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Shingles

NICE CKS Shingles. Last revised Nov 2024. NICE CKS Post-herpetic neuralgia. Last revised: Aug 2024.

Guidelines

Clinical diagnosis - based on typical clinical features.
 

  • Prodromal phase of 2-3 days
    • Pain in the affected dermatome
    • Abnormal skin sensations (e.g. pruritus, paraesthesia, dysesthesia, numbness)
 
  • Unilateral painful rash in a dermatomal distribution (does not cross midline)
    • Erythematous maculopapular rash for 1-2 days
    • → Vesicles for 3-4 days
    • → Pustules within 1 week
    • → Ulceration and crusting after 3-5 days
    • → Healing over 2-4 weeks, often with scarring and permanent pigmentation

Admit or seek immediate specialist advice if ANY of the following:
  • Immunocompromised (severely immunocompromised adult / immunocompromised children)
  • Shingles in the ophthalmic distribution of CN V, especially those with:
    • Hutchinson's sign (rash on the nose, representing the dermatome of the nasociliary nerve, is associated with a high complication rate.)
    • Eye pain
    • Photophobia
    • Reduced corneal sensitivity
    • Visual impairment
    • An unexplained red eye
  • Head and neck involved (esp. in elderly people)
  • Signs of visceral / CNS involvement (including vasculitis)
  • Haemorrhagic / necrotic lesions, multisegmental involvement, aberrant vesicles/satellite lesions, mucosal involvement or generalised herpes zoster.

Advise that shingles is infectious until all vesicles have crusted over (~7 days after rash onset).
  • Patient should avoid work / school / daycare if the rash is weeping and cannot be covered

Measures to prevent transmission:
  • Avoid skin contact with people at high risk of complications 
  • Avoid sharing clothes and towels
  • Wash their hands often

Skin / rash care measures:
  • Avoid touching / scratching the rash 
  • Avoid using topical antibiotics and adhesive dressing
  • Keep rash clean and dry to reduce risk of bacterial superinfection
  • Wear loose-fitting clothes 
  • Cover lesions that are not under clothes if it is still weeping

Scenarior Management
Mild to moderate pain
  • Paracetamol / NSAID 
  • +/- Weak opioid
Moderate to severe pain Neuropathic pain drugs:
  • Amitriptyline
  • Duloxetine
  • Pregabalin 
  • Gabapentin

Also consider oral steroids, but only if immunocompetent and given in combination with antivirals.
If oral treatment not appropriate Topical capsaicin cream
 

Indications for antiviral therapy (any of the following):
  • Immunocompromised
  • >50 y/o
  • Non-truncal involvement
  • Moderate / severe pain
  • Presence of predisposing skin conditions 

Antiviral therapy should not be offered to immunocompetent children.

Choice of anti-viral therapy:
  • 1st line: oral aciclovir / valaciclovir / famciclovir for 7 days
  • To be started within 72 hours of rash onset (if not possible, consider up to 1 week after rash onset)

 

Antiviral therapy is established to reduce the risk of post-herpetic neuralgia, esp. in older patients. 

2 doses of Shingrix vaccine are routinely offered to all immunocompetent people at 60 y/o

 

Currently, it is under a 10-year implementation period. 

References

Author: Adams Lau
Reviewer:
Last edited: 24/04/25