stroke and heart attack were documented to increase significantly among those who experienced shingles. In a ten-year study of almost 520,000 people, those with the condition had a 59% increased risk for heart attack and a 35% increased risk for stroke.¹⁸

Because the shingles virus travels along the nerves, some people experience different types of 'nerve palsies' after having an outbreak, which causes numbing, tingling, or paralysis due to nerve damage. 

PHN (debilitating post-outbreak pain) is another complication that affects about 10–13% of people aged 60 and older who've had shingles, although it's uncommon in people under age 40. It can last up to a year or even longer.¹⁹

A recent analysis of studies revealed that there might be some similarities between the complications of shingles and herpes. It was determined that those with HSV-1 and HSV-2 had a "significant" increase in their risk for developing atherosclerosis (plaque build-up in the arteries) as compared to those without these viruses. Atherosclerosis may cause complications such as heart attack and stroke.²⁰

Although uncommon, HSV-1 (and sometimes HSV-2) can also cause infections of the eye, known as eye keratosis.

Other potential herpes simplex virus complications include:

• A three times greater risk of developing HIV for people with HSV-2²¹

• Neonatal herpes (when the virus is transmitted from the pregnant mother to her baby)

• Severe skin infection for those with a condition called atopic eczema

• Infection of the brain, known as herpes encephalitis

Identifying shingles and herpes: methods of testing

To find out if you have shingles, your doctor will begin by examining the rash and asking you about your symptoms. 

The main type of lab test done to confirm a shingles diagnosis is a PCR test (short for polymerase chain reaction), which looks for the DNA of the varicella-zoster virus. Usually, your doctor will take a swab of your blisters or the crust that's formed over them in order to get the most accurate results.

Some people don't remember if they've had chickenpox or not. In this case, an antigen test (also known as a serological test) can be ordered by your doctor. This will test for the 'IgM' and 'IgG' antibodies that are present when you have been infected with the shingles virus. This can help rule out other conditions that might be mistaken for shingles.

What else can be mistaken for shingles?

Conditions like psoriasis, eczema, hives and even oral herpes may appear similar to shingles. A diagnostic exam and testing can solidify which condition is causing your skin rash.

How are you tested for herpes?

Just like with the shingles virus, the HSV-1 and HSV-2 viruses that cause herpes are diagnosed using PCR tests. Since symptoms may be nonexistent for these viruses, an antigen test may be performed instead to find out if you have the herpes simplex virus.

In addition, your doctor may use an endoscope (a tube with an attached camera and light) to check for signs of the virus if you have throat herpes, also known as esophagitis.

How to treat shingles and herpes

Antiviral and anti-inflammatory treatments

The antiviral drugs acyclovir (Zovirax), valacyclovir, and famciclovir are commonly prescribed for both shingles and herpes infections to help reduce the time it takes for the outbreak to heal. They also can cut in half your risk of developing shingles PHN pain, especially if taken within the first three days of symptom onset.

For genital herpes, your doctor may prescribe these antivirals for ongoing daily use in order to help reduce the risk of spreading the infection.

Sometimes, anti-inflammatory drugs called corticosteroids are prescribed for shingles, especially if face and eye nerves are affected. Prednisone is one such drug.

Pain treatments

People who have oral or genital herpes and shingles may use over-the-counter or prescription creams like lidocaine and benzocaine to help numb their pain. Patches or creams with capsaicin, an ingredient found in chili peppers, have been shown to have modest beneficial effects against pain, including post-herpetic neuralgia.

For shingles, pain can be extremely intense. Your doctor may prescribe gabapentinoids or tricyclic antidepressants to help reduce your discomfort during an outbreak or if you develop PHN. Pregabalin has also shown success in reducing acute (strong) pain during the first 30 days of shingles onset.²²

Emerging treatments

Plant-based therapies are being studied to help treat oral and genital herpes outbreaks for people who develop resistance to anti-viral medication, and some of these have shown positive results for better managing the symptoms of both HSV-1 and HSV-2. 

Another emerging treatment for herpes simplex virus, low-intensity laser therapy has been used in herpes zoster treatment. More recently, it was applied to the HSV-1 outbreak areas of 50 patients with recurrent HSV, and it increased the time between new outbreaks by 34.5 weeks over those who didn't have the treatment.²³

For the shingles virus, research is being conducted to understand what biological mechanisms help keep the virus from reactivating. This will help to develop therapies to keep these mechanisms running smoothly. 

Several clinical trials are being conducted, including for a new vaccine aimed at enhancing cell-mediated immunity to help prevent shingles reactivation in older adults.²⁴

Is it possible to prevent herpes and shingles?

While there's no cure for shingles or herpes, there are some treatments and strategies to help you prevent the reactivation of these viruses and reduce your risk of infection or outbreaks.

The Shingrix vaccine has been shown to be over 90% effective at preventing both a shingles outbreak and the PHN associated with it, and effectiveness stays above 85% for four years or more when two doses are taken.²⁵

Prevention strategies to reduce herpes simplex virus infections and outbreaks include:

• Washing your hands regularly

• Using condoms during sexual activity

• Wearing sunscreen to prevent sunburns

• Avoiding sharing personal items such as toothbrushes 

The lowdown

Because both shingles and herpes are caused by different types of herpes viruses, they share some similarities, as well as some differences. 

Oral and genital herpes are typically recurrent, while most people only have one shingles outbreak in their lifetime, and it's most common in people aged 50 and older. The rashes that occur when the viruses reactivate can appear similar, although the blisters tend to be smaller for herpes than shingles. 

Women are more often affected by both shingles and herpes than men. Both conditions also share some treatments in common, including antiviral drugs and pain treatments. Herpes tends to spread easier than shingles, in part because of the more frequent number of outbreaks and also because symptoms of herpes may not be present even when the virus is reactivated. 

The vaccine Shingrix is 90% effective at preventing shingles outbreaks, and having a strong immune system is also key. There is no effective vaccine for herpes, although antiviral medications and practicing good hygiene can help with keeping outbreaks to a minimum.

Frequently asked questions

How can you tell the difference between shingles and herpes?

Shingles form as a flat, red rash that may turn into blisters. This rash often (though not always) forms a band or cluster on one side of the body, such as your waist, chest, face, or arm. Herpes blisters are typically smaller than shingles blisters and appear most often on the mouth, genitalia, anus, and sometimes the face or buttocks. A doctor's examination and testing can help you determine which condition you have.

Can you have shingles and not have herpes?

Yes, since shingles is caused by the varicella-zoster virus and herpes is caused by the herpes simplex virus, you can have shingles and not have herpes.

Where do herpes rashes appear?

Herpes rashes can appear anywhere on the body. Shingles often develop on just one side of the body and commonly appear on the torso, chest, face, arm, or leg. Oral herpes typically develops on or above the lips, in the mouth and throat, or on the face, while genital herpes generally appears on the genitalia, anus, and buttocks.

How contagious are they?

The herpes simplex virus that causes oral and genital herpes is considered highly contagious, especially when symptoms are present. You also may not see any symptoms even when the virus is reactivated.  This means that it's easy to spread the virus, which is transmitted through skin-to-skin contact, saliva, mucous, sexual activity, and by contact with the fluid in the blisters.

The varicella-zoster virus that causes shingles is contagious during an outbreak and is spread by skin-to-skin contact or by infected fluids that enter your body. Most people only have one shingles outbreak in their lifetime, and covering the rash and avoiding physical contact until symptoms subside significantly reduces the risk of transmission.