Shingles
Questionnaire/history:
Visual symptoms?
Past medical history?
- Immune compromise?
Current medication?
Known drug allergies?
Examination:
Location of rash?
- Trunk?
- Neck?
- Limb?
- Ophthalmic involvement?
--- Red eye?
--- Hutchinson’s sign ((a rash on the tip, side or root of the nose, representing the dermatome of the nasociliary nerve and a strong predictor of ocular damage)?
Management:
Antivirals within 72 hours of shingles/zoster rash onset for:
Patients aged ≥ 50 years old
Patients of any age with:
Ophthalmic involvement - seek immediate specialist advice, especially those with:
- Hutchinson's sign
- Visual symptoms or an unexplained red eye
Non-truncal involvement (eg affecting limbs, neck or perineum)
Moderate or severe pain
Moderate or severe rash
Immunocompromised:
- Continue antiviral at full dose until 2 days after all lesions have healed, rather than stopping after the usual 7-day course
- Only treat in primary care if not severely immunocompromised, localised rash and systemically well, otherwise refer
Consider starting antiviral treatment up to 1 week after rash onset if:
Higher risk of severe shingles/complications (eg continued vesicle formation, older age, immunocompromised, severe pain)
Drug choices:
Aciclovir 800 mg 5 times daily for 7 days
2nd line if poor compliance: famciclovir 250-500 mg TDS or 750mg BD or valaciclovir 1 g TDS (both for 7 days)
Advised:
Infectious until scabs crusted, usually within 5-7 days
Can catch chickenpox from shingles if never been exposed to the varicella virus/chickenpox in the past, so avoid immunocompromised and babies < 1 month
Only avoid work, if the rash is weeping, wet and cannot be covered
Antiviral safety in pregnancy is not firmly established, so we urgent specialist advice should be sought
Antivirals are not recommended or licensed in immunocompetent children, infection is usually mild and rarely leads to post-herpetic neuralgia in children
Paracetamol alone or in combination with codeine or a nonsteroidal anti-inflammatory drug (NSAID) (avoid NSAIDs in children)
If not effective or severe pain: option to take amitriptyline (off-label use), duloxetine (off-label use), gabapentin or pregabalin
Consider oral corticosteroids in the first 2 weeks following rash onset in immunocompetent adults with localised shingles if the pain is severe, but only in combination with antiviral medication
Resource(s):
NICE/PHE antimicrobial guideline