What is usually the first sign of herpes zoster?

The first sign of herpes zoster, commonly known as shingles, is typically a stabbing or burning type of pain localized to a specific area of the body. This pain is often described as intense and can precede other symptoms, such as the characteristic vesicular rash, by several days. The pain is usually unilateral, following a dermatomal distribution, which is key in diagnosing herpes zoster.

When considering the other options, the vesicular skin lesions do occur in herpes zoster but they appear after the initial pain. The pain becoming worse upon awakening is not specific to herpes zoster and can occur in various conditions, making it less indicative of the diagnosis. Finally, lesions in the exterior ear canal, though they may be relevant in certain cases like Ramsey Hunt syndrome, do not represent the typical first sign of herpes zoster overall. The initial sharp pain signaling the condition is crucial for timely recognition and management.