PART 3 OF 5: There are many viral skin infections that range from mild to the severe. Some viral skin infections affect just the skin and others are associated with systemic diseases.  This article features massage modifications for viral skin infections including cold sores, shingles, and warts. The shingles entry contains valuable information for pregnant massage practitioners. 

Cold Sores (Oral Herpes Simplex): Cold sores are recurrent viral infections affecting the skin and mucous membranes. The lesions can appear anywhere on the body, but most are often found around the mouth. Cold sores can also occur around the nose, over the chin, or on the fingers (called herpetic whitlow). Cold sores may be found inside the mouth and are often confused with canker sores. However, canker sores are not caused by viruses, and are not contagious. Cold sores are also called fever blisters.

Cold sores are spread by contact with infected skin and indirectly by contact with contaminated items such as razors, towels, and eating utensils. Oral-to-genital contact with an infected person may cause genital herpes. Lesions tend to recur because the virus lies dormant in sensory nerve cells corresponding to the site of infection. Reactivation of the virus can be triggered by exposure to sunlight, wind, or the presence of another infection such as the common cold (hence the name “cold” sores). Fever (“fever” blisters), hormonal changes occurring during menstruation or pregnancy, stress, anxiety; chapped lips can also trigger reactivation of the virus.


Herpes simplex virus type 1 (HSV-1) is the most common cause of cold sores; HSV-1 is closely related to herpes simplex virus type 2 (HSV-2), which causes genital herpes. HSV-2 can also cause cold sores around the mouth. The first symptom is usually a tingly or burning sensation. After a few days, painful fluid-filled vesicles appear on a reddened area. These vesicles erupt, emitting a clear or yellow fluid which dries to form a crust


Massage and Cold Sores: Cold sores are local contraindications. Use gloves or other barrier such as the sheet when for massaging the hands as they may be contaminated by the client touching his or her own lesions (CDC, 2018). Massage linens are treated as contaminated. Bear in mind that healthcare–associated transmission of cold sores is rare (Goodman & Fuller, 2014).

Shingles (Herpes Zoster): Shingles is an acute, localized viral infection of the skin. It is essentially a reactivation of the chickenpox virus. The virus can be transmitted to someone who is not immune to chickenpox, usually through contact with the open lesions. However, the newly-infected person will develop chickenpox, not shingles. Anyone who has had chickenpox may develop shingles. But not everyone who had chickenpox develops shingles later in life; in fact, only 1 in 10 adults who had chickenpox will develop shingles.

dermatome-2-mAfter chickenpox resolves, the virus travels down a dermatome (areas of skin supplied by a single sensory spinal nerve) and is kept inactive by healthy immune responses. However, if immune responses become weakened, the virus can be reactivated and cause the lesions of shingles. The dermatome the virus previously retreated determines the area where skin lesions appear. The lesions are usually unilateral and typically affect only a small area of the body, usually the torso. However, the rash can appear on the face, and both sides of the body may be involved.

Shingles are fairly common, with about one million shingles cases occurring in the U.S. every year; almost one in three U.S. adults will get shingles in their lifetime. Shingles is more common because the chickenpox vaccine has reduced occurrences; both situations (naturally-occurring and artificially-acquired chickenpox) provides lifetime immunity. However, the vaccine may not prevent shingles later in life, and many people have multiple episodes of shingles. People most likely to acquire shingles are adults older than 50 years of age and people who are immunosuppressed, such as those who are positive for HIV, have diabetes, are taking immunosuppressant medications, or are under extreme psychosocial stress. Shingles is caused by a reactivation of VZV—one of the herpesviruses. VZV is the same virus causing chickenpox.

Approximately 20% of people with shingles experience postherpetic neuralgia (PHN), localized pain which persists for months or even years. PHN is thought to result from nerve damage caused by shingles.

Initial symptoms of shingles are pain, burning, tingling, itching, pricking, or numbness, followed by eruptions of blisters over reddened skin appearing in a bandlike pattern along affected dermatomes. The area is hypersensitive to touch. Blisters then erupt, crust over, and fall off 7 to 10 days after their debut. Other symptoms of shingles are chills and fever, mild nausea, and abdominal cramping.


Massage and Shingles: Practitioners not susceptible to VZV (has had chickenpox or the chickenpox vaccine) or practitioners not pregnant, shingles is a local contraindication because lesions are painful. Use gloves or other barrier such as the sheet when for massaging the hands as they may be contaminated by the client touching his or her own lesions (CDC, 2018). In cases of PHN, inquire about sensitivity over affected areas and adjust pressure accordingly. Massage linens are treated as contaminated to protect at-risk individuals.

Practitioners who have not had chickenpox or who have not received the chickenpox vaccine should not massage a client who has shingles. Additionally, pregnant practitioners should not massage a client who has shingles, even if she has prior immunity as VZV can be activated in the unborn, possibly causing shingles in the first few years of his or her life (RCOG, 2015); this risk to the unborn increases after 28 weeks gestation. These precautions remain in effect until the shingles blisters scab over.

Warts: Warts are a small, rough, raised, viral-induced skin growths. They may occur anywhere on the body, but most warts are located on the hands, feet called plantar warts, face and legs called flat warts, and genitals called genital warts. Warts may appear singularly or as multiple growths. Warts are contagious and are mainly spread by direct skin contact, but they may also be spread by touching objects like towels or razors. People who have warts in one location of the body can also spread the infection to other body parts. It can take a wart as long as 2-6 months to develop after exposure to the virus. Warts are also called verrucas. Warts are caused by the human papillomavirus virus (HPV). Certain strains of HPV are responsible for cervical cancer.

Most warts are rough, raised, and round or oval growths and lighter or darker in color than the surrounding skin. In most cases, warts cause little or no discomfort unless they are in an area of repeated pressure, such as hands, elbows, and soles of the feet. Warts may contain small clotted blood vessels resembling small black dots often called wart seeds. However, contrary to old wives’ tales, warts do not contain seeds, nor do they have underlying branches.


Massage and Warts: Warts are local contraindications or contact precautions because they can be transmitted by contact. Use gloves or other barrier such as the sheet when for massaging the hands as they may be contaminated by the client touching his or her own lesions (CDC, 2018). Massage linens are treated as contaminated.

If the massage practitioner has warts on the hands, gloves are worn during the massage.

Picture Credits:


Centers for Disease Control and Prevention. (2018). Type and duration of precautions recommended for selected infections and conditions: appendix A updates. Retrieved from

Goodman, C.C., Fuller, K.S. (2014). Pathology: implications for the physical therapist. 4th ed. St Louis: Elsevier.

Royal College of Obstetricians and Gynaecologists. (2015). Chickenpox and pregnancy. Retrieved from

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Dr. Susan Salvo is a massage therapist, author, educator, researcher, explorer, and perpetual student. To learn more, check out the “About Susan” tab. You can contact Susan at